Citation Nr: 1318063 Decision Date: 06/04/13 Archive Date: 06/11/13 DOCKET NO. 09-35 908 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to a rating in excess of 30 percent for posttraumatic stress disorder (PTSD) prior to January 5, 2011. 2. Entitlement to a rating in excess of 70 percent for PTSD after January 5, 2011. 3. Whether new and material evidence has been presented to reopen a service connection claim for low back pain, claimed as low back condition, and if so, whether service connection may be granted. 4. Whether new and material evidence has been presented to reopen a service connection claim for headaches and if so, whether service connection may be granted. 5. Entitlement to an effective date prior to April 2, 2010, for the award of a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). 6. Entitlement to service connection for sinus infection. 7. Entitlement to service connection for cataracts secondary to diabetes mellitus. 8. Entitlement to service connection for hypertension secondary to diabetes mellitus. 9. Whether new and material evidence has been presented to reopen a service connection claim for sleep apnea and if so, whether service connection may be granted. REPRESENTATION Veteran represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD Laura E. Collins, Associate Counsel INTRODUCTION The Veteran served on active duty from October 1960 to May 1968, including service in the Republic of Vietnam. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions issued in December 2006, June 2007, and September 2008 by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. The December 2006 rating decision declined to reopen a previously-denied claim for service connection for low back pain, claimed as low back condition. The June 2007 rating decision continued a 30 percent rating for PTSD. The September 2008 rating decision declined to reopen a previously-denied claim for service connection for migraine headaches. In a December 2012 rating decision the RO granted a rating increase to 70 percent disability for PTSD, effective January 5, 2011. In his September 2009 substantive appeal, the Veteran requested a hearing before a Veterans Law Judge (VLJ). Shortly thereafter, he withdrew that request and asked for a hearing before a Decision Review Officer instead. A hearing was scheduled for May 2010 but the Veteran requested that it be cancelled. As such, his hearing request is deemed withdrawn. The United States Court of Appeals for Veterans Claims (Court) has held that "a claimant's identification of the benefit sought does not require any technical precision." Brokowski v. Shinseki, 23 Vet. App. 79, 85 (2009); see also Ingram v. Nicholson, 21 Vet. App. 232, 256-57 (2007) ("It is the pro se claimant who knows what symptoms he is experiencing and that are causing him disability, .... [and] it is the Secretary who knows the provisions of title 38 and can evaluate whether there is a potential under the law to compensate an averred disability based on a sympathetic reading of the material in a pro se submission." (citations omitted)). The Veteran filed a claim for service connection for migraines. The evidence of record shows the Veteran has been diagnosed with various types of headaches, but not migraines. The Veteran's submissions show intent to establish service connection for his headaches, and not only for migraines. Therefore, the Board has recharacterized the issue as shown on the title page. By way of background, a January 2006 rating action granted service connection for PTSD, assigning an initial disability rating of 30 percent effective September 13, 2005. Within one year of this determination, the Veteran did not express disagreement with this initial disability evaluation, nor was any relevant new and material evidence, medical or lay, physically or constructively received by VA prior to the expiration of the appellate period. See 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. §§ 3.156(b); 20.201 (2012); Buie v. Shinseki, 24 Vet. App. 242, 251-52 (2011). As such, the January 2006 rating action became final. The RO reopened the Veteran's claims of entitlement to service connection for low back pain and migraines and denied them on the merits in the August 2007 statement of the case and June 2010 supplemental statement of the case, respectively. However, prior to consideration of the Veteran's claim on the merits, the Board is required to consider the issue of finality, and as such, the issue has been characterized as shown on the title page. See 38 U.S.C.A. §§ 5108, 7104(b); Jackson v. Principi, 265 F.3d 1366, 1369 (Fed. Cir. 2001). As discussed in further detail below, the Board is reopening the claims for service connection because new and material evidence has been received; however, as further development is needed prior to adjudication, the merits of the issues are addressed in the REMAND portion of the decision below and these claims are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, D.C. FINDINGS OF FACT 1. For the period prior to June 3, 2010, the preponderance of the evidence is against a rating in excess of 30 percent for the Veteran's PTSD. During that period, the Veteran's PTSD was manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal) as the result of mild short-term memory loss; depressed mood without panic attacks; chronic sleep impairment; some flattened affect; some difficulty with social and work relationships; normal and clear speech; understanding of complex commands; good long-term memory; fair judgment; and normal abstract thinking; without more severe manifestations that more nearly approximate occupational and social impairment with reduced reliability and productivity. 2. For the period from June 3, 2010 to January 5, 2011, the preponderance of the evidence is against a rating in excess of 50 percent for the Veteran's PTSD. During that period, the Veteran's PTSD was manifested by occupational and social impairment with reduced reliability and productivity as the result of difficulty establishing and maintaining effective work and social relationships; some difficulty adapting to stressful circumstances; maintenance of minimal personal hygiene; normal speech; disturbances of motivation and mood; fleeting passive suicidal ideation without intent or plans; and anger and irritability; without more severe manifestations that more nearly approximate occupational and social impairment with deficiencies in most areas. 3. After January 5, 2011, the preponderance of the evidence is against a rating in excess of 70 percent for the Veteran's PTSD. Since that date, the Veteran's PTSD was manifested by occupational and social impairment with deficiencies in most areas as the result of an inability to establish or maintain effective work relationships; impaired impulse control; and difficulty adapting to stressful circumstances including work; without any of the more severe manifestations that more nearly approximate total occupational and social impairment. 4. A rating decision issued in December 2001 denied service connection for low back pain. Following receipt of notification of this determination, the Veteran did not timely perfect an appeal, and the decision became final. 5. The evidence received since the December 2001 rating decision is new and raises a possibility of substantiating the claim for service connection for low back pain. 6. A rating decision issued in December 2001 denied service connection for migraines. Following receipt of notification of this determination, the Veteran did not timely perfect an appeal, and the decision became final. 7. The evidence received since the December 2001 rating decision is new and raises a possibility of substantiating the claim for service connection for headaches. 8. The veteran was employed in a full-time job through at least June 3, 2010, and thus his service-connected PTSD did not preclude him from securing or following substantially gainful employment before April 2, 2010. 9. On May 3, 2010, prior to the promulgation of a decision in the appeal, the Board received notification from the Veteran that a withdrawal of the appeal of the issue of entitlement to service connection for sinus infection is requested. 10. On May 3, 2010, prior to the promulgation of a decision in the appeal, the Board received notification from the Veteran that a withdrawal of the appeal of the issue of entitlement to service connection for cataracts secondary to diabetes mellitus is requested. 11. On May 3, 2010, prior to the promulgation of a decision in the appeal, the Board received notification from the Veteran that a withdrawal of the appeal of the issue of entitlement to service connection for hypertension secondary to diabetes mellitus is requested. 12. On May 3, 2010, prior to the promulgation of a decision in the appeal, the Board received notification from the Veteran that a withdrawal of the appeal of the issue of entitlement to service connection for sleep apnea is requested. CONCLUSIONS OF LAW 1. Prior to June 3, 2010, the criteria for a rating in excess of 30 percent for PTSD were not met. 38 U.S.C.A. §§ 1154(a), 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2012). 2. For the period from June 3, 2010 to January 5, 2011, the criteria for a rating in excess of 50 percent for PTSD were not met. 38 U.S.C.A. §§ 1154(a), 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2012). 3. After January 5, 2011, the criteria for a rating in excess of 70 percent for PTSD have not been met. 38 U.S.C.A. §§ 1154(a), 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2012). 4. The unappealed December 2001 rating decision that denied service connection for low back disability is final. 38 U.S.C.A. §§ 7105 (West 2002); 38 C.F.R. §§ 20.302, 20.1103 (2012). 5. New and material evidence has been received to reopen a claim of entitlement to service connection for low back disability. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156 (2012). 6. The unappealed December 2001 rating decision that denied service connection for migraines is final. 38 U.S.C.A. §§ 7105 (West 2002); 38 C.F.R. §§ 20.302, 20.1103 (2012). 7. New and material evidence has been received to reopen a claim of entitlement to service connection for headaches. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156 (2012). 8. An effective date earlier than April 2, 2010, for the award of a TDIU is not warranted. 38 U.S.C.A. § 5110 (West 2002); 38 C.F.R. §§ 3.400, 4.16 (2012). 9. The criteria for withdrawal of an appeal of the issue of entitlement to service connection for sinus infection by the Veteran have been met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. § 20.204 (2012). 10. The criteria for withdrawal of an appeal of the issue of entitlement to service connection for cataracts secondary to diabetes mellitus by the Veteran have been met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. § 20.204 (2012). 11. The criteria for withdrawal of an appeal of the issue of entitlement to service connection for hypertension secondary to diabetes mellitus by the Veteran have been met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. § 20.204 (2012). 12. The criteria for withdrawal of an appeal of the issue of entitlement to service connection for sleep apnea by the Veteran have been met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. § 20.204 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Withdrawal of Appeals The Board may dismiss any appeal that fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C.A. § 7105 (West 2002). An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204 (2012). Withdrawal may be made by the Veteran or by his or her authorized representative. 38 C.F.R. § 20.204. In the present case, in a signed statement dated May 3, 2010, the Veteran has withdrawn the appeals of the issues of entitlement to service connection for sinus infection, cataracts secondary to diabetes mellitus, hypertension secondary to diabetes mellitus, and sleep apnea. Hence, there remain no allegations of errors of fact or law for appellate consideration. Accordingly, the Board does not have jurisdiction to review these appeals and they are dismissed. II. VA's Duty to Notify and Assist As the Board's decision to reopen the claims for service connection for low back pain and headaches herein is completely favorable, no further action is required with respect to these issues to comply with the Veterans Claims Assistance Act of 2000 (VCAA) and the implementing regulations. Consideration of the merits of these claims is deferred pending additional development consistent with the VCAA. As to the issue of an earlier effective date for the TDIU, the application of the law to the undisputed facts is dispositive; thus no discussion of VA's duties to notify and assist is necessary. Mason v. Principi, 16 Vet. App. 129 (2002). The VCAA and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper VCAA notice 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; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). The notice requirements apply to all five elements of a service connection claim, including Veteran status, existence of a disability, a connection between the Veteran's service and the disability, degree of disability, and effective date of the disability. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2012); Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Notice must be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on the claim for VA benefits. 38 U.S.C.A. § 5103(a) (West 2002); Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, the VCAA notice requirements may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Id. As to the Veteran's increased rating claim for PTSD, a March 2007 letter provided notice, before the initial unfavorable decision in June 2007, regarding what information and evidence was needed to substantiate his claim for increased rating, as well as what information and evidence must be submitted by the Veteran and what information and evidence will be obtained by VA. The same letter advised him of the information and evidence necessary to establish a disability rating and an effective date in accordance with Dingess/Hartman, supra. VA also has a duty to assist the Veteran in the development of the claim. This duty includes assisting the Veteran in the procurement of service treatment records, pertinent treatment records, and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Veteran's service treatment records, private medical records, and VA treatment records have been obtained. He has not identified any additional outstanding records that VA should seek to obtain on his behalf. The Veteran was provided with VA PTSD examinations in October 2001, November 2005, May 2007, January 2008, June 2010, and July 2011. He has not alleged that such are legally inadequate for adjudication purposes. Moreover, the Board finds that the examinations are adequate in order to evaluate the Veteran's service-connected PTSD as they include interviews with the Veteran and review of the claims file. The Veteran has not alleged, nor does the record show, that his service-connected PTSD has worsened in severity since the most recent examination in 2011. As such, a new examination is not required. See Palczewski v. Nicholson, 21 Vet. App. 174 (2007). The Board finds that all relevant facts have been properly developed, and all reasonable efforts were made by VA to obtain evidence necessary to substantiate the Veteran's claim, and no further assistance to develop evidence is required. Therefore, the Veteran will not be prejudiced as a result of the Board proceeding to the merits of his claim. III. Reopening Claims The Veteran seeks to reopen his previously denied claims of entitlement to service connection for low back pain and headaches. Where, as here, a claim of entitlement to service connection has been previously denied and that decision has become final, the claim can be reopened and reconsidered only if new and material evidence is presented with respect to that claim. 38 U.S.C.A. § 5108 (West 2002). Moreover, where, as here, the prior final decisions were unappealed RO rating decisions, the United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that "the statutes make clear that the Board has a jurisdictional responsibility to consider whether it was proper for a claim to be reopened, regardless of whether the previous action denying the claim was appealed to the Board." Jackson. Thus, the Board must now consider whether new and material evidence has been submitted to reopen the previously denied claims. In making this determination, the Board must review all of the evidence submitted since the last final rating decisions. New evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened. 38 C.F.R. § 3.156(a). In Shade v. Shinseki, 24 Vet. App. 110, 118 (2010), the Court stated that when determining whether the submitted evidence meets the definition of new and material evidence, VA must consider whether the new evidence could, if the claim were reopened, reasonably result in substantiation of the claim. Thus, pursuant to Shade, evidence is new if it has not been previously submitted to agency decisionmakers and is material if, when considered with the evidence of record, it would at least trigger VA's duty to assist by providing a medical opinion, which might raise a reasonable possibility of substantiating the claim. Id. The Court interpreted the language of 38 C.F.R. § 3.156(a) as creating a low threshold, and viewed the phrase "raises a reasonable possibility of substantiating the claim" as enabling rather than precluding reopening. The Court emphasized that the regulation is designed to be consistent with 38 C.F.R. § 3.159(c)(4), which does not require new and material evidence with respect to each previously unproven element of a claim. Shade, supra; see also Evans v. Brown, 9 Vet. App. 273, 284 (1996) (the newly presented evidence need not be probative of all the elements required to award the claim; rather it need only be probative in regard to each element that was a specified basis for the last disallowance). Newly submitted evidence is presumed to be credible for the purpose of determining whether evidence is sufficiently new and material. See Justus v. Principi, 3 Vet. App. 510, 513 (1992); Kutscherousky v. West, 12 Vet. App. 369, 371 (1999). A rating decision issued in December 2001 denied entitlement to service connection for both low back pain and migraine headaches. The Veteran did not file a notice of disagreement with the denial of these two issues. No additional evidence pertinent to these two issues was physically or constructively associated with the claims file within one year of the rating decision. See 38 C.F.R. § 3.156(b) (2012); Bond v. Shinseki, 659 F.3d 1362 (Fed. Cir. 2011); see also Buie, supra. Thus, the December 2001 rating decision became final based on the evidence then of record. 38 U.S.C.A. §§ 7104, 7105 (West 2002); 38 C.F.R. § 20.1105 (2012). The prior evidence considered in the final December 2001 denial consisted of the Veteran's service treatment records (STRs), private treatment records from a chiropractor dated from September 1987 to September 1998, a statement from the Veteran's spouse, and lay statements from the Veteran. Since the December 2001 rating decision, new evidence added to the record consists of VA treatment records dated August 2004 to August 2005, December 2007 to March 2008, January 2009 to June 2009, and August 2010 to December 2012; private treatment records dated from December 1999 to February 2007 and July 2008; Social Security Administration records including disability evaluations of the lumbar spine dated July 2007 and September 2007; a June 2010 VA general medical examination report; a letter from private physician Dr. M; and lay statements from the Veteran. All of this evidence is new because it was not previously considered by the RO. Low back disability The basis of the final denial of service connection for low back pain was the absence of complaints, findings, or evidence of clinical treatment for a back condition in service or before September 1987, and absence of evidence that the current disability was caused by service. The new evidence includes two statements from private physicians that suggest a medical link between the Veteran's current low back disability and his in-service back complaints. Specifically, a February 2007 letter from Dr. M. states that the Veteran had been evaluated and treated by her office for degenerative joint disease and low back pain. "Upon examination and reviewing the patient['s] history of service...it is [my professional opinion that] this medical condition could be directly related. [The Veteran] was subjected to manual lifting of heavy objects over and over again, without the assistance of any machinery... for over a period of a year." Similarly, a July 2008 private treatment note from Dr. K states that the Veteran "has a history of increasing back pain starting while he was in the service with a repetitive heavy lifting type job. He has significant degenerative changes by MRI...It is likely that a lot of his pain continues to stem from the early injuries he did have, however you cannot say if other things have not likely added to this problem." The absence of nexus evidence is one of the elements of service connection upon which the prior denial was based. Accordingly, this new evidence of a link between his current back disability and service relates to an unestablished fact necessary to substantiate the claim and raises a reasonable possibility of substantiating it. It is therefore material and sufficient to reopen the previously-denied claim. Shade. The Board reopens the Veteran's claim of entitlement to service connection for low back pain for a de novo review on the merits. 38 U.S.C.A. §§ 5108, 7105; 38 C.F.R. § 3.156. The RO reopened the Veteran's claim in the August 2007 statement of the case and denied it on the merits. The Board herein reopens the Veteran's claim. Therefore, he is not prejudiced by the Board's actions herein. Bernard v. Brown, 4 Vet. App. 384, 390-92 (1993). Headaches The basis of the final denial of service connection for migraine headaches was that the evidence showed that the Veteran's headaches resolved with no residual disabling condition, and therefore migraine headaches did not occur in and were not caused by service. The new evidence includes a VA treatment record showing report of occasional headaches in December 2007. A June 2010 VA general medical examination report states that he has mild headaches twice per month, but they used to be more frequent and intense and his last severe headache was several years ago. They start in the back of the head, radiating to the front behind both eyes. The severe headaches were accompanied by sensitivity to light, sound, and smell, some nausea, and blurred vision. The VA examiner diagnosed recurrent tension headaches. The conclusion that in-service headaches resolved without residuals was the basis of the prior denial. Thus, this evidence of current disability, as well as a history of headaches that may be residual, relate to an unestablished fact necessary to substantiate the claim and raises a reasonable possibility of substantiating the Veteran's claim. It is therefore material and sufficient to reopen the previously-denied claim. Shade. The Board reopens the Veteran's claim of entitlement to service connection for headaches for a de novo review on the merits. 38 U.S.C.A. §§ 5108, 7105; 38 C.F.R. § 3.156. The RO reopened the Veteran's claim in the June 2010 statement of the case and denied it on the merits. The Board herein reopens the Veteran's claim. Therefore, he is not prejudiced by the Board's actions herein. Bernard. IV. Increased Rating Claim Disability evaluations are determined by the application of a schedule of ratings that is based on the average impairment of earning capacity. Separate diagnostic codes (DCs) identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R., Part 4. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. The Veteran's entire history is reviewed when making disability evaluations. See Schafrath v. Derwinski, 1 Vet. App. 589 (1995). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. Where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibits symptoms that would warrant different evaluations during the course of the appeal, the assignment of staged ratings is appropriate. See Fenderson v. West, 12 Vet. App. 119, 126-127 (1999); Francisco v. Brown, 7 Vet. App. 55, 58 (1994). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and recurrence of his symptoms. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau, 492 F.3d at 1376-77. The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the Federal Circuit, citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the Court has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). A. Analysis The Veteran's PTSD is rated 30 percent disabling prior to January 5, 2011, and 70 percent disabling after that date. The Veteran contends that throughout the appeal period his PTSD was more severe than the assigned ratings and that he is entitled to increased ratings. The Veteran's PTSD is rated under the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130, DC 9411 (2012). Ratings are assigned according to the manifestation of particular symptoms. The use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Thus, the evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the Diagnostic Code. VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). Under the General Rating Formula for Mental Disorders, a 30 percent rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation; obsessional rituals that interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. A 100 percent rating is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. In addition to his PTSD, VA treatment records show that during the appeal period the Veteran had additional Axis I diagnoses of depressive disorder, generalized anxiety disorder, adjustment disorder, and alcohol abuse in partial remission. When it is not possible to separate the effects of the service-connected condition from a nonservice-connected condition, such signs and symptoms must be attributed to the service-connected condition. 38 C.F.R. § 3.102 (2012); Mittleider v. West, 11 Vet. App. 181 (1998). In this case, no physician or examiner has separated the effects of the PTSD from other Axis diagnoses. Accordingly, the Board will attribute those signs and symptoms to the Veteran's service-connected PTSD. The evidence of record relevant to the appeal period includes a private treatment record dated December 2006; VA treatment records dated January 2009 to June 2009 and August 2010 to December 2012; the Veteran's lay statements; and VA examination reports dated May 2007, January 2008, June 2010, and July 2011. Following a review of that evidence, the Board concludes that the preponderance of the evidence is against a rating in excess of 30 percent for the period prior to June 3, 2010. Prior to June 3, 2010, the evidence does not show characteristics of a 50 percent rating, including circumstantial, circumlocutory, or stereotyped speech; difficulty in understanding complex commands; impairment of long-term memory; impaired judgment; or impaired abstract thinking. Rather, the Veteran's speech was normal and clear in tone, volume, and rate; his long-term memory was good; his judgment was fair; and his thought processes and perceptions were goal-oriented, logical, coherent, and relevant. He did have some problems with short-term memory and forgetting to complete tasks. As to disturbances of motivation and mood, in December 2006 his mood was "much less depressed" and his attention and concentration were impaired but functional. In May 2007 he had been "feeling his depression more" for a few years and had some sleep disturbance. He had begun noticing his anxiety and dislike of crowds in the last three years. He experienced rare crying spells, anhedonia, fatigue, and low level depression. The Veteran showed no clear signs of overt depression or anxiety during the examination, and the VA examiner noted that his fatigue was likely partially related to his untreated sleep apnea. The VA examiner stated that the Veteran described emotional numbing rather than actual major depressive episodes. The VA examiner assessed his depression as mild in both May 2007 and January 2008. In a January 2009 treatment note he had lost interest in activities and his mood was bleak and pessimistic. The Veteran did not have panic attacks. In May 2007 he had anxiety attacks in confined spaces but they did not meet the full criteria for panic attacks. There is no evidence that the Veteran's depressed mood and anxiety caused occupational or social impairment with reduced reliability and productivity prior to June 3, 2010. Therefore, these mild symptoms more closely approximate a 30 percent rating. As to other symptoms indicative of a 50 percent rating, there is evidence of flattened affect prior to June 3, 2010. A private treatment record shows restricted range of affect in December 2006 and at the May 2007 VA examination, his affect was slightly blunted. Prior to June 3, 2010, the Veteran also showed some difficulty establishing and maintaining effective work and social relationships. The Veteran told the May 2007 VA examiner that he and his spouse of 43 years got along and did not argue much. He socialized with his spouse's family to some degree, and was involved in the local VA, VFW, and DAV. Most of the time he kept to himself, but he did have a few friends. In January 2008 he reported going to VA meetings less often. In a March 2009 VA treatment note, it was reported that he directs his impatience and strain at his spouse and was sarcastic. In a May 2009 VA treatment note he reported some disharmony with his spouse because he was snippy with her. As to work relationships, he reported a history of difficulty with authority and bosses in the workplace in his prior careers. After retiring in 2004, he became self-employed and opened his own business. In January 2009 he stated that he discovered his lack of temper control after starting his own business. In May 2009 he reported telling customers to "get the h--- out of here" when irritated by them. In May 2007 the Veteran was self-employed, worked 40 hours a week, and did not miss work due to his symptoms. He stated that mild concentration problems on the job were a nuisance but did not truly impact his job performance. Short-term memory was fair and caused some mild problems on the job. He was able to generally care for himself and did not report any impairment in his activities of daily living. The May 2007 VA examiner stated that the Veteran reported only mild impact of mental health symptoms on his occupational and social functioning. The examiner concluded that the Veteran's PTSD symptoms were low-level, mild, stable, and had not significantly worsened since his last examination in November 2005. The same VA examiner evaluated the Veteran again in January 2008, and stated that overall his symptomatology was at the same level as May 2007: mild, stable, and not significantly worsened. The Board finds that the Veteran's overall disability picture and symptomatology prior to June 3, 2010, taken as a whole and in combination with the objective mental status examinations, did not more nearly approximate a rating in excess of 30 percent under the General Rating Formula. While he had some flattened affect, short-term memory problems, and difficulty with social and work relationships, the evidence shows that his symptoms were mild, low-level and stable. His symptoms were not of such a severity or frequency to result in occupational and social impairment with reduced reliability and productivity, deficiencies in most areas, or total occupational and social impairment. Rather, they resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal). A VA examination report dated June 3, 2010, shows a worsening of the Veteran's PTSD symptoms and a finding by the VA examiner that they caused occupational impairment with reduced reliability and productivity, and had at least a moderate negative effect on his social functioning. At the June 2010 examination, the Veteran reported increased anger and mood and motivation disturbances. He had lost significant interest in activities he used to enjoy, and only socialized with his grandchildren. He had "little relationship" with his spouse. As to occupational impairment, he was still working 40 hours a week at his own business but people were getting on his nerves and he was starting to lose the ability to deal with them. He had yelled at customers and lost control. At times it took a lot of self control not to get physical. His short-term memory deficits led him to forget customers and requests and he had to write everything down. He had word-finding difficulties, and felt bombarded by excessive information or demands on his attention. He was preparing to sell the business. The June 2010 VA examiner diagnosed chronic moderate PTSD and found that his function had deteriorated at least slightly since the January 2008 VA examination. Based on the foregoing, the Board finds that the Veteran's overall disability picture and PTSD symptomatology most nearly approximated a 50 percent rating, effective on June 3, 2010. From June 3, 2010 to January 5, 2011, the preponderance of the evidence does not show characteristics of a 70 percent rating, including obsessional rituals or spatial disorientation. Neither is there evidence of intermittently illogical, obscure, or irrelevant speech, nor neglect of personal appearance and hygiene. Rather, the Veteran was consistently observed to be clean, neatly groomed, able to maintain minimal personal hygiene, and capable of normal speech. Further, the evidence does not show depression during this period so severe as to be near-continuous. Nor was the Veteran unable to establish and maintain effective relationships during this period. While he had difficulty doing so, the evidence shows that he maintained relationships with his grandchildren and spouse. The Veteran had some difficulty in adapting to stressful circumstances (including work), from June 3, 2010 to January 5, 2011. In 2008 he lost his home, his spouse was diagnosed with cancer, and they had to move into a trailer behind his business. He continued to run his own business, but with increasing difficulty and customer altercations. Prior to this period, he had been active with the local VA and occasionally with DFW and DAV. He had enjoyed fishing and other activities, but by June 2010 he no longer did any of these things. VA treatment records and examination reports show that the Veteran was engaged in mental health treatment and anger management during this period. As to other symptoms indicative of a 70 percent rating, the Veteran denied suicidal ideation and intent throughout the appeal period, with a few exceptions. In May 2007 he reported mild passive fleeting thoughts of suicide, but had never acted on them and had no impulses or plans to act on them. In January 2009 he had thought it would be nice not to wake up but felt responsible to and for his spouse and his religion forbade suicide. In June 2010 he repeated the wish of not waking up but had responsibility to his grandchildren, spouse, and religion. Thus, at most, the Veteran had fleeting passive suidical ideation without intent or plans. The Veteran reported in May 2007 that he had anger problems and would yell and scream but was not physically aggressive. In January 2008 he reported irritability. In a May 2009 VA treatment note he reported being pushed over the limit by a customer twice in the last week, getting snippy with his spouse, and having a sharp tone despite attempts to maintain his composure. This left him upset for a few days, but he felt that it was okay and "not a problem in his life." Anger management treatment was recommended and undergone. In June 2010 he reported a lot of anger, road rage, short fuse, irritability with even simple questions, and yelling at customers. It took a lot of control sometimes for him not to become physically aggressive. He stated that five years ago he had homicidal ideation but not more recently. While the evidence shows an increase in anger and impaired impulse control from May 2007 to June 2010, it does not show the unprovoked irritability with periods of violence that are characteristic of a 70 percent rating. Based on the foregoing, the Board does not find that the Veteran's social and occupational impairment results in deficiencies in most areas. While he exhibits some deficiencies is the areas of work, spousal relations, and mood, these deficiencies are contemplated by the 50 percent rating. His impairment prior to January 5, 2011, most closely approximates reduced reliability and productivity. The RO granted a 70 percent rating effective January 5, 2011. The Board also finds that the Veteran's symptoms warrant a 70 percent rating effective on this date. A July 2011 VA examination shows that the Veteran had closed his business due to anger issues because interacting with people was so difficult. He preferred to be alone and did not like to socialize with anyone, including family. He tolerated his two children but was not close to them. He was grumpy, moody, and irritable most of the time. He was angry daily for at least an hour, had nightmares and intrusive memories once or twice a week, and sleep disturbance every night. He argued with his spouse a lot, but described their relationship as "fair." This VA examination report shows a worsening of the Veteran's PTSD symptoms from the June 2010 examination, and, as a result, increased occupational and social impairment. His inability to continue his business due to interpersonal difficulty is especially notable, suggesting that had become unable to establish or maintain effective work relationships. After January 5, 2011, the evidence does not show any of the characteristics of a 100 percent rating, including: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Moreover, the Veteran is not totally occupationally and socially impaired. The July 2011 VA examiner stated that he could work in a job with no social contact, and his relationship with his spouse was fair. Therefore, the Board finds that the Veteran's symptomatology most closely approximates a 70 percent rating effective January 5, 2011. The evidence also shows that the Veteran has additional symptomatology that is not enumerated in the rating criteria, including intrusive thoughts, nightmares, avoidant behavior, hypervigilance, and exaggerated startle response. However, the symptoms listed in the disability rating criteria are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan. The Board has also considered the Veteran's Global Assessment of Function (GAF) scores assigned during the course of the appeal. The GAF is a scale indicating the psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness. A GAF score between 31and 40 indicates some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work). GAF scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). A GAF score between 51and 60 indicates moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or coworkers). GAF scores of 61 to 70 are indicative of some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, with some meaningful interpersonal relationships. A GAF score is highly probative as it relates directly to the Veteran's level of impairment of social and industrial adaptability, as contemplated by the rating criteria for mental disorders. DSM-IV; Massey v. Brown, 7 Vet. App. 204, 207 (1994). VA treatment records show that during the appeal period Veteran was assigned GAFs ranging from 45 to 60. Therefore, the Veteran's scores indicate moderate to serious symptoms. The Board finds that the Veteran's symptomatology is accurately reflected in the staged ratings assigned by the Board that reflect his symptoms worsening over time. In sum, the Board finds that the preponderance of the evidence is against a rating in excess of 30 percent for his PTSD prior to June 3, 2010. From June 3, 2010 to January 4, 2011, a rating of 50 percent, but no higher, is warranted. Effective January 5, 2011, a rating of 70, but no higher, is warranted. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). B. Other considerations The Board has considered whether staged ratings are appropriate for the Veteran's service-connected disability, and has assigned them accordingly. See Fenderson; Francisco. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321. The Court has set out a three-part test, based on the language of 38 C.F.R. § 3.321(b)(1), for determining whether a Veteran is entitled to an extraschedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant's disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extraschedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The Board finds that the rating criteria contemplate the Veteran's disability. The Veteran's PTSD is characterized by occupational and social impairment of varying levels due to such symptoms as depressed mood, anxiety, suspiciousness, chronic sleep impairment, short term memory loss, disturbances of mood and motivation, difficulty in establishing and maintaining effective social relationships, flattened affect, suicidal ideation, irritability and anger, and difficulty in adapting to stressful circumstances. These manifestations are contemplated in the applicable rating criteria. The Board has carefully compared the level of severity and symptomatology of the Veteran's PTSD with the criteria found in the rating schedule. The Board has also considered symptoms of intrusive thoughts, nightmares, avoidant behavior, hypervigilance, and exaggerated startle response, which are not found in the rating schedule. In sum, the Board finds that the Veteran has not described other functional effects that are "exceptional" or not otherwise contemplated by the assigned evaluation. Rather, his descriptions of PTSD symptoms are consistent with the degree of disability addressed by such evaluation. The rating criteria are therefore adequate to evaluate the Veteran's disability and referral for consideration of an extraschedular rating is not warranted. V. Earlier effective date for a TDIU The Veteran was granted individual unemployability (IU) effective April 2, 2010. The Court has held that entitlement to a TDIU is an element of all appeals for a higher rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). Here, the medical and lay evidence uniformly shows that the veteran was self-employed on a full-time basis during the appeal period through at least June 3, 2010, and the Veteran does not contend otherwise. The VA PTSD examination report of the same date shows he was still working 40 hours per week, though he was planning to sell his business. VA treatment records show that by October 2010 he reported his lawnmower mechanic work to be only a hobby, and by the July 2011 VA examination, he had closed his business. Thus, because the undisputed facts show that the veteran was employed on a full-time basis prior to April 2, 2010, the date his IU became effective, there is no entitlement under the law to the benefit sought. Accordingly, his claim must be denied as a matter of law. See Sabonis v. Brown, 6 Vet App 426 (1994); see Faust v. West, 13 Vet. App. 342, 356 (2000). ORDER For the period prior to June 3, 2010, a rating in excess of 30 percent for PTSD is denied. From June 3, 2010 to January 5, 2011, a 50 percent disability evaluation, and no higher, for PTSD is granted, subject to the law and regulations governing the payment of VA monetary benefits. Effective January 5, 2011, a rating in excess of 70 percent for PTSD is denied. New and material evidence has been received to reopen the claim of entitlement to service connection for low back disability; to this extent, the appeal is granted. New and material evidence has been received to reopen the claim of entitlement to service connection for headaches; to this extent, the appeal is granted. An effective date prior to April 2, 2010, for the award of a TDIU is denied. The appeal of the issue of entitlement to service connection for sinus infection is dismissed. The appeal of the issue of entitlement to service connection for cataracts secondary to diabetes mellitus is dismissed. The appeal of the issue of entitlement to service connection for hypertension secondary to diabetes mellitus is dismissed. The appeal of the issue of entitlement to service connection for sleep apnea is dismissed. REMAND Reopening the service connection claims does not end those inquiries. Rather, the claims must now be considered on the merits. For the reasons that follow, the Board finds that the claims must be remanded. VA's duty to assist includes a duty to provide a medical examination or obtain a medical opinion where it is deemed necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). The Board may order an examination when the record shows that the Veteran has a current disability, indicates that this disability may be associated with the Veteran's active service, and does not contain sufficient evidence for the Board to make a decision on the issue. 38 U.S.C.A. § 5103A(d)(2); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Veteran's separation examination dated 1968 indicates recurrent back pain. His entrance examination is silent for any back diagnoses, complaints, or treatment. While the Veteran had a car accident prior to service, he has reported via lay statement and to various medical professionals that his low back was not injured in that accident; rather his low back pain began during service as the result of a long-term assignment that required repetitive heavy lifting. Two physicians have stated that his current low back pain may be directly related to his in-service injury. Accordingly, the Board finds a medical examination is necessary to address whether his current low back disability is related to service. McLendon. The Veteran's service treatment records show complaints of and treatment for headaches. The Veteran and his spouse both reported via lay statement that his headaches continued after service, and treatment records show reports of headaches during the appeal period. The Veteran has claimed that his headaches began in service, and alternately that they are related to or aggravated by his service-connected diabetes mellitus. The June 2010 VA examiner diagnosed recurrent tension headaches but opined that they were less likely than not related to service or diabetes. His rationale for this opinion was that the Veteran's headaches "now are a lot less frequent and a lot less intense than they used to be." This rationale fails to explain 1) why the headaches would not be related to or aggravated by his service-connected disability, and 2) why less frequent and intense current headaches are not related to the headaches documented in service. Therefore, this medical opinion is inadequate. Once VA undertakes the effort to provide an examination, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Therefore a remand is necessary to obtain a VA examination with medical opinion, following claims file review, as to whether the current headaches are related to service, including as secondary to service-connected diabetes mellitus. Moreover, the Veteran has not been provided with VCAA notice regarding the secondary aspect of his service connection claim for headaches. In his September 2009 substantive appeal, he offered an alternate theory of service connection that his headaches are secondary to diabetes mellitus. As the Veteran is service-connected for diabetes mellitus and has not been provided with VCAA notice that expressly addresses the requirements for secondary service connection, such notice should be provided on remand. Finally, the most recent VA treatment records in the claims file are dated in December 2012 and the Veteran may have received additional treatment in the intervening time. Therefore, on remand, relevant VA treatment records from the Dallas VA Medical Center (VAMC), Tyler outpatient clinic, and North Texas health care system (HCS) dated after December 2012 to the present should be obtained for consideration in his appeal. Accordingly, the case is REMANDED for the following action: 1. Send the Veteran a VCAA notice letter regarding the evidence and information necessary to substantiate his claim of entitlement to service connection for headaches, to include as secondary to his service- diabetes mellitus, in accordance with 38 C.F.R. § 3.310. 2. Obtain VA treatment records, physically or electronically, from the Dallas VAMC, Tyler outpatient clinic, and North Texas HCS dated after December 2012 to the present that are relevant to the Veteran's headaches or low back disability. 3. Notify the Veteran that he may submit lay statements from himself and from other individuals who have first-hand knowledge or were contemporaneously informed of the onset and/or recurrence of headaches or low back problems and any relationship between his headaches and service-connected diabetes mellitus. The Veteran should be provided an appropriate amount of time to submit this lay evidence. 4. After completing the above, schedule the Veteran for an appropriate VA examination to determine the nature, extent, onset and etiology of any low back disability found to be present. The claims file should be made available and reviewed by the examiner. All indicated studies should be performed and all findings should be reported in detail. The examiner should state the likelihood that any low back disability found to be present existed prior to service. If the examiner concludes that low back disability found to be present existed prior to service, the examiner should indicate that likelihood that the disability worsened during service. If the examiner diagnoses the Veteran as having low back disability that did not pre-exist service, the examiner should opine as to whether it is at least as likely as not that the condition is related to or had its onset during service. In offering each of these opinions, the examiner should specifically acknowledge and comment on the Veteran's competent report of a recurrence of low back symptoms since service. The rationale for all opinions expressed should be set forth in a legible report. 5. Schedule the Veteran for a VA examination to determine the nature, extent, onset and etiology of his headaches. The claims file should be reviewed by the examiner in conjunction with the examination. Any necessary tests should be conducted. After examining the Veteran and reviewing the claims file, the examiner should state whether it is at least as likely as not that the Veteran's headaches: a) are related to service, including the headaches noted in the service treatment records, or b) were caused, at least in part, by the Veteran's service-connected diabetes mellitus, or c) were aggravated, at least in part, by the Veteran's service-connected diabetes mellitus? The examiner should consider the Veteran's lay statements regarding the onset of his headaches. A complete rationale for any opinion expressed and conclusion reached should be set forth in the report. 6. Then readjudicate the claims. If the benefits sought remain denied, the Veteran and his representative must be furnished a supplemental statement of the case and be given an opportunity to submit written or other argument in response before the claims file is returned to the Board for further appellate consideration. 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 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). ______________________________________________ STEVEN D. REISS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs