Citation Nr: 1315347 Decision Date: 05/09/13 Archive Date: 05/15/13 DOCKET NO. 08-28 112 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Boise, Idaho THE ISSUES 1. Entitlement to service connection for pancreatic cancer. 2. Entitlement to service connection for colonic polyps. 3. Entitlement to an initial rating higher than 40 percent for degenerative disc disease of the lumbar spine with fusion. 4. Entitlement to an initial rating higher than 10 percent for seborrhea of the scalp. 5. Entitlement to an initial compensable rating for cholelithiasis prior to July 16, 2007. 6. Entitlement to a compensable rating for cholelithiasis from July 16, 2007. 7. Entitlement to an initial compensable rating for hemorrhoids prior to February 25, 2011. 8. Entitlement to a rating in excess of 10 percent for hemorrhoids from February 25, 2011. 9. Entitlement to a total disability compensation rating based on individual unemployability due to service-connected disability. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD D. Johnson, Counsel INTRODUCTION Pursuant to 38 C.F.R. § 20.900(c), the appeal has been advanced on the Board's docket. The Veteran, who is the appellant, served on active duty from January 1983 to August 2005. This matter is before the Board of Veterans' Appeals (Board) on appeal of September 2006 and May 2007 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). While on appeal, in November 2008, a Decision Review Officer increased the rating for degenerative disc disease of the lumbar spine with fusion to 40 percent effective September 1, 2005. The Veteran continued his appeal for a higher rating. AB v. Brown, 6 Vet. App. 35, 38 (1993). In January 2013, in accordance with 38 U.S.C.A. § 7109 and 38 C.F.R. § 20.901, the Board obtained a medical expert opinion from the Veterans Health Administration. The opinion is favorable. In January 2011, the Board remanded the case for further development, which has been completed. Stegall v. West, 11 Vet. App. 268, 271 (1998). Claims of entitlement to increased ratings for service-connected gastroesophageal reflux disorder, tension headaches, bilateral carpal tunnel syndrome, and bilateral knee strain have been raised by the Veteran and are referred to the RO for appropriate action. The issue of entitlement to TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Pancreatic islet cell tumor had onset in service. 2. There is no current diagnosis of colonic polyps. 3. Degenerative disc disease of the lumbar spine with fusion is manifested by limitation of motion, and not unfavorable ankylosis of the entire thoracolumbar spine or incapacitating episodes having a total duration of at least six weeks during the past 12 months is not shown. 4. Seborrhea of the scalp is manifested by symptoms that affect an area that is less than 20 percent of the Veteran's entire body and exposed areas; the use corticosteroids and systemic therapy is not shown. 5. Prior to July 16, 2007, cholelithiasis was manifested by mild symptoms; gall bladder dyspepsia and attacks of gallbladder colic were not shown. 6. From July 16, 2007, cholelithiasis, status-post cholectcystectomy, is manifested by mild to moderate symptoms of abdominal pain, nausea, vomiting, and colic; severe cholelithiasis is not shown. 7. Prior to February 25, 2011, hemorrhoids were manifested by occasional bleeding; evidence of large or thrombotic hemorrhoids, irreducible, with excessive redundant tissue was not shown. 8. From February 25, 2011, hemorrhoids are manifested by bleeding and excessive redundant tissue; thrombosis and persistent bleeding with secondary anemia or fissures is not shown. CONCLUSIONS OF LAW 1. The criteria for service connection for pancreatic cancer have been met. 38 U.S.C.A. §§ 1110, 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2012). 2. The criteria for service connection for colonic polyps have not been met. 38 U.S.C.A. §§ 1110, 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2012). 3. The criteria for an initial rating higher than 40 percent for degenerative disc disease of the lumbar spine have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237, 5243 (2012). 4. The criteria for an initial rating higher than 10 percent for seborrhea of the scalp have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.118, Diagnostic Code 7806 (2012). 5. Prior to July 16, 2007, the criteria for a compensable rating for cholelithiasis have not been met. 38 U.S.C.A. § 1155, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. § 4.114, Diagnostic Code 7318 (2012). 6. From July 16, 2007, the criteria for a 10 percent rating for cholelithiasis have been met. 38 U.S.C.A. § 1155, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. § 4.114, Diagnostic Code 7318 (2012). 7. Prior to February 25, 2011, the criteria for an initial compensable rating for hemorrhoids have not been met. 38 U.S.C.A. § 1155, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. § 4.114, Diagnostic Code 7336 (2012). 8. From February 25, 2011, the criteria for a rating in excess of 10 percent for hemorrhoids have not been met. 38 U.S.C.A. § 1155, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. § 4.114, Diagnostic Code 7336 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, codified in part at 38 U.S.C.A. §§ 5103, 5103A, and implemented in part at 38 C.F.R § 3.159, amended VA's duties to notify and to assist a claimant in developing information and evidence necessary to substantiate a claim. Duty to Notify Under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b), when VA receives a complete or substantially complete application for benefits, it will notify the claimant of the following: (1) any information and medical or lay evidence that is necessary to substantiate the claim, (2) what portion of the information and evidence VA will obtain, and (3) what portion of the information and evidence the claimant is to provide. Also, the VCAA notice requirements apply to all five elements of a service connection claim. The five elements are: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The VCAA notice must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004). The RO provided pre-adjudication VCAA notice by letters dated in January 2006 and in March 2006. As for the content of the VCAA notice, the documents complied with the specificity requirements of Quartuccio v. Principi, 16 Vet. App. 183, 186-87 (2002) (identifying evidence to substantiate a claim and the relative duties of VA and the claimant to obtain evidence); of Charles v. Principi, 16 Vet. App. 370, 374 (2002) (identifying the document that satisfies VCAA notice); of Pelegrini v. Principi, 18 Vet. App. 112, 119-120 (2004) (to the extent of pre-adjudication VCAA notice); and of Dingess v. Nicholson, 19 Vet. App. 473, 484-86 (2006) (notice of the elements of the claim). In a claim for increase, the VCAA notice requirements are the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009) (interpreting 38 U.S.C.A. § 5103(a) as requiring generic claim-specific notice and rejecting Veteran-specific notice as to effect on daily life and as to the assigned or a cross-referenced Diagnostic Code under which the disability is rated). Furthermore, where service connection has been granted and the initial disability rating has been assigned, the claim has been more than substantiated, it has been proven, thereby rendering 38 U.S.C.A. § 5103(a) notice no longer required because the purpose that the notice was intended to serve has been fulfilled. Once a claim for benefits has been substantiated, the filing of a notice of disagreement with the RO's decision rating the disability does not trigger additional 38 U.S.C.A. § 5103(a) notice. Therefore, further VCAA notice under 38 U.S.C.A. § 5103(a) and § 3.159(b)(1) with respect to the claims for higher ratings for the service-connected degenerative disc disease of the lumbar spine, seborrhea of the scalp, cholelithiasis, and hemorrhoids is no longer applicable. Goodwin v. Peake, 22 Vet. App. 128 (2008). Duty to Assist Under 38 U.S.C.A. § 5103A, VA must make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate a claim. The RO has obtained the service records as well as VA and private medical records. The Veteran was afforded VA examinations in June 2006, November 2008, February 2011, and September 2012. As the examination reports contains pertinent medical history and findings, to include those pertaining to the rating criteria, the Board finds that the reports are adequate to decide the claims. See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007) (a medical examination must be based on consideration of the history and describe the disability in sufficient detail so that the Board's evaluation of the claimed disability will be a fully informed one). As the Veteran has not identified any additional evidence pertinent to the claim and as there are no additional records to obtain, the Board concludes that no further assistance to the Veteran in developing the facts pertinent to the claim is required to comply with the duty to assist. I. Principles and Theories of Service Connection A Veteran is entitled to VA disability compensation if there is a disability resulting from personal injury suffered or disease contracted in line of duty in active military service or for aggravation of a preexisting injury suffered or disease contracted in line of duty in active military service. 38 U.S.C.A. § 1110 (wartime service) and § 1131 (peacetime service). Generally, to establish entitlement to compensation for a present disability, a Veteran must show: (1) a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service, the so-called "nexus" requirement. All three elements must be proved. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed.Cir. 2004). Service connection may also be granted for disability shown after service, when all of the evidence, including that pertinent to service, shows that it was incurred in service. 38 C.F.R. § 3.303(d). In addition, for Veterans who served 90 days or more of during a war period, certain chronic disabilities, including malignant tumors, are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C.A. § 1101, 1112, 1113; 38 C.F.R. § 3.307(a), 3.309(a). Evidentiary Standards VA must give due consideration to all pertinent lay and medical evidence in a case where a Veteran is seeking service connection. 38 U.S.C.A. § 1154(a). As the Veteran did not serve in combat, the combat provision of 38 U.S.C.A. § 1154(b) does not apply. Competency is a legal concept in determining whether lay or medical evidence may be considered, in other words, whether the evidence is admissible as distinguished from credibility and weight, factual determinations going to the probative value of the evidence, that is, does the evidence tend to prove a fact, once the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997). Competency is a question of fact, which is to be addressed by the Board. Jandreau, v. Nicholson, 492 F.3d 1372, 1377 (2007). When the evidence is admissible, the Board must then determine whether the evidence is credible. "Credible evidence" is that which is plausible or capable of being believed. See Caluza v. Brown, 7 Vet. App. 478, 511 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (the determination of credibility is a finding of fact to be made by the Board in the first instance). If the evidence is credible, the Board, as fact finder, must determine the probative value or weight of the admissible evidence, that is, does the evidence tend to prove a material fact. Washington v. Nicholson, 19 Vet. App. 362, 369 (2005). If the evidence is not credible, the evidence has no probative value. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the Veteran. 38 U.S.C.A. § 5107(b). Pancreatic Cancer Facts Service treatment records are negative for findings of a pancreatic tumor or pancreatic cancer. In January 2007 a VA ultrasound and computed tomography (CT) scan showed an abnormal 3 cm. mass at the neck or possibly the proximal body of the Veteran's pancreas. An endoscopic retrograde cholangiopancreatography (ERCP) and needle biopsy were performed in February 2007 which confirmed an islet cell tumor. The ERCP induced severe pancreatitis, which delayed pancreatic surgery until July 2007, at which time the Veteran underwent a distal pancreatectomy. In June 2008, a VA examiner was asked to determine if there were symptoms consistent with the Veteran's tumor either on active duty or within a year after service. The examiner considered the Veteran's long history of abdominal pain and diarrhea, but found that the symptoms of right abdominal pain - for which the Veteran had sought treatment in October 2006 and which eventually led to additional testing in January 2007 and the disclosure of the pancreatic islet cell tumor - were less likely than not related to any symptomatology that the Veteran had experienced either during service or within a one-year period after service. In support of his claim, the Veteran provided a copy of an email from the VA surgical oncologist who performed the distal pancreatectomy in July 2007. The oncologist stated that it was very likely and probable that the Veteran's nonfunctional 3 cm pancreatic islet cell tumor without malignant features had been present for more than 12 to 18 months prior to the July 2007 surgery. In January 2013 the Board requested a medical expert opinion from the VHA as to the onset and etiology of Veteran's pancreatic islet cell tumor, in light of the opposing medical opinions. In January 2013, a VA physician with board certifications in medical oncology, hematology, and internal medicine provided an opinion regarding the onset, nature, and etiology Veteran's pancreatic islet cell tumor. The expert opined that the Veteran's pancreatic islet cell tumor was malignant and such tumors are more commonly referred to as pancreatic neuroendocrine tumors (Pancreatic NET). He noted that these are rare pancreatic malignancies characterized by their slow growth. They are not considered benign because if not surgically intervened on, over time they will metastasize and eventually become fatal. The expert further opined that it is more likely than not (a greater than 50 percent probability) that the Veteran's tumor had onset prior to August 2005. The rationale was that the slow growth of these malignancies is well-documented. In the Veteran's case, further support for the slow growth of his tumor is shown by the apparent lack of growth in the six-month period from the January 2007 ultrasound until the resection in July 2007. Analysis Service connection may be granted for disability shown after service, when all of the evidence shows that it was incurred in service. The medical evidence shows pancreatic cancer was initially diagnosed in February 2007, more than a year after service and beyond the one year period after discharge from service in August 2005. However, there is competent medical evidence of record which indicates that the Veteran's pancreatic islet cell tumor, first documented after service, had initial onset during service. The competent medical evidence of record consists of the report of a VHA expert, who is qualified by education, training and expertise to offer such an opinion, and the VA surgical oncologist who treated the Veteran in 2007. As this evidence is favorable to the claim, and because the opposing June 2008 VA medical opinion is of no greater weight, the evidence is in equipoise. Service connection for pancreatic cancer is warranted. Colon Polyps Facts Service treatment records show the Veteran underwent two colonoscopies, one in September 2002 and another in January 2005. These colonoscopies showed colon polyps. Post-service VA treatment records reflect that the Veteran underwent a colonoscopy in October 2007, which was normal. He was advised to undergo another colonoscopy in three years because recurring polyps required more frequent testing. He underwent a subsequent colonoscopy in June 2009, which was also normal. The Veteran was afforded a VA examination in February 2011 to determine whether he currently experienced recurring colon polyps and if so, whether they represented a progression of the colonic polyps in service or the development of a new and separate condition. The VA examiner reviewed the entire claims file and determined that there was a history of colon polyps, non-malignant, removed. He further indicated that there were no recent polyps. SSA records were reviewed, but do not reveal any evidence of current colon polyps. Analysis As a layperson, the Veteran is competent to identify a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (citing Jandreau, 492 F.3d at 1377). A diagnosis of colon polyps is medical in nature and requires a medical diagnosis. Accordingly, the Veteran's unsupported lay statement indicating that he currently has a disability manifested as colon polyps is neither competent nor probative evidence supporting his claim. See Davidson, 581 F.3d at 1316; Jandreau, 492 F.3d at 1376-77. The only competent medical evidence with respect to the question of whether colon polyps are present is the October 2007 and June 2009 colonoscopies, and the February 2011 VA examiner's findings. This evidence establishes that there is no current diagnosis of colon polyps, and there is no contrary medical finding or opinion in the record. The Veteran's unsupported lay statements are outweighed by the competent and more probative clinical findings, or more specifically, the lack thereof. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet.App. 428, 435 (2011), as to the specific issue in this case, whether the Veteran currently has colon polyps, this falls outside the realm of common knowledge of a lay person. Rather, this is a complex medical question that even a physician requires clinical testing to determine, and thus is not capable of direct lay observation. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). As the evidence does not establish that the Veteran currently has colon polyps, or residuals from the colon polyps noted in service; there can be no valid claim for service connection. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); McClain v. Nicholson, 21 Vet. App. 319 (2007). As the preponderance of the evidence is against the claim, there is no doubt to be resolved and service connection is not warranted. II. General Rating Principles Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. Separate Diagnostic Codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet. App. 589, 592-93 (1991). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings." Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505, 519 (2007). The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis and demonstrated symptomatology. Any change in a diagnostic code by VA must be specifically explained. Pernorio v. Derwinski, 2 Vet. App. 625 (1992). Rating Factors Rating factors for a disability of the musculoskeletal system include functional loss. A disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. The functional loss may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Functional loss may also be due to weakness or atrophy. 38 C.F.R. § 4.40; DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). As for joints, the factors of disability reside in reductions of the joints normal excursion of movements in different planes. Factors for considerations include more or less movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, atrophy of disuse, instability of station, disturbance of locomotion, interference with sitting and standing, and weight-bearing. 38 C.F.R. § 4.45; DeLuca, 8 Vet. App. at 206-07. Also with periarticular pathology, painful motion is factor to be considered. The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Rating Degenerative Disc Disease of the Lumbar Spine Degenerative disc disease of the lumbar spine is rated 40 percent under Diagnostic Code 5241. The rating was effective September 1, 2005, the date the Veteran filed his claim for service connection. Under 38 C.F.R. § 4.71a, Diagnostic Code 5241 is rated under the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula). Under the General Rating Formula, the criteria for a rating of 40 percent, are forward flexion of the thoracolumbar spine 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine. The criterion for the next higher rating, 50 percent, is unfavorable ankylosis of the entire thoracolumbar spine. Also, any objective neurological abnormality may be separately rated under the appropriate diagnostic code. The criteria under the General Rating Formula for Diseases and Injuries of the Spine provide that normal flexion of the thoracolumbar spine is zero to 90 degrees, normal extension is zero to 30 degrees, normal left and right lateral flexion is zero to 30 degrees, and normal left and right lateral rotation is zero to 30 degrees. All measured ranges of motion will be rounded to the nearest five degrees. Ankylosis is a condition in which the entire cervical spine is fixed in flexion or extension. Ankylosis is immobility and consolidation of a joint due to disease, injury or surgical procedure. 38 C.F.R. § 4.71a, General Rating Formula, Note (5). Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. In evaluating disabilities of the spine, the criteria is for application with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. 38 C.F.R. § 4.71a, the General Rating Formula for Diseases and Injuries of the Spine. In addition, under Diagnostic Code 5243, the disability may be rated under either the General Rating Formula or the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever results in a higher rating. Under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, the criteria for the next higher rating, 60 percent, are incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. An incapacitating episode is a period of acute signs and symptoms that required bed rest prescribed by a physician and treatment by a physician. Facts Service treatment records reflect several episodes of lumbar strain and back pain. The Veteran was diagnosed with degenerative joint disease in July 2002. A subsequent MRI revealed a broad-based disc protrusion at L5 and S1 which caused stenosis of the L5 nerve roots bilaterally. The Veteran underwent fusion of the spine in February 2004. On VA examination in June 2006, the Veteran stated that he had daily low back pain and tenderness; including radicular pain in the right lower extremity which radiated down into the right buttock and occasionally the right leg. He denied having any radicular symptoms in the left lower extremity since his spine surgery in 2004. He denied bowel or bladder incontinence. He stated that he had had to modify his behavior due to pain and could not do any significant lifting or bending. He also stated that he was unable to sit for prolonged periods, jog, skate, or play basketball. On physical examination, the spine was nontender to palpation. Forward flexion was to 40 degrees with pain. Extension was to 5 degrees. Right lateral rotation was possible to 15 degrees and left lateral rotation was to 25 degrees. With repetition, right and left lateral side bending was restricted to 10 and 20 degrees, respectively. X-rays showed a prior posterior fusion at L5-S1. A neurologic exam showed the Veteran had normal strength. A sensory examination was intact to touch, position sense and vibratory sense. Deep tendon reflexes were normal and symmetrical. The diagnosis was osteoarthritis of the lumbosacral spine status post spinal fusion with intermittent radicular symptoms in the right SI distribution. In his September 2007 Notice of Disagreement, the Veteran stated that his mobility was limited due to his pain and increased pressure. He also stated he could not walk more than 200 feet without discomfort and could not lift anything heavy. On the Veteran's September 2008 VA Form 9, he stated that he had decreased flexibility in his back, difficulty dressing, and functional loss in that physical activities were precluded including recreational activities with family. He also noticed gait changes and a need for pain pills. On VA spine examination in November 2008, the Veteran stated that since his surgery in 2004 he no longer had constant sciatic pain affecting his left lower extremity. However, once or twice a week he experienced low back pain with radiation to the calf, left greater than right, which lasts two hours. The Veteran stated that his left leg was weaker than his right, and he favored the left leg when walking. As for functional impairment, he stated that he had been unable to jog since his surgery in 2004. The Veteran's walking was limited to no more than 30 minutes, twice a week. He was unable to enjoy sports. His flare-ups cause him to miss work on an average of one day a week. He indicated that his activity was limited by pain, weakness, fatigue and lack of endurance. On physical examination, flexion was to 30 degrees and extension was to 30 degrees. Lateral flexion was to 30 degrees, on each side to a point of tightness. Straight leg raising was to 40 degrees on the right and 30 degrees on the left, to the point of tightness. After three ranges of motion, there was no loss of lumbar flexion. The Veteran's left lower extremity was weaker than the right. Deep reflexes were active. The diagnosis was lumbar fusion with continued pain and limited range of activity. VA treatment records show intermittent complaints of back pain. For instance, in October 2009 the Veteran stated he had pain in the area of his spinal surgery and sciatic nerve, with increased pain on right. The pain also radiated to the left leg, to the back of the leg and below the knee. On physical examination, strength was 5/5 and pulses were 2/4 and palpable. His gait was also normal. February 2010 treatment records reflect a complaint of increasing back pain. The Veteran denied bowel and bladder dysfunction and also denied having weakness or numbness in his legs. Deep tendon reflexes were normal and symmetrical in the lower extremities, and strength was intact bilaterally. On VA examination in February 2011, the Veteran stated that he had leg and foot weakness in addition to low back pain. The pain radiated to his left posterior buttock and the posterior thigh to the mid-calf. On the right, the pain radiated to the right buttock. He stated that he could walk no more than a quarter of a mile to one mile. He denied bowel and bladder dysfunction. On physical examination, the Veteran's posture and gait were normal. There were no abnormal spinal curvatures or ankylosis. Range of motion included flexion from 0 to 70 degrees and extension from 0 to 22 degrees. Left and right lateral flexion was possible from 0 to 30 degrees; and left and right lateral rotation was possible from 0 to 30 degrees. There was pain with repetitive motion, but this did not result in any additional limitation of motion. Sensory examination was normal. Reflexes were normal bilaterally. Muscle tone was normal; no atrophy was present. The diagnosis was degenerative disc disease, L5-S1 with fusion. Analysis Under the General Rating Formula, the criterion for the next higher rating, 50 percent, is unfavorable ankylosis of the entire thoracolumbar spine. The evidence clearly demonstrates the Veteran has some limitation of motion in his lumbar spine. However, there is no medical evidence of unfavorable ankylosis of the entire thoracolumbar spine. On VA examinations in June 2006, November 2008 and February 2011, the Veteran had some limited motion, but he did not have any ankylosis. There is no other competent evidence of unfavorable ankylosis of the thoracolumbar spine at any time during the course of the appeal. Further, there is no evidence that any of the following are present: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Although Veteran complains of some gastrointestinal symptoms, there is no evidence this has resulted from the lumbar spine disability as opposed to being a residual of his service-connected GERD or cholelithiasis. In the absence of evidence of unfavorable ankylosis of the thoracolumbar spine, on VA examinations or in any other medical evidence of record, the criterion for a higher rating under the General Rating Formula for Diseases and Injuries of the Spine based on orthopedic manifestations have not been met. The criteria for the next higher rating of 60 percent, under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, have not been met. A 60 percent rating requires incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. The Board has considered the Veteran's testimony that he has missed work due to back pain. However, there is no evidence of physician-prescribed bed rest for a period of at least 6 weeks at any time during the appeal period in question. Accordingly, a higher rating may not be assigned under DC 5243 on the basis of incapacitating episodes. The assignment of a separate rating for neurologic manifestations resulting from the lumbar spine degenerative disc disease requires that the neurologic signs and symptoms be present constantly, or nearly so. While neurologic complaints have been made throughout the appeal period, these complaints have not been constant or nearly so. For instance, the Veteran denied radicular symptoms at the June 2006 examination. The November 2008 VA examination report shows a complaint of radiating pain and weakness in the right lower extremity that occurred only once or twice per week. The Veteran denied symptoms of numbness or weakness in his lower extremities when seen in February 2010. Further, none of the neurologic manifestations reported and attributable to the lumbar spine disability have been demonstrated on objective clinical evaluation. The VA examiner in June 2006 noted the Veteran's history of intermittent radicular symptoms in the S1 distribution, but indicated that the sensory examination was clinically normal. The objective neurologic evaluations in October 2009 and February 2010 were normal. The VA examiner in February 2011 noted the Veteran's complaint of weakness and numbness in his lower extremities, but stated that the clinical sensory examination was normal. Therefore, a separate rating for neurologic manifestations of the degenerative disc disease of the lumbar spine is not warranted. The Veteran's overall disability picture does not more nearly approximate or equate to the criteria for the next higher rating of 50 percent, and the lower rating must be assigned. 38 C.F.R. § 4.7. The preponderance of the evidence is against the claim for a higher initial rating; there is no doubt to be resolved; and a higher initial rating is not warranted. Rating Seborrhea of the Scalp The Veteran's seborrhea of the scalp is rated 10 percent under Diagnostic Code7806. The rating was effective September 1, 2005, the date the Veteran filed his claim for service connection. Seborrhea is not a listed disability under the Schedule for Rating Disabilities, 38 C.F.R., Part 4. Rather, it is rated, by analogy, under 38 C.F.R. § 4.118, DC 7806. Diagnostic Code 7806 provides ratings for dermatitis or eczema. Dermatitis or eczema is to be rated under either the criteria under DC 7806, or as disfigurement of the head, face, or neck (DC 7800) or scars (DCs 7801, 7802, 7803, 7804, or 7805), depending upon the predominant disability. In this case, Diagnostic Code 7806 is the applicable diagnostic code, as dermatitis is the Veteran's predominant disability. The evidence does not suggest that the seborrhea manifests with any actual scars. Under Diagnostic Code 7806, a 10 percent rating is warranted for a skin disorder that affects at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of the exposed areas, or that requires intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of less than 6 weeks during the past 12-month period. The next highest rating is 30 percent, and is warranted for a skin disorder that affects 20 to 40 percent of the entire body or 20 to 40 percent of the exposed areas, or that requires systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of 6 weeks or more, but not constantly, during the past 12-month period. Facts On VA examination in June 2006, an examiner stated the Veteran had marked seborrhea of the scalp that had been treated with multiple medications. The examiner stated that the Veteran was currently on Kenalog spray and Clobetasol, a topical solution, which he uses on a daily basis with some temporary relief. The examiner indicated that the seborrhea caused pain, tenderness, and a large amount of scaling and itching in the Veteran's scalp. Physical examination revealed a 40 percent involvement over the parietal area with marked seborrhea. On the Veteran's September 2008 VA Form 9, he stated that he used Triamcinolone Acetonide Cream (a topical solution) on a daily basis for treatment of his seborrhea. On VA examination in February 2011, the Veteran stated that he had symptoms of dry, flaky, and itchy skin. His treatment consisted of a daily topical medication- Calcipotriene, which the examiner noted was neither a corticosteroid nor an immunosuppressive medication. The examiner also noted that this medication had expired prior to October 2009. Physical examination showed that the area affected was greater than 5 percent, but less than 20 percent, of the exposed areas. The total area of the body affected was less than 5 percent. There were only some dry dandruff-like flaking on the left parietal scalp; no discrete lesions consistent with seborrhea were present. Analysis The next highest rating of 30 percent requires that the skin disorder affect 20 to 40 percent of the entire body or 20 to 40 percent of the exposed areas, or requires systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of 6 weeks or more during the past 12-month period. Here, it has not been shown that the service-connected seborrhea has at anytime during the appeal, affected an area that was at least 20 percent of the Veteran's entire body or exposed areas, or that he required systemic therapy. While the evidence shows diagnosis and treatment for another service-connected skin condition namely, dermatofibromas affecting multiple body parts, but not the scalp, this condition has been distinguished from the service-connected skin disability as a separate condition. The Veteran's scalp is the area affected by seborrhea and the scalp is considered to be an 'exposed' area. The June 2006 VA examination report indicates that the Veteran's service-connected seborrhea affected 40 percent of that specific exposed area. However, there is no evidence that the seborrhea affects at least 40 percent of the entire exposed areas on the Veteran's body. The February 2011 examiner indicated that the seborrhea has affected less than 20 percent of the Veteran's entire exposed areas and less than 5 percent of his entire body. In addition, the Veteran has used only over-the-counter topical medications that were not corticosteroids. There is no evidence that he has required systemic therapy. In short, the evidence does not show that the Veteran meets the criteria for the next higher rating under Diagnostic Code7806. As the predominant disability picture for seborrhea is a skin condition affecting no more than 5 percent of an exposed area or of the entire body without a requirement for intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs, and as no other diagnostic codes, namely, Diagnostic Code 7800 and Diagnostic Codes 7801 to 7805, can be applied to the Veteran's advantage, there is no basis for a rating in excess of 10 percent. Rating Cholelithiasis The Veteran's cholelithiasis is currently rated as noncompensably disabling under Diagnostic Code 7315 pertaining to chronic cholecystitis. The rating was effective September 1, 2005, the date the Veteran filed his claim for service connection. Diagnostic Code 7315 provides that chronic cholecystitis is to be rated as cholecystitis, chronic. Cholecystitis, chronic is evaluated under Diagnostic Code 7314. Under Diagnostic Code 7314, a noncompensable evaluation is warranted when the disability is mild. A 10 percent evaluation is assigned for a moderate disability; gall bladder dyspepsia, confirmed by X-ray technique, and with infrequent attacks (not over two or three a year) of gallbladder colic, with or without jaundice. A maximum 30 percent evaluation is warranted when the disability is severe; frequent attacks of gallbladder colic. 38 C.F.R. § 4.114, Diagnostic Code 7314 (2012). The Veteran's gallbladder has been removed. Thus, Diagnostic Code 7318 is also for consideration. Under this Diagnostic Code, a 0 percent evaluation is provided for nonsymptomatic removal of gall bladder. A 10 percent evaluation is provided for removal of gall bladder with mild symptoms. A 30 percent evaluation is provided for removal of gall bladder with severe symptoms. 38 C.F.R. § 4.114, DC 7318 (2012). Facts On VA examination in June 2006 the examiner stated that, historically, the Veteran's symptoms had included pain and tenderness in his right upper quadrant abdominal area. The examiner also noted that it had been previously recommended that the Veteran undergo a cholecystectomy, but he elected to change his diet instead. He subsequently decreased the amount of fat and remained relatively symptom-free. Physical examination showed the Veteran was in no acute distress. His abdomen was mildly obese. Guarding and rebound were not present, and no organomegaly or masses were appreciated. The diagnosis was symptomatic cholelithiasis with an infection fraction of 22 percent by HIDA scan requiring an alteration of diet. VA outpatient treatment records show a finding of multiple gallstones after an echogram abdomen in January 2007. The notes indicate the Veteran had complained of right-sided pain, diarrhea or constipation since a renal pyeloplasty related to stones that were present 11 years ago. A March 2007 gastroenterology consult showed the Veteran had known cholelithiasis since the 1990's, but there was no evidence for cholecystitis. VA treatment records also show gallstones were noted during a CT scan of the abdomen in April 2007. The Veteran underwent a cholecystectomy in July 2007 for his diagnoses of cholelithiasis and biliary colic. In an October 2007 the Veteran sought treatment for sharp pain at his right abdomen, mid-ax line, which had been present for three days. The pain was a colicky in nature and was intermittent. On physical examination, bowel sounds were active to hyperactive. The Veteran was mildly tender in the right lower quadrant to mild percussion, but was without flank pain. The examining clinician noted that the Veteran had a strong history of nephrolithiasis but the current examination leaned towards cholelithiasis. An abdominal ultrasound was scheduled to evaluate his gallbladder for stones. Additional July 2009 VA treatment records show complaints of severe abdominal pain in right upper quadrant and epigastrium, but these were associated with flares of pancreatitis. On VA examination in February 2011 an examiner stated that the Veteran underwent surgery on July 16, 2007, to remove an Islet cell tumor at the head of his pancreas. The July 2007 discharge summary after the surgery indicated that the Veteran had undergone a distal pancreatectomy and splenectomy with en bloc posterior gastric wall resection, as well as a cholecystectomy and two layer primary gastric repair. The examiner further stated that since the surgery, the Veteran had right-sided abdominal pain, nausea, vomiting, and alternating constipation and diarrhea. The examiner stated that the Veteran used Morphine for the abdominal pain. The abdominal pain has been daily and moderate in severity. The nausea and vomiting occurred daily, but are of mild severity. He has had less than 7 episodes of colic, abdominal pain, nausea and vomiting in the past 12-month period. On physical examination, abdominal examination was normal. The diagnosis was cholecystectomy residuals. The affect on activities of daily living (e.g. chores, exercise, sports, feeding) was mild to moderate. Analysis The next highest rating of 10 percent is assigned for moderate cholelithiasis demonstrated by gall bladder dyspepsia, confirmed by X-ray technique, and with infrequent attacks of gallbladder colic, with or without jaundice. 38 C.F.R. § 4.114, Diagnostic Code 7314. Prior to July 16, 2007, the Veteran's service-connected cholelithiasis was of no more than mild severity. No symptoms were noted at the June 2006 examination. The VA treatment records showed some complaints of right upper quadrant pain along with diarrhea and constipation, but these complaints were not associated with cholelithiasis. The March 2007 gastroenterology consultation for these complaints revealed that there was no clinical evidence for cholelithiasis. There also was no objective evidence demonstrating the presence of definite gallbladder dyspepsia such as that contemplated by a moderate disability under Diagnostic Code 7314. Accordingly, the Veteran's overall disability picture does not more nearly approximate or equate to the criteria for a compensable rating, and a noncompensable rating must be assigned. 38 C.F.R. § 4.7. The preponderance of the evidence is against the claim for an initial compensable rating; there is no doubt to be resolved; and an initial compensable rating is not warranted prior to July 16, 2007. The Veteran underwent a cholectcystectomy on July 16, 2007. It is clear from the record that he had residual symptoms associated with the removal of his gall bladder. His reported symptom of intermittent colicky pain in his right abdominal area, following the July 2007 cholectcystectomy, was associated with cholelithiasis at the October 2007 gastroenterology consultation. In addition, the February 2011 VA examiner specifically identified the Veteran's complaint of abdominal pain, nausea, vomiting, and colic as residuals of his July 2007 cholecystectomy. The examiner further opined that the Veteran's cholecystectomy residuals were of mild to moderate severity. Under Diagnostic Code 7318, removal of the gallbladder with mild symptoms warrants a 10 percent rating. Based on the Veteran's subjective complaint and the February 2011 VA opinion that the residuals range from mild to moderate severity, the Board is assigning a 10 percent rating for mild cholecystectomy residuals from July 16, 2007, under Diagnostic Code 7318. See Butts v. Brown, 5 Vet. App. 532, 539 (1993). A maximum rating of 30 percent under Diagnostic Code 7318 requires severe residual symptoms. The evidence does not indicate that the Veteran suffers from severe cholelithiasis; therefore a 30 percent rating is not warranted. A 30 percent rating is also not warranted under Diagnostic Code 7314, as this Code requires that cholelithiasis is severe, and manifest with frequent attacks of gallbladder colic. Here, the evidence does not support a finding of frequent attacks of gallbladder colic. In October 2007, the Veteran described his colic attacks as intermittent, and did not indicate that his attacks were severe in nature. And the VA records do not show frequent complaints of severe gallbladder colic. The February 2011 VA examiner stated that the Veteran had less than 7 episodes of colic, abdominal pain, nausea and vomiting in the past 12-month period. Accordingly, there is no basis for a rating in excess of 10 percent for the period beginning July 16, 2007. The Veteran's overall disability picture does not more nearly approximate or equate to the criteria for the next higher rating of 30 percent, and the lower rating of 10 percent must be assigned. 38 C.F.R. § 4.7. The preponderance of the evidence is against the claim for a higher rating; there is no doubt to be resolved. Rating Hemorrhoids The Veteran's hemorrhoids are rated as noncompensably disabling pursuant to 38 C.F.R. § 4.114, Diagnostic Code 7336. This rating was effective September 1, 2005, the date the Veteran filed his claim for service connection. The Veteran's hemorrhoids are rated at 10 percent, effective from February 25, 2011, the date of a VA examination. Under Diagnostic Code 7336, a 0 percent rating is warranted for mild or moderate external or internal hemorrhoids. A 10 percent rating is warranted where there is evidence of large or thrombotic hemorrhoids, irreducible, with excessive redundant tissue, evidencing frequent recurrences. A 20 percent rating is warranted where there is evidence of hemorrhoids with persistent bleeding and with secondary anemia, or with fissures. On VA examination in June 2006, the Veteran stated that he had experienced intermittent rectal bleeding two to three times a month. He associated the rectal bleeding with right upper quadrant pain, dehydration or diarrhea. No significant cramping occurred with the bleeding. On physical examination, there were skin tags at 12 o'clock and 6 o'clock. There was no tenderness present. The diagnosis was bright red blood per rectum, intermittent. The examiner stated that the etiology of bleeding was not clear despite multiple workups. The examiner stated that the only finding that could explain the Veteran's bleeding has been internal hemorrhoids. In the Veteran's September 2007 Notice of Disagreement, he stated that he had severe hemorrhoids that manifested with frequent bloody stool along with anal pain and discomfort. The episodes lasted for several days and the pain was debilitating. In his September 2008 VA Form 9, the Veteran stated that at times he had been unable to sit or walk due to pain, and that he bled with bowel movements. On VA examination on February 25, 2011, the Veteran stated that he did not have current symptoms of hemorrhoids, but he felt as if a fissure was present. He stated that he had recently experienced mild rectal bleeding. He also stated that he felt pain upon sitting in January 2007, which he believed was related to hemorrhoids. His current symptoms included diarrhea, pain, and difficulty passing stools. He denied anal itching, burning, swelling and tenesmus. On physical examination, small internal hemorrhoids were present. They were reducible. There was evidence of excessive redundant tissue. There was no evidence of prolapse, thrombosis, bleeding, anal fissures or fistulas, or strictures. The diagnosis was hemorrhoids, recurrent. On VA examination in September 2012, the Veteran stated that he did not currently have any hemorrhoids, although he stated that he previously had two to three a month. When the hemorrhoids do occur, he has peri-anal itching and burning, and bright red blood on his stool. He had no current complaints of an anal fissure. There were no hemorrhoids or anal fissure noted on perianal clinical examination. Analysis A compensable evaluation for hemorrhoids is not warranted at any time for the appeal period prior to February 25, 2011. The evidence does not reflect that the Veteran's hemorrhoids manifested as large irreducible or thrombotic hemorrhoids and there is no indication that excessive redundant tissue was present at any time. This was not found at the June 2006 VA examination, nor is this noted in the VA treatment records. The Veteran's overall disability picture does not more nearly approximate or equate to the criteria for the next higher rating of 10 percent, and the lower rating of 0 percent must be assigned. 38 C.F.R. § 4.7. The preponderance of the evidence is against the claim for a higher rating; there is no doubt to be resolved. A rating in excess of 10 percent is not warranted at any time for the appeal period beginning February 25, 2011. To warrant a 20 percent rating, there must be evidence of hemorrhoids with persistent bleeding and with secondary anemia, or with fissures. 38 C.F.R. § 4.114, Diagnostic Code 7336. Although the Veteran has competently and credibly stated that he has pain and frequently sees blood in his stool, there is no evidence that his hemorrhoids have resulted in persistent bleeding with secondary anemia or fissures. At the February 2011 examination, there was no evidence of bleeding or anal fissures. Also, at the February 2012 examination, he stated that he did not currently have any hemorrhoids, and neither hemorrhoids nor anal fissures were seen on physical examination. There is no other evidence of severe complications such that medical intervention has been required during the appeal. The Veteran's overall disability picture does not more nearly approximate or equate to the criteria for the next higher rating of 20 percent, and the lower rating of 10 percent must be assigned. 38 C.F.R. § 4.7. The preponderance of the evidence is against the claim for a higher rating; there is no doubt to be resolved. Extraschedular Consideration Although the Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance, it is not precluded from considering whether the case should be referred to the Director of VA's Compensation and Pension Service for such a rating. The threshold factor for extraschedular consideration is a finding that the evidence presents such an exceptional disability picture that the available schedular ratings for that service-connected disability are inadequate. This is accomplished by comparing the level of severity and symptomatology of the service-connected disability with the established criteria. If the criteria reasonably describe a disability level and symptomatology, then the disability picture is contemplated by the Rating Schedule, and the assigned schedular evaluation is, therefore, adequate and referral for an extraschedular rating is not required. Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The Veteran's service-connected lumbar spine disability is primarily manifested by pain and limitation of motion. There is no ankylosis and no objective clinical findings of neurologic deficits. The Veteran's service-connected seborrhea of the scalp involves less than 20 percent of the Veteran's entire body and less than 20 percent of exposed areas affected, and requires no corticosteroid or immunosuppressive treatment. The Veteran's gallbladder dysfunction is manifested by mild symptoms such as periodic colic, vomiting, nausea, and right upper quadrant pain. The Veteran's hemorrhoids are small and manifest with pain and rectal bleeding. There is no secondary anemia and no fissures. Comparing the Veteran's current disability level and symptomatology to the Rating Schedule, the rating criteria encompass the manifestations of the lumbar spine, seborrhea, gallbladder, and hemorrhoid disabilities. In other words, the Veteran does not experience any symptomatology not already encompassed in the Rating Schedule. The assigned schedule ratings are, therefore, adequate and no referral to extraschedular ratings is required under 38 C.F.R. § 3.321(b)(1). ORDER Entitlement to service connection for pancreatic cancer is granted. Entitlement to service connection for colon polyps is denied. Entitlement to an initial rating higher than 40 percent for degenerative disc disease of the lumbar spine with fusion is denied. Entitlement to an initial rating higher than 10 percent for seborrhea of the scalp is denied. Entitlement to an initial compensable rating for cholelithiasis prior to July 16, 2007, is denied. Entitlement to a rating of 10 percent, and not more, for cholelithiasis from July 16, 2007, is granted. (The Order continues on the next page.). Entitlement to an initial compensable rating for hemorrhoids prior to February 25, 2011, is denied. Entitlement to a rating in excess of 10 percent for hemorrhoids from February 25, 2011, is denied. REMAND On VA examination in September 2012, an examiner indicated that the Veteran would be precluded from exertional labor due to some of his service-connected disabilities, but he would not be precluded from sedentary labor. In this decision, the Board has granted service connection for pancreatic cancer and has awarded a 10 percent rating for cholelithiasis from July 16, 2007. The effectuation of these decisions may impact the Veteran's pending TDIU claim. The Board also has referred claims for increased ratings for service-connected gastroesophageal reflux disorder, tension headaches, bilateral carpal tunnel syndrome, and bilateral knee strain. These claims may also impact the pending TDIU claim. In light of the record, the claim of entitlement to TDIU is remanded for the following action: After performing any additional development necessitated by the record, adjudicate the claim for entitlement to TDIU. If the benefit sought is denied, furnish the Veteran and his representative a supplemental statement of the case and return the case to the Board. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). The claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ George E. Guido Jr. Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs