Citation Nr: 1318117 Decision Date: 06/04/13 Archive Date: 06/11/13 DOCKET NO. 06-05 615 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an initial increased rating for adjustment disorder with depressed mood, evaluated as 10 percent disabling. 2. Entitlement to a total rating based upon individual unemployability, due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Anthony M. Flamini, Counsel INTRODUCTION The Veteran served on active duty from May 1978 to January 1985. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2005 rating decision of the St. Petersburg, Florida, Department of Veterans Affairs (VA) Regional Office (RO). This case was remanded by the Board in February 2010 and March 2012 for further development. The Board is satisfied as to substantial compliance with its February 2010 remand directives regarding the issue adjudicated in this decision. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999); Stegall v. West, 11 Vet. App. 268 (1998). This included obtaining an VA psychiatric addendum opinion to assist in determining the current severity of the Veteran's service-connected adjustment disorder. As such, the case is now ready for disposition. The issue of entitlement to a TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDING OF FACT The Veteran's service-connected adjustment disorder with depressed mood is mild and controlled by continuous medication; additional psychiatric symptomatology has been attributed to separate, non-service-connected disabilities which are not manifestations of or otherwise intertwined with the Veteran's service-connected adjustment disorder with depressed mood. CONCLUSION OF LAW The criteria for an initial disability rating in excess of 10 percent for service-connected adjustment disorder with depressed mood have not been met. 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.321, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION Duties to Notify and Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2010). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his/her representative, if applicable, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from 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; and (3) that the claimant is expected to provide. This notice must be provided prior to an initial unfavorable decision by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); see also 73 Fed. Reg. 23,353-56 (Apr. 30, 2008). Further, upon receipt of a claim for service connection for a disability, VA is required to review the evidence presented with the claim and to provide the claimant with notice of what evidence not previously provided will help substantiate his/her claim. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). Specifically, VA must notify the claimant of what is required to establish service connection and that a disability rating and effective date for the award of benefits will be assigned if service connection is awarded. Dingess v. Nicholson, 19 Vet. App. 473 (2006). In cases where service connection has been granted and an initial disability rating and effective date have been assigned, the claim for service connection has been substantiated, and any defect in the notice regarding that claim was therefore not prejudicial to the claim. See Dingess, 19 Vet. App. at 491. In such cases, where the Veteran then files a notice of disagreement with the initial rating and/or the effective date assigned, he/she has initiated the appellate process and different, and in many respects, more detailed notice obligations arise, the requirements of which are set forth in sections 7105(d) and 5103A of the statute. Id., see also Goodwin v. Peake, 22 Vet. App. 128, 137 (2008); 38 U.S.C.A. §§ 5103(A), 7105(d). In this case, the notice obligations set forth in sections 7105(d) and 5103A of the statute were met when the RO issued a February 2010 letter following the initial adjudication. The issue was subsequently readjudicated in an October 2012 supplemental statement of the case. Accordingly, the Board concludes that, in this case, the RO met the notice obligations set forth in sections 7105(d) and 5103A of the statute. VA has also satisfied its duty to assist the Veteran in this case. The Veteran's service treatment records as well as all identified and available VA treatment records pertinent to the years after service are in the claims file and were reviewed by both the RO and the Board in connection with the Veteran's claim. The Veteran has not identified any outstanding medical records. In addition, the Veteran was afforded VA examinations with respect to the issues on appeal in November 2004 and March 2010. 38 C.F.R. §3.159(c)(4). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the VA examinations obtained in this case are adequate for rating purposes because they provided the necessary clinical findings to evaluate the disability under the rating criteria. 38 C.F.R. § 3.159(c)(4). Accordingly, the duty to assist the Veteran with the development of evidence pertinent to his claim has been satisfied. Law and Analysis Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. See 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7 (2012). Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. See 38 C.F.R. § 4.3 (2012). In every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. See 38 C.F.R. § 4.31 (2012). The veteran's entire history is reviewed when making a disability determination. See 38 C.F.R. § 4.1 (2012). Where the veteran timely appealed the rating initially assigned for the service-connected disability within one year of the notice of the establishment of service connection for it, VA must consider whether the veteran is entitled to "staged" ratings to compensate him for times since filing his claim when his disability may have been more severe than at other times during the course of his appeal. See Fenderson v. West, 12 Vet. App. 119 (1999). Where service connection has already been established, and increase in the disability rating is at issue, it is the present level of the disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, in such cases, when the factual findings show distinct time periods during which a claimant exhibits symptoms of the disability at issue and such symptoms warrant different evaluations, staged evaluations may also be assigned. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran seeks entitlement to an initial increased rating in excess of 10 percent for adjustment disorder with depressed mood. By way of history, the Veteran was initially granted service connection for adjustment order with depressed mood in a March 2005 rating decision and assigned a 10 percent evaluation pursuant to Diagnostic Code 9434 effective June 7, 2004. Under Diagnostic Code 9434, the General Rating Formula for Mental Disorders is used. The General Rating Formula provides that a 10 percent rating is assigned for occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication. A 30 percent rating is assigned 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 assigned 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 assigned 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 which 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. Finally, a 100 percent rating is assigned 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. See 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). Although major depressive disorder is rated under the General Rating Formula, the use of the term "such as" in 38 C.F.R. § 4.130 indicates that the listed symptoms are not intended to constitute an exhaustive list. Rather, the symptoms listed under the General Rating Formula for Mental Disorders are to serve as examples of the type and severity of symptoms or their effects that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Accordingly, the symptoms to be considered when rating a Veteran's PTSD are not limited to those listed in 38 C.F.R. § 4.130. Instead, VA shall consider all symptoms of a Veteran's PTSD that affect his level of occupational and social impairment, including, if applicable, those identified in the fourth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Within the DSM-IV, Global Assessment of Functioning (GAF) scores are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996). A GAF score is, of course, just one part of the medical evidence to be considered and is not dispositive. The same is true of any physician's statement as to the severity of a disability. It remains the Board's responsibility to evaluate the probative value of any doctor's opinion in light of all the evidence of record. The Veteran underwent a VA Psychiatry Initial Assessment in July 2004, at which time he was diagnosed as having mood disorder due to medical condition, alcohol dependence, marijuana dependence, and antisocial personality disorder. Subjectively, he described a "very serious problem with depression," as well as some suicidal ideation with no plan or intent. He further reported irritability, crying, moodiness, and poor sleep, which was interfering with his relationships. Upon objective examination, the Veteran was alert and oriented as to person, time, and place. He was neatly groomed and cooperative. However, his mood was depressed and his affect was sad. His speech was normal in form, rate, and volume. His behavior was also normal and appropriate. His intellect was of average range, and his insight and judgment were intact. The VA psychologist assigned him a GAF score of 65, indicative of some mild symptoms or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, with some meaningful interpersonal relationships. The Veteran was afforded a VA mental disorders examination in November 2004, at which time he was diagnosed with adjustment disorder with depressed mood (secondary to his service-connected degenerative disc disease of the lumbar spine and radiculopathy), cannabis abuse, and alcohol abuse. Upon physical examination, the Veteran was alert and fully oriented. He had the capacity to complete activities of daily living, and did not exhibit inappropriate or bizarre behavior. His speech was clear, coherent, goal directed, and normal in rate and volume. The Veteran endorsed experiencing auditory hallucinations, although his subjective account of the voices he heard included a number of atypical features. The Veteran denied experiencing visual hallucinations, and did not report any bizarre delusional beliefs, although he was unsure if he experienced any delusions. He denied experiencing paranoia or grandiosity. His range of affect was mildly restricted, and he described his mood as a "little jittery." He described tearfulness and depression during the prior week. He reported sleeping 7 to 8 hours per night, but indicated that he often woke up several times per night. He also reported poor concentration and low self esteem. He indicated that he had thought of harming himself in the past, but denied any current plan or intent to do so. He reported feelings of anxiety, but denied any panic, compulsions, or obsessions. The examiner opined that the depressive symptoms associated with the adjustment disorder appeared to be relatively mild. The examiner emphasized that both the cannabis and alcohol abuse began before the onset of depression, and thus were not caused by the adjustment disorder. The examiner further opined that the Veteran was not unemployable due to the adjustment disorder because the depression was only mild. The Veteran was again assigned a GAF score of 65, indicative of some mild symptoms or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, with some meaningful interpersonal relationships. In a March 2005 addendum, the November 2004 VA examiner opined that the Veteran's adjustment disorder with depressed mood was secondary to his lumbar spine degenerative disc disease with radiculopathy to both lower extremities. The examiner further indicated that the Veteran was not unemployable due to the adjustment disorder because his depression was only mild and he continued to seek employment. A November 2004 VA treatment note indicated that the Veteran had reported an increase in depression symptoms over the previous 3 months. The Veteran reported tearfulness, depressed mood, emotional withdrawal, social isolation, some decreased interest, and fleeting suicidal thoughts. He further reported using cannabis and drinking 6 to 12 beers per day. His urine drug screening was positive for cannabis and cocaine, and he was diagnosed as having alcohol and cannabis abuse, as well as mood disorder secondary to his general medical condition. VA treatment records dated from December 2004 through January 2006 indicated that the Veteran was no longer using alcohol or cannabis. A November 2008 VA treatment note diagnosed the Veteran as having recurrent depression. He was noted to have depressed mood, irritability, tearfulness, social withdrawal, and fluctuating sleep patterns. The Veteran reported drinking 7 to 8 beers per week. A urine drug screening conducted in August 2009 was positive for cocaine and cannabis. In April 2010, the Veteran reported struggling with feelings of depression and emotion. He additionally reported trouble falling and staying asleep and fluctuation of his energy. In May 2010, another urine drug screening was positive for cocaine and cannabis. The Veteran's treatment records reflect that he is treated with Wellbutrin (bupropion). The Veteran was afforded another VA mental disorders examination in March 2010, at which time he was diagnosed with malingering, adjustment disorder with depressed mood, cannabis abuse in reported remission, and alcohol abuse in reported remission. Upon psychiatric examination, the Veteran was clean, neatly groomed, and appropriately dressed. His speech was spontaneous, clear, and coherent. His affect was constricted, while his mood was frustrated. His attention was intact, and his orientation was intact as to person and place, although not to time, as he missed the correct date by one day. His thought processes and thought content were unremarkable, and he did not report any delusions or panic attacks. He understood the outcome of his behavior, and also understood that he had a problem. He was noted to be of below average intelligence. He did not exhibit any inappropriate, obsessive, or ritualistic behavior. The Veteran reported having passive homicidal and suicidal thoughts in the past, but no current homicidal or suicidal thoughts. He also reported sleep impairment, indicating that he could only sleep 4 to 8 hours per night. His memory was normal. The examiner explained that the Veteran's depressed mood was associated with his service-connected adjustment disorder, which did not cause any occupational or social impairment. However, the examiner associated the Veteran's "atypical description of hallucinations" (e.g., hearing voices only through one ear) with malingering. The examiner also indicated that it was unclear if there were any residual symptoms associated with the Veteran's cannabis or alcohol abuse, both in reported remission. The examiner indicated that the Veteran was unemployed, although he did not contend his unemployment was due to the effects of his mental disorder. The VA examiner assigned him a GAF score of 72, indicative of symptoms that were transient and expectable reactions to psychosocial stresses, if present at all, with no more than slight impairment in social, occupational, or school functioning. The examiner explained that this score was for his service-connected adjustment disorder with depressed mood alone, which did not cause any occupational or social impairment. The RO subsequently requested another VA mental disorders opinion to determine whether the diagnoses of "mood disorder" and "major depressive disorder" found in the Veteran's VA treatment records were manifestations of or otherwise intertwined with the Veteran's service-connected adjustment order with depressed mood. In a May 2011 report, a VA psychologist indicated that, "The undersigned would have to resort to mere speculation to provide the requested opinion." The VA psychologist continued that the Veteran had a chronic history of alcohol, cannabis, and cocaine abuse, and because research indicated a strong link between substance abuse and depression, the psychologist was unable to provide the requested opinion. The RO returned the claims file to the May 2011 VA psychologist for an addendum clarifying his opinion. The psychologist responded that, "The undersigned would have to resort to mere speculation to provide the requested opinion. The veteran has experienced post-military stressors including unemployment and financial problems that at least as likely as not contribute to the veteran's current depression." In its March 2012 decision, the Board found that the VA examiner's opinions in March 2010 and May 2011 were inadequate for evaluation purposes without a thorough explanation as to why the examiner could not render an opinion without resorting to mere speculation. As such, the Board remanded the issue in order to obtain an addendum opinion. Pursuant to the Board's remand instructions, an addendum opinion was obtained in April 2012, at which time the examiner again indicated that he would have to resort to mere speculation to provide the requested opinion for two reasons. First, the Veteran was asked during the March 2010 VA examination to what he attributed his depression, and he provided a vague response, stating "sometimes just thinking about I guess where things are, what's happening in life." Second, the examiner indicated that a review of VA treatment records reflected that the diagnoses of mood disorder and major depressive disorder appeared to be associated with a variety of factors, such as problems with a girlfriend, unemployment, back pain, alcohol consumption, and VA's refusal to operate on his shoulder due to his cocaine use. The examiner indicated that his review of the treatment notes reflected that the diagnoses of mood disorder and major depressive disorder appeared to be associated with a number of issues, many of which occurred following the Veteran's military service; and because these diagnoses had multifactorial etiologies, the examiner would have to resort to mere speculation to opine whether the VA diagnoses of mood disorder and major depressive disorder were manifestations of or otherwise intertwined with the Veteran's service-connected adjustment disorder with depressed mood. This issue was returned to the Board in December 2012, at which time the Board sought an advisory opinion by a psychiatry specialist to determine whether the diagnoses of mood disorder and major depressive disorder were manifestations of or otherwise intertwined with the Veteran's service-connected adjustment disorder with depressed mood. In correspondence dated in January 2013, the psychiatry specialist issued her opinion with respect to the issue following a thorough review of the Veteran's claims file. The specialist opined that the VA diagnoses of mood disorder and major depressive disorder were not manifestations of or otherwise intertwined with the Veteran's service-connected adjustment disorder with depressed mood. She explained that the symptoms described during the Veteran's November 2008 visit did not meet the requirement to warrant a diagnosis of major depression. Furthermore, the Veteran denied, over a two week time frame, sustained problems with energy, concentration, appetite, suicidal thoughts, feelings of hopelessness or worthlessness, consistent loss of energy or fatigue, and depressed mood most of the day and nearly every day. He described episodes of depressed mood 2 or 3 times per week which lasted hours or days. His alcohol use could account for the 2 to 3 times per week depressed mood and tearfulness. In addition, the April 2010 VA treatment note did not change the specialist's opinion, especially given the positive urine drug screen reported in May 2010 which was positive for cocaine and cannabis. The specialist concluded that the symptoms described by the Veteran could easily be attributed to these substances. Given the entire record in concert, it is concluded that the Veteran's adjustment disorder symptoms are mild and controlled by continuous medication (Wellbutrin), therefore more nearly approximating the currently-assigned 10 percent rating. This is supported by the assigned GAF scores assigned during the appeal period, which range from 65 to 72, and the repeated conclusion that the Veteran's adjustment disorder symptomatology was "mild" in nature. To warrant an increased rating, the Veteran would have to exhibit such symptoms as depressed mood, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment and mild memory loss (such as forgetting names, directions or recent events). Such impairment, related to the service-connected adjustment disorder alone, is simply not demonstrated by the record. Although the Veteran has exhibited depressed mood, the psychiatry specialist opined that the VA diagnoses of mood disorder and major depressive disorder were not manifestations of or otherwise intertwined with the Veteran's service-connected adjustment disorder with depressed mood. Moreover, there is no evidence of suspiciousness, panic attacks, or mild memory loss. Accordingly, on this record, the Board finds that the evidence preponderates against the claim for increase. It is also not shown that the Veteran's symptoms associated with his adjustment disorder have varied significantly in severity during the course of the appeal period, and the rating assigned is based on the greatest level of impairment shown during the appellate period. Consequently, there is no competent evidentiary basis for a staged rating in this case. The current 10 percent rating assigned encompasses the maximum level of disability during the appellate period. The Board has considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not for application. See Gilbert, 1 Vet. App. at 54. In Thun v. Shinseki, F.3d 1366 (Fed. Cir. 2009), the United States Court of Appeals for Veterans Claims (Court) articulated a three-step inquiry for determining whether a Veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation is found inadequate because it does not contemplate the claimant's level of disability and symptomatology, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether the Veteran's disability picture requires the assignment of an extraschedular rating. The Board finds that the disability is not so unusual or exceptional as to render impractical the application of the regular schedular standards at any time during the pendency of the initial evaluation period. 38 C.F.R. § 3.321(b)(1). In this regard, the Board notes that the Veteran's adjustment has not necessitated frequent periods of hospitalization and there is no objective evidence that adjustment disorder alone has resulted in marked interference with his employment. The facts of this case do not present such an extraordinary disability picture such that the Board is required to remand this matter to the RO for the procedural actions outlined in 38 C.F.R. § 3.321(b)(1), which concern the assignment of extra-schedular evaluations in "exceptional" cases. See Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 94-95 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995); Thun v. Peake, 22 Vet. App. 111, 115 (2008). ORDER An initial increased rating in excess of 10 percent for the service-connected adjustment disorder with depressed mood is denied. REMAND The Veteran also seeks entitlement to a TDIU. Although VA examiners have opined that the Veteran is not unemployable due to his service-connected adjustment disorder alone, the Board notes that he is also service connected for a number of other disabilities. The Veteran is currently service-connected for degenerative disc disease at L4-L5, rated as 40 percent disabling; radiculopathy of the right lower extremity, rated as 20 percent disabling; radiculopathy of the left lower extremity, rated as 10 percent disabling; and adjustment disorder with depressed mood, rated as 10 percent disabling. His combined disability rating is 60 percent. The Board emphasizes that the Veteran has not been afforded a recent VA examination to determine the effects of all of his service-connected disabilities in the aggregate on his ability to obtain or maintain employment consistent with his education and occupational experience. As such, the Board finds that the Veteran should be afforded such as examination. Accordingly, the case is REMANDED for the following action: 1. The Veteran must be afforded an examination to determine the effects of his service-connected disabilities in the aggregate on his ability to obtain or maintain employment consistent with his education and occupational experience. The claims file and any records on Virtual VA must be made available to the examiner, and the examiner must specify in the examination report that the claims file and Virtual VA records have been reviewed. All necessary special studies or tests are to be accomplished. The examiner must elicit from the Veteran and record for clinical purposes his full work and educational history. Based on a review of the evidence of record, a clinical examination, and with consideration of the Veteran's statements, the examiner must provide an opinion as to whether the Veteran is unable to obtain or retain employment due only to his service-connected disabilities, to include any medications taken for those disabilities, consistent with his education and occupational experience, and irrespective of age and any nonservice-connected disorders. The opinion provided must include a complete rationale. If the examiner cannot provide the requested opinion without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. The examiner must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the examiner must indicate whether the opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. The report must be typed. 2. The RO must notify the Veteran that it is his responsibility to report for the scheduled VA examination, and to cooperate in the development of the claim. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158 , 3.655 (2012). In the event that the Veteran does not report for the scheduled examination, documentation must be obtained which shows that notice scheduling the examinations was sent to the last known address. It must also be indicated whether any notice that was sent was returned as undeliverable. Copies of all documentation notifying the Veteran of the scheduled VA examination must be placed in the Veteran's claims file. 3. After the above actions have been completed, the RO must readjudicate the issue on appeal. If the benefit remains denied, the Veteran and his representative must be provided a supplemental statement of the case. After the Veteran has had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ L. M. BARNARD Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs