Citation Nr: 1317644 Decision Date: 05/30/13 Archive Date: 06/06/13 DOCKET NO. 06-35 992 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for residuals of a stroke. 2. Entitlement to service connection for erectile dysfunction (ED). 3. Entitlement to service connection for left foot callus, also characterized as intractable plantar keratosis (IPK) and Morton's neuroma. 4. Entitlement to service connection for a skin-related disability of the feet, to include athlete's foot and onychomycosis. 5. Entitlement to service connection for an acquired psychiatric disorder, including major depressive disorder. 6. Entitlement to service connection for diabetes mellitus, claimed as secondary to stroke. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD J. Hager, Counsel INTRODUCTION The Veteran served on active duty from January 1977 to January 1997. These matters initially came before the Board of Veterans' Appeals (Board) from a September 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. In that decision, the RO denied entitlement to service connection for major depression, left foot callus, stroke with memory loss, limp, speech impediment, diabetes, and impotence. The RO also granted an application to reopen a previously denied claim for entitlement to service connection for bilateral athlete's foot (claimed as a bilateral foot condition), and denied the reopened claim, on the merits. Some of the issues on appeal have been recharacterized, as indicated on the title page, for the reasons stated below. In August 2011, the Board determined that new and material evidence had been received with regard to the bilateral foot claim, reopened the claim, and remanded the reopened claim, along with the other service connection claims, for additional development. For the reasons stated below, with regard to the claims being decided herein, the RO/AMC complied with the Board's remand instructions. Stegall v. West, 11 Vet. App. 268, 271 (1998). As discussed in more detail below, the physician who prepared the November 2012 medical opinion addressed the question of whether the Veteran had hypertension in service. As noted by the Veteran's representative in the April 2013 post remand brief, the issue of entitlement to service connection for hypertension has not been adjudicated by the agency of original jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it and it is referred to the AOJ for appropriate action. The issues of entitlement to service connection for a skin-related disability of the feet, to include athlete's foot and onychomycosis, entitlement to service connection for an acquired psychiatric disorder, including major depressive disorder, and entitlement to service connection for diabetes mellitus, claimed as secondary to stroke are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Stroke residuals are related to service. 2. ED is related to service. 3. Left foot callus, also described as IPK and Morton's neuroma, did not manifest in service and is unrelated to service. CONCLUSIONS OF LAW 1. Stroke residuals were incurred in service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2012). 2. ED was incurred in service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2012). 3. Left foot callus, also described as IPK and Morton's neuroma, was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VCAA The Veterans Clams Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159. Under the VCAA, VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must request that the claimant provide any evidence in his possession that pertains to the claim. Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004); 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). The United States Court of Appeals for Veterans Claims (Court) has also held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 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/Hartman v. Nicholson, 19 Vet. App. 473 (2006). As the Board is granting the claims for entitlement to service connection for stroke residuals and ED, further discussion of the VCAA is unnecessary with regard to these claims. Wensch v. Principi, 15 Vet. App. 362, 367-368 (2001). As to the remaining claim being decided herein, for entitlement to service connection for left foot callus, also described as IPK and Morton's neuroma, in an October 2004 pre-rating letter, the RO notified the Veteran of the evidence needed to substantiate the claim for entitlement to service connection for left foot callus. This letter also satisfied the second and third elements of the duty to notify by delineating the evidence VA would assist in obtaining and the evidence it was expected that he would provide. Quartuccio v. Principi, 16 Vet. App. 183, 186-87 (2002); Charles v. Principi, 16 Vet. App. 370 (2002). For claims pending before VA on or after May 30, 2008, 38 C.F.R. § 3.159 was amended to eliminate the requirement that VA request that a claimant submit any evidence in his or her possession that might substantiate the claim. 73 Fed. Reg. 23,353 (Apr. 30, 2008). In any event, the October 2004 letter complied with this requirement. The Veteran has substantiated his status as a veteran. The Veteran was not given notice of the other Dingess elements. As claim for entitlement to service connection for left foot callus is being denied, no new disability rating or effective date is being assigned. Consequently, any question of non-compliance or prejudice with regard to the Dingess notice requirements regard is moot. The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). In this case, VA obtained the Veteran's service treatment records (STRs) and all of the identified post-service private and VA treatment records. In its August 2011 remand, the Board instructed that the RO obtain outstanding VA treatment records, including those of the Biloxi, Mississippi New Orleans, Louisiana, and Mobile, Alabama VA Medical Centers (VAMCs). The RO obtained these records and therefore complied with the Board's remand instructions and its duty to assist in this regard. Stegall v. West, 11 Vet. App. 268, 271 (1998). The RO also afforded the Veteran a VA examination as to the nature and etiology of his left foot callus. For the reasons stated below, the November 2011 VA examination and a November 2012 opinion obtained in connection with this examination are adequate to decide this claim and therefore complied with the Board's remand instructions. For the reasons set forth above, the Board finds that VA has complied with the VCAA's notification and assistance requirements. The claims for entitlement to service connection for stroke residuals, ED, and left foot callus, also characterized as IPK and Morton's neuroma, are thus ready to be considered on the merits. Analysis Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service disease, injury, or event; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). Pursuant to 38 C.F.R. § 3.303(b), where a chronic disease is shown as such in service, subsequent manifestations of the same chronic disease are generally service connected. If a chronic disease is noted in service but chronicity in service is not adequately supported, a showing of continuity of symptomatology after separation is required. Entitlement to service connection based on chronicity or continuity of symptomatology pursuant to 38 C.F.R. § 3.303(b) applies only when the disability for which the Veteran is claiming compensation is due to a disease enumerated in the list of chronic diseases in 38 U.S.C.A. § 1101(3) or 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Stroke Residuals With regard to stroke residuals, the evidence reflects that the Veteran suffered a stroke in August 2004 and has had residual symptoms. For example, a July 2006 University of South Alabama Hospital discharge summary indicated that the Veteran had a history of stroke in 2004 with residual right sided weakness. February and July 2006 treatment notes from the same facility note continued stroke residuals. As the Veteran has had a stroke and residuals since filing his August 2004 claim, he has met the current disability requirement. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (the presence of a disability at the time of filing of a claim or during its pendency warrants a finding that the current disability requirement has been met, even if the disability resolves prior to the Board's adjudication of the claim). In addition, the STRs contain a diagnosis of significant carotid atherosclerosis in June 1995. The Veteran has also had high cholesterol readings during and since service, including a diagnosis of hypercholesterolemia in December 1992. Moreover, he submitted a medical publication indicating a risk of stroke with high cholesterol in patients with diabetes, and the Veteran has been diagnosed with diabetes, as discussed below. Finally in this regard, a June 1995 ultrasound report indicated that the Veteran had significant carotid atherosclerosis. Subsequent radiology report and discharge summary indicated, however, that systolic function was normal with no aortic sclerosis and cardiac catherization revealed clean carotid arteries. The Veteran has therefore established the existence of an in-service disease or event. The only remaining question is whether current stroke residuals are related to the in-service disease or event. The June 2007 VA examiner, diagnosed an old, frontal lobe cerebrovascular accident and right sided weakness, residual of old left frontal cerebrovascular accident. He noted that the in-service testing reflected that it was not likely that the Veteran had significant vascular atherosclerosis in service and concluded that the Veteran's long term cigarette use aggravated the effects of his elevated cholesterol beyond the expected course and resulted in progression to stroke in 2004. In contrast, in November 2012, the VA physician who was asked to review the October 2011 VA brain and spinal cord examination report and the remainder of the claims file noted the Veteran's multiple high cholesterol and high blood pressure readings during service and concluded that it was at least as likely as not that the Veteran's in-service hypertension and elevated cholesterol contributed to his post service stroke. She noted that the medical community recognizes the high incidence of hypertension and cholesterol as leading causes of stroke, and cited a specific study in support of her conclusion. While, as noted by the RO/AMC, the Veteran is not in receipt of entitlement to service connection for hypertension, the VA physician did not simply opine that the Veteran's stroke was caused by his hypertension. Rather, she used the term hypertension as the equivalent of the documented high blood pressure readings and explained why she concluded that the Veteran's stroke was related to his in-service high blood pressure and cholesterol readings in service. The fact that hypertension is not service connected therefore does not undercut her opinion. Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2012) (medical reports must be read as a whole and in the context of the evidence of record). As the VA physician in November 201 explained the reasons for her conclusions based on an accurate characterization of the evidence, her opinion is entitled to substantial probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). The June 2007 VA examiner also explained the reasons for his conclusion. As the medical opinions on the dispositive question of whether the Veteran's stroke was related to service are of approximately even weight, the doubt created by this relative equipoise in the evidence must be resolved in the Veteran's favor. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; see also Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009). ED The Veteran has been diagnosed with ED, most recently on the October 2011 VA examination. As noted in the Board's August 2011 remand, the service treatment records indicate diagnoses of and treatment for nonspecific urethritis (July 1977), gonococcal urethritis (July 1977), burning on urination (September 1977), venereal warts in scrotal area (January 1979), abscess in the left groin area (November 1980), asymptomatic pyuria (June 1986), as well as prostatitis/ cystitis (February 1992), left testicle torsion (September 1984), epididymitis on the left (September 1984), a left epididymectomy (October 1984), and recurrent epididymitis on the left (November 1984). Moreover, the separation examination report indicated that the Veteran had a cyst at the base of his scrotum, but the examination report also indicated that an ultrasound was normal. The Veteran has therefore met the current disability and in-service disease elements and the remaining question is whether there is a nexus between the two. The only medical opinion on this question is that of the VA physician in her November 2012 opinion. The physician noted the Veteran's in-service high blood pressure and the high degree of correlation between ED and idiopathic hypertension. She cited a study in support of this assertion. She also noted lifestyle factors such as obesity as well as lower urinary tract symptoms that have been linked to the development of ED. She therefore concluded there was sufficient evidence to warrant a conclusion that there was a nexus between the Veteran's ED and service. The Board again notes that, while the physician referred to the Veteran's hypertension, the context of her remarks reflects that she was doing so based on the high blood pressure readings and not the assumption that the Veteran had been granted service connection for hypertension. Acevedo, 25 Vet. App. at 294. As the VA physician explained the reasons for her conclusion that ED was related to service, this conclusion is entitled to substantial probative weight. See Nieves-Rodriguez, 22 Vet. App. at 304. Moreover, because this was the only medical opinion on the dispositive nexus question on this issue, the weight of the evidence supports entitlement to service connection for ED. Left Foot Callus The Veteran has been diagnosed with a left foot callus, also characterized as IPK and Morton's neuroma, in VA treatment notes including in November 2010 and on the November 2011 VA examination. He has thus met the current disability requirement. The Veteran claims that he developed his callus as a result of the requirement of wearing combat boots for over 15 hours per day. More generally, the Veteran stated that he wore socks and boots constantly during service and has continuous foot symptomatology since service, including treatment in service. The extensive service treatment records do not contain any references to left foot callus or related symptoms, while they do contain references to right leg and left knee symptoms, as well as dermatitis on the hand. Moreover, the July 1996 retirement examination report indicated that the feet were normal, and the Veteran indicated on the contemporaneous report of medical history that he did not have and had never had foot trouble. The Veteran is competent to testify as to observations, such as the wearing of boots and socks and a resulting left foot or related disorder, but his testimony must be weighed against the other evidence of record. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). In this case, the Board finds that the weight of the evidence reflects the absence of left foot callus or related disorders in service or at separation. The Veteran's statement to a health care provider at the time of separation is of greater probative weight than his statements made many years later during the course of an appeal from the denial of compensation benefits. See Pond v. West, 12 Vet. App. 341, 345 (1999); Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (interest may affect the credibility of testimony). See also Fed. R. Evid. 803(4) (noting that statements made to physicians for the purposes of diagnosis and treatment are exceptionally trustworthy and not excluded by the hearsay rule because the declarant has a strong motive to tell the truth in order to receive proper care); Rucker v. Brown, 10 Vet. App. 67, 73 (1997) ("[R]ecourse to the [Federal] Rules [of Evidence] is appropriate where they will assist in the articulation of the Board's reasons.")). In addition, the normal examination of the feet at separation weighs against a finding of a left foot disorder or symptoms in service. Finally, the presence in the STRs of symptoms of the lower extremities as well as skin symptoms, combined with the absence of notation of foot symptoms also weighs against a finding of foot symptoms in service. Buczynski v. Shinseki, 24 Vet. App. 221 (2011) (citing Fed. R. Evid. 803(7) for the proposition that the absence of an entry in a record may be evidence against the existence of a fact if it would ordinarily be recorded); Kahana v. Shinseki, 24 Vet.App. 428, 440 (2011) (Lance, J., concurring) (clarifying that the absence of evidence is not negative evidence unless it is the type of information that would necessarily have been recorded). With regard to continuity of symptomatology, even if the Veteran's testimony were credible in this regard, left foot callus, IPK and Morton's neuroma are not listed as chronic diseases in 38 U.S.C.A. § 1101(3) or 38 C.F.R. § 3.309(a). The chronicity and continuity provisions of 38 C.F.R. § 3.303(b) are therefore not for application. Walker, 708 F.3d at 1338. The only remaining question is whether the left foot callus, IPK, and Morton's Neuroma diagnosed after service is related to service. The only two opinions on this question are that of the Veteran and the doctor of podiatric medicine (DPM) who prepared the November 2012 opinion as an addendum to the November 2011 foot examination. The DPM indicated that she reviewed the clinical files including updated C&P examinations, CAPRI, and medical records. She concluded that it was "less likely than not" that the claimed foot disability was incurred in or caused by the Veteran's service. She explained that the comprehensive review of the clinical file and medical records does not provide sufficient active duty documentation to substantiate the development of an IPK or Morton's neuroma while in service, as the service records lacked sufficient evidence of trauma or structural deformities over his 20 years in service. As the DPM explained the reasons for her conclusion based on an accurate characterization of the evidence of record, her opinion is entitled to substantial probative weight. See Nieves-Rodriguez, 22 Vet. App. at 304. Although she did not specifically reference the Veteran's statements indicating treatment in service, she implicitly found that any such treatment was not significant enough to indicate an in-service disease, injury, or event that would warrant the conclusion that the current disability is related to it. See Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012) (the fact that the rationale provided by an examiner "did not explicitly lay out the examiner's journey from the facts to a conclusion," did not render the examination inadequate); Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2012) (medical reports must be read as a whole and in the context of the evidence of record). The only other opinion is that of the Veteran, who indicated that the extensive wearing of socks and boots caused the left foot symptoms from which he currently suffers. Veterans are competent to opine as to some matters of diagnosis and etiology, and the Board must determine on a case by case basis whether a veteran's particular disability is the type of disability for which lay evidence is competent. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Kahana v. Shinseki, 24 Vet. App. 428, 433, n. 4 (2011). In this case, the Veteran's testimony that the cause of his left foot callus was the extensive wearing of boots and socks in service appears to be testimony as to an internal medical process that took place over time and which extends beyond an immediately observable cause-and-effect relationship that is of the type that the courts have found to be beyond the competence of lay witnesses. Compare Jandreau, 492 F.3d at 1376 (lay witness capable of diagnosing dislocated shoulder); Barr v. Nicholson, 21 Vet. App. 303, 308-9 (2007); Falzone v. Brown, 8 Vet. App. 398, 403 (1995) (lay person competent to testify to pain and visible flatness of his feet); with Clemons v. Shinseki, 23 Vet. App. 1, 6 (2009) ("It is generally the province of medical professionals to diagnose or label a mental condition, not the claimant"); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis); Jandreau, 492 F.3d at 1377, n. 4 ("sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer"). See also Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir.2010) (recognizing that in some cases lay testimony "falls short" in proving an issue that requires expert medical knowledge). To the extent that the Veteran's testimony on this question is competent, the Board finds that the specific, reasoned opinion of the DPM in November 2012 is of greater probative weight than the Veteran's more general lay assertions. For the foregoing reasons, the preponderance of the evidence is against the claim for entitlement to service connection for left foot callus, also described as IPK and Morton's neuroma. The benefit-of-the-doubt doctrine is therefore not for application, and the claim must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; see also Fagan, 573 F.3d at 1287. ORDER Entitlement to service connection for residuals of a stroke is granted. Entitlement to service connection for an erectile dysfunction (ED) is granted. Entitlement to service connection for left foot callus, also characterized as IPK and Morton's neuroma, is denied. REMAND In addition to his left foot callus, IPK, and Morton's neuroma, the Veteran has also been diagnosed with athlete's foot and onychomycosis. The DPM did not, however address whether these foot disabilities were related to service. It does not appear that these disorders were addressed on the November 2011 VA examination and a new foot examination, which focuses on skin-related disorders of the feet, is warranted. As to the claim for entitlement to service connection for diabetes, that disability was claimed as secondary to stroke. The claim was denied because entitlement to service connection for stroke had not been established. 38 C.F.R. § 3.310(a),(b) (entitlement to service connection warranted for disability proximately due to, the result of, or aggravated by, service connected disease or injury). As the Board has granted entitlement to service connection for stroke residuals in the decision above, a remand is required for consideration of entitlement to service connection for diabetes secondary to stroke, to be preceded by a VA examination as to whether the stroke either caused or aggravated the diabetes. 38 C.F.R. § 3.159(c)(4)(i)(C) (examination warranted where evidence indicates disability may be associated with another service connected disability). As to the claim for entitlement to service connection for an acquired psychiatric disorder including major depressive disorder, the Veteran indicated during the November 2011 VA psychiatric examination that pain from his service connected back disability was a cause of his depression. No opinion was offered as to whether depression is caused or aggravated by service-connected back disability. In addition, as noted by the Veteran's representative in the April 2013 post-remand brief, the November 2011 VA examiner's opinion was somewhat unclear, focusing on seemingly irrelevant inconsistencies in the Veteran's statements as to how many times he was charged with public intoxication, and not addressing the fact that VA treatment records reflect psychiatric treatment in 2001 and diagnosis of major depressive disorder in January 2002, prior to any public intoxication charges. Although service connection is not available on a continuity of symptomatology basis for major depressive disorder or any non-psychotic psychiatric disorder, treatment four years after service is a relevant consideration in determining whether there is a nexus between current psychiatric disability and service. A new opinion should therefore be obtained from the November 2011 VA psychiatric examiner. Accordingly, the claims for entitlement to service connection for a skin-related disability of the feet, to include athlete's foot and onychomycosis, entitlement to service connection for an acquired psychiatric disorder, including major depressive disorder, and entitlement to service connection for diabetes mellitus, claimed as secondary to stroke, are REMANDED for the following action: 1. Schedule the Veteran for a VA examination as to the nature and etiology of any skin-related disorders of the feet, to include athlete's foot (also known as ringworm of the foot and tinea pedis) and onychomycosis. All necessary tests should be conducted. The claims file must be sent to the examiner for review. The examiner should indicate whether it is as least as likely as not (50 percent probability or more) that any skin-related disorder of the feet is related to the Veteran's service. A complete rationale should accompany any opinion provided. The examiner is advised that the Veteran is competent to report symptoms, treatment, and injuries, and that his reports must be taken into account, along with the other evidence of record, in formulating the requested opinions. 2. Schedule the Veteran for a VA examination as to the etiology of his diabetes. All necessary tests should be conducted. The claims file must be sent to the examiner for review. The examiner should indicate whether it is as least as likely as not (50 percent probability or more) that the Veteran's diabetes is either caused OR aggravated (i.e., made worse) by his service-connected stroke residuals. A complete rationale should accompany any opinion provided. The examiner is advised that the Veteran is competent to report symptoms, treatment, and injuries, and that his reports must be taken into account in formulating the requested opinion. 3. Obtain an opinion from the psychologist who prepared the November 2011 VA examination report. If the psychologist is unavailable another psychologist or psychiatrist should be asked the following: a. Is it as least as likely as not (50 percent probability or more) that the Veteran's major depressive disorder (or other acquired psychiatric disorder) is either caused OR aggravated (i.e., made worse) by his service-connected back disability. b. Regardless of any inconsistencies in the Veteran's statements as to his public intoxication arrests, is his current major depressive or related disorder related to service, to include consideration of the fact that psychiatric treatment began as early as 2001. 4. After the above development has been completed, readjudicate the claims for entitlement to service connection for a skin-related disability of the feet, to include athlete's foot and onychomycosis, entitlement to service connection for an acquired psychiatric disorder including major depressive disorder, and entitlement to service connection for diabetes mellitus, claimed as secondary to stroke. If any benefit sought on appeal remains 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 matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims 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). ______________________________________________ J. SMITH Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs