Citation Nr: 1318669 Decision Date: 06/07/13 Archive Date: 06/11/13 DOCKET NO. 07-23 546 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Phoenix, Arizona THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder, to include anxiety. 2. Entitlement to service connection for hemorrhoids. 3. Entitlement to service connection for bilateral hearing loss. 4. Entitlement to service connection for tinnitus. 5. Entitlement to service connection for athlete's foot and a toenail fungus. 6. Entitlement to service connection for plantar fasciitis. 7. Entitlement to service connection for a sinus disability. 8. Entitlement to service connection for a back disability with sciatica. 9. Entitlement to service connection for numbness of the right lower extremity. 10. Entitlement to service connection for a ruptured disc. 11. Entitlement to service connection for residuals of a neck injury. 12. Entitlement to service connection for a left arm and shoulder disability. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Appellant ATTORNEY FOR THE BOARD M.W. Kreindler, Counsel INTRODUCTION The Appellant served on active duty from August 1958 to August 1960. This matter came to the Board of Veterans' Appeals (Board) on appeal from a January 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Phoenix, Arizona. In December 2009, the Appellant testified at a Board hearing at the RO. Unfortunately, the transcript of that hearing is incomplete, due to apparent technical difficulties. In March 2011, the Board remanded the matter to afford the Appellant the opportunity to testify at another Board hearing. In June 2011, the Appellant testified at a second Board hearing at the RO, pursuant to his request. A complete transcript of that hearing is of record. Because the Appellant has testified before two different Veterans Law Judges regarding the claims on appeal, review of this matter has been assigned to a panel of three Veterans Law Judges, in accordance with 38 C.F.R. § 20.707 (2012). Both Veterans Law Judges who conducted hearings in this case will participate in making the decision on the claims. In October 2011, the Appellant waived his right to appear at a Board hearing before the third panel member and asked that the panel proceed immediately with consideration of his appeal. Arneson v. Shinseki, 24 Vet. App. 379, 386 (2011). These matters were remanded in January 2012. In January 2012, the Board denied entitlement to service connection for a dental disability for VA disability compensation purposes. See 38 C.F.R. §§ 3.381(a), 4.150 (2012). As discussed in the Introduction of the decision, the issue of entitlement to service connection for a dental disability for purposes of entitlement to VA outpatient dental treatment has not yet been addressed by the Agency of Original Jurisdiction, despite the Appellant's assertion of in-service dental trauma. See 38 C.F.R. § 17.161. The United States Court of Appeals for Veterans Claims (Court) has held that a claim of service connection for a dental disability for compensation purposes must also be considered as a claim for VA outpatient dental treatment. See Mays v. Brown, 5 Vet. App. 302, 306 (1993). Inasmuch as the claim of service connection for a dental disability for purposes of entitlement to VA outpatient dental treatment has not been adjudicated by the RO, the Board does not have jurisdiction over it. Thus, the issue of entitlement to service connection for a dental disability for purposes of entitlement to VA outpatient dental treatment is referred to the RO for appropriate action. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). The issues of entitlement to service connection for anxiety disorder; hemorrhoids; bilateral hearing loss; tinnitus; sinus disability; back disability with sciatica; numbness of the right lower extremity; ruptured disc; residuals of a neck injury; and, left arm and shoulder disability are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the Appellant if further action is required on his part. FINDINGS OF FACT 1. Plantar fasciitis is due to active service. 2. Tinea pedis and onychomycosis are due to active service. CONCLUSIONS OF LAW 1. The criteria for an award of service connection for plantar fasciitis have been met. 38 U.S.C.A. §§ 1131, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 3.303 (2012). 2. The criteria for an award of service connection for tinea pedis and onychomycosis (claimed as athlete's foot and toenail fungus) have been met. 38 U.S.C.A. §§ 1131, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Under the Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; see also 38 C.F.R. §§ 3.102, 3.156(a), 3.326(a), VA has a duty to notify the claimant of any information and evidence needed to substantiate and complete a claim, and of what part of that evidence is to be provided by the claimant and what part VA will attempt to obtain for the claimant. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). In light of the favorable decision as it relates to the issue of the grant of service connection for plantar fasciitis, and athlete's foot and toenail fungus, no further discussion of VCAA is necessary at this point. The matter of VCAA compliance with regard to the remaining issues will be addressed in a future merits decision on those issues after action is undertaken as directed in the remand section of this decision. Any notice deficiency, per Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), constitutes harmless error (see Bernard v. Brown, 4 Vet. App. 384, 394 (1993)), as section 5103(a) notice provisions have been satisfied, and if the Appellant so chooses, he will have an opportunity to initiate the appellate process again should he disagree with the disability rating or effective date assigned to the awards. Then, more detailed obligations arise, the requirements of which are set forth in sections 7105(c) and 5103A. Dingess, 19 Vet. App. at 489. Criteria & Analysis Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (1) evidence of a current disability; (2) evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table); Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. The Appellant claims entitlement to service connection for plantar fasciitis which he claims is due to marching and participating in maneuvers in service. He contends that his foot problems have persisted since service. Post-service clinical records document a diagnosis of plantar fasciitis in 2003. The Appellant also claims entitlement to service connection for athlete's foot and toenail fungus which he asserts developed during service and continued to the present day. He indicates that he uses medication to treat his condition. The Board notes that the Appellant's service treatment records are unavailable. In June 2006, the National Personnel Records Center (NPRC) advised the RO that the Appellant's service records had likely been destroyed in the July 1973 fire at their facility and that there were no alternative records available. Based on the unambiguous response from NPRC, the Board finds that further requests for the Appellant's service treatment records would be futile. Under such situations the Board has a heightened obligation to explain its findings and conclusions and carefully consider the benefit-of-the-doubt rule. See Cuevas v. Principi, 3 Vet. App. 542, 548 (1992); O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). The caselaw, however, does not lower the legal standard for proving a claim of service connection but rather increases the Board's obligation to evaluate and discuss in its decision all of the evidence that may be favorable to the Veteran. See Russo v. Brown, 9 Vet. App. 46 (1996). Moreover, there is no presumption, either in favor of the claimant or against VA, arising from missing records. See Cromer v. Nicholson, 19 Vet. App. 215, 217-18 (2005) (wherein the Court declined to apply an "adverse presumption" where records have been lost or destroyed while in government control which would have required VA to disprove a claimant's allegation of injury or disease). In November 2012, the Appellant underwent a VA examination pertaining to the feet. Upon examination, the examiner diagnosed plantar fasciitis. The examiner opined that plantar fasciitis is at least as likely as not related to the Appellant's active duty service. The examiner acknowledged that there was no medical documentation in the claims folder supporting the diagnosis of plantar fasciitis. The examiner stated that the only documentation is the Appellant's accounting of his condition and diagnosis. The examiner stated that due to the army military boot issued in 1958-1960, it is as least at likely as not that he developed plantar fasciitis. In November 2012, the Appellant underwent a VA examination pertaining to the skin. Upon examination, the examiner diagnosed tinea pedis and onychomycosis. The examiner opined that tinea pedis and onychomycosis are at least as likely as not related to the Appellant's active duty service. The examiner acknowledged that there was no medical documentation in the claims folder supporting the diagnoses of tinea pedis and onychomycosis. The only documentation is the Appellant's accounting of his condition and diagnosis. The examiner stated that given the conditions of his basic training at Ft. Lewis in Washington state it is at least as likely as not that he developed tinea pedis which then resulted in onychomycosis. In this case, the Board finds that the credible and competent evidence supports the Appellant's claims of service connection for plantar fasciitis, tinea pedis, and onychomycosis. As detailed, service treatment records are unavailable, and in applying the benefit-of-the-doubt provisions, the Board finds the Appellant's descriptions of foot problems in service due to marching and participating in maneuvers, and his assertion that he developed foot fungus during service to be credible. The VA examiner also found the Appellant's assertions credible in light of the boots worn during service, and the conditions during service. The Board finds that the competent medical evidence is in support of the Appellant's claims. Accordingly, the Board concludes that the probative and persuasive evidence of record supports the Appellant's claims of service connection for plantar fasciitis, and tinea pedis and onychomycosis. In applying the benefit of the doubt rule, service connection is warranted for plantar fasciitis, and tinea pedis and onychomycosis. ORDER Entitlement to service connection for plantar fasciitis is granted. Entitlement to service connection for tinea pedis and onychomycosis, claimed as athlete's foot and toenail fungus, is granted. REMAND Although the Board regrets the additional delay, remand is necessary to obtain adequate examinations regarding the remaining issues in appellate status. Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The Board has an obligation to insure that its remand instructions and those of the Court are substantially complied with. Stegall v. West, 11 Vet App 268 (1998). The Board notes that the Appellant's service treatment records are unavailable. In June 2006, the National Personnel Records Center (NPRC) advised the RO that the Appellant's service records had likely been destroyed in the July 1973 fire at their facility and that there were no alternative records available. Based on the unambiguous response from NPRC, the Board finds that further requests for the Appellant's service treatment records would be futile. Under such situations the Board has a heightened obligation to explain its findings and conclusions and carefully consider the benefit-of-the-doubt rule. See Cuevas v. Principi, 3 Vet. App. 542, 548 (1992); O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). The caselaw, however, does not lower the legal standard for proving a claim of service connection but rather increases the Board's obligation to evaluate and discuss in its decision all of the evidence that may be favorable to the Veteran. See Russo v. Brown, 9 Vet. App. 46 (1996). Moreover, there is no presumption, either in favor of the claimant or against VA, arising from missing records. See Cromer v. Nicholson, 19 Vet. App. 215, 217-18 (2005) (wherein the Court declined to apply an "adverse presumption" where records have been lost or destroyed while in government control which would have required VA to disprove a claimant's allegation of injury or disease). Hemorrhoids The Appellant contends that he developed hemorrhoids during his period of active duty after straining to lift heavy equipment and after sitting on wood and metal benches. He indicated that he had continued to have hemorrhoids in his civilian life which have required surgery. Post-service clinical records note a history of hemorrhoids. In November 2012, the Appellant underwent a VA examination. The examiner diagnosed internal or external hemorrhoids. The examiner opined that the Appellant's hemorrhoid condition was less likely than not incurred in or caused by service based on the rationale that the claims folder does not document the Appellant had hemorrhoids in service. As service treatment records are unavailable and the sole rationale for the negative etiological opinion was the lack of hemorrhoids being shown in service, the Board finds that this VA examination in inadequate. When medical evidence is inadequate, VA must supplement the record by seeking an advisory opinion. Colvin v. Derwinski, 1 Vet. App. 171 (1991); Hatlestad v. Derwinski, 3 Vet. App. 213 (1992); see also Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007) (once VA provides an examination to a Veteran, VA has a duty to ensure that the examination is adequate for evaluation purposes); Hicks v. Brown, 8 Vet. App. 417, 422 (1995) (inadequate medical evaluation frustrates judicial review). A VA physician with appropriate expertise must review the claims folder and provide an opinion as to whether the Appellant's hemorrhoids are etiologically due to service. Bilateral hearing loss and tinnitus The Appellant contends that he developed hearing loss and tinnitus in service as a result of considerable noise exposure from heavy artillery. He reports that his symptoms have persisted since that time. In November 2012, the Appellant underwent a VA audiological examination. Upon audiological examination, the examiner diagnosed sensorineural hearing loss in both ears. The examiner noted review of the claims folder but checked the box indicated that an opinion could not be provided regarding the etiology of the Appellant's hearing loss without resorting to speculation. The examiner noted that service treatment records were unavailable, but acknowledged that the appellant was a Communications Sergeant exposed to 155s, 105s and range noise with ear protection worn. There was negative pre-military occupational noise exposure. After the military he worked testing communications equipment for 10 years for the military and was exposed to "[B]eaver operators and forklifts" with no use of ear protection. He also worked 36 years for the post office and was exposed to sorting machine noise with no use of ear protection. He reported no noisy hobbies. The examiner stated that there is no documentation of ear/frequency specific hearing levels at the "time of RAD." Thus, based on the Appellant's reported history of significant noise exposure both during and after military service, the examiner stated that it was not possible to determine if the etiology of the hearing loss is related to military noise exposure without resorting to mere speculation. The examiner was also unable to offer an opinion with regard to the etiology of tinnitus without resorting to mere speculation. In Jones v. Shinseki, 23 Vet. App. 382 (2010), the Court held that when a VA medical examiner states no conclusion as to etiology or diagnosis can be reached without resorting to speculation, it must be clear, from either the examiner's statements or the Board's decision, that the examiner has considered "all procurable and assembled data," by obtaining all tests and records that might reasonably illuminate the medical analysis; and when the record leaves the issue in doubt, it is the Board's duty to remand for further development. In further discussion, the Jones Court indicated there must be some assurance that VA exhausted all due diligence in seeking relevant medical information that may have bearing on the requested opinion, and the examiner must explain the basis for such an opinion that he cannot comment conclusively. The Jones Court recognized, however, there will be times when this requested opinion simply cannot be provided-such as when it cannot be determined from current medical knowledge that a specific in-service injury or disease can possibly cause the claimed condition or that the actual cause cannot be selected from multiple potential causes. See Clemons v. Shinseki, 23 Vet. App. 1, 6 (2009) (noting the Board need not obtain further medical evidence where the medical evidence "indicates that determining the cause is speculative"). But, again, this must be clear from the record. And, if not, additional clarifying medical comment will need to be obtained. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (indicating an opinion is considered adequate when it is based on consideration of an appellant's medical history and examinations and describes the disability in sufficient detail so the Board's evaluation of the claimed disability is a fully informed one. An opinion must support its conclusion with an analysis the Board can consider and weigh against contrary opinions.). In light of the VA examiner's inability to offer an opinion without resorting to mere speculation, and in light of the fact that it is not entirely clear to the Board that the VA examiner fully considered the Appellant's medical history and examinations, the Board finds that the Appellant should be afforded a new VA examination to determine the nature and etiology of his bilateral hearing loss and tinnitus. Sinus disability The Appellant contends that he had a lot of sinus problems in service, including a running nose and sinus infections, for which he took sinus pills. He reports that he continues to experience sinus problems for which he receives treatment from a civilian physician, including antibiotics and other pills. Post-service treatment records document treatment for sinusitis in December 2002 and August 2005. In December 2012, the Appellant underwent a VA examination. The examiner diagnosed chronic sinusitis. The examiner did not provide an etiological opinion with regard to his chronic sinusitis. A VA physician with appropriate expertise must review the claims folder and provide an opinion as to whether the Appellant's chronic sinusitis is etiologically due to service. Back disability with sciatica; numbness of the lower extremity; ruptured disc; residuals of neck injury; and, left shoulder disability The Appellant claims that he developed pain in his neck, back, and legs during service as a result of lifting heavy radio equipment which persisted in his civilian years. He contends that his current low back, right leg, and neck disabilities may be related to the heavy lifting in service. In November 2012, the Appellant underwent VA examinations pertaining to the cervical spine, thoracolumbar spine, and left shoulder. The Board notes that the examiner completed separate reports regarding each condition using the boilerplate "Disability Benefits Questionnaire" for each condition. The examiner diagnosed degenerative joint disease of the cervical spine; lumbar strain with right lower extremity radiculopathy; and, left shoulder strain. Attached to the reports is "Medical Opinion 1, Disability Benefits Questionnaire" in which the examiner checked the box corresponding to the following: "The claimed condition was at least as likely as not (50 percent or greater probability) incurred in or caused by the claimed in-service injury, event, or illness. Provide rationale in section c." The examiner's rationale was "Review of c-file, DD214; veteran's self-reported history; and physical exam findings." The Board is unable to determine what "condition" the examiner is referring to that is "at least as likely as not" due to service as the document follows examinations for the cervical spine, thoracolumbar spine, and left shoulder. The Board has determined that the Appellant should undergo new VA orthopedic examinations with physicians with appropriate expertise to determine the nature and etiology of his claimed back disability with sciatica; numbness of the lower extremity; ruptured disc; residuals of neck injury; and, left shoulder disability. Acquired psychiatric disorder The Appellant asserts that he developed an anxiety disorder in service as a result of the stress of being around noisy artillery and from serving as a leader of his section. He recalls going to sick call during service and seeking treatment for anxiety and stress. He claims that the doctor prescribed aspirin and pain pills for his symptoms. See e.g. July 2006 statement. The Appellant further claims that his anxiety has persisted to the present day. In November 2012, the Appellant underwent a VA examination. Upon mental status examination, the examiner diagnosed anxiety disorder, not otherwise specified. The examiner did not provide an etiological opinion. In February 2013, a VA examiner reviewed the claims folder and opined that it is less likely than not that the Appellant's claimed mental condition is due to service. The examiner's negative etiological opinion was based on the fact that the Appellant entered service during peacetime, he was capable of maintaining his position in the postal office service until retirement, and he cared for a family and handled his finances. The Appellant reported his mood as "not too bad" and reported that he becomes stressed due to his tinnitus which irritates his ears. In light of the Appellant's assertions, his claim of service connection for an acquired psychiatric disorder may hinge on establishing service connection for tinnitus which is currently in appellate status. The Appellant's claim of entitlement to service connection for an acquired psychiatric disability should be adjudicated pursuant to 38 C.F.R. § 3.310, and finds that it is inextricably intertwined with the tinnitus issue being remanded, and thus the Board will defer consideration of the appeal with regard to entitlement to an acquired psychiatric disability. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are "inextricably intertwined" when they are so closely tied together that a final Board decision on one issue cannot be rendered until the other issue has been considered). Accordingly, the case is REMANDED for the following actions: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). Expedited handling is requested.) 1. Schedule the Appellant for a VA examination with a physician with appropriate expertise to ascertain whether his claimed hemorrhoids are the result of a disease or injury in service. It is imperative that the claims file be made available to and be reviewed by the examiner. The examiner should offer an opinion as to whether it is at least as likely as not (a 50 percent or higher degree of probability) that hemorrhoids had their onset during his period of service or are otherwise related to the Appellant's period of service; The examiner must provide a rationale for the opinion. The examiner is advised that the Appellant's service treatment records are unavailable. The examiner is advised that the Appellant is competent to report his symptoms and history, and that his reports must be considered in formulating the requested opinion. If the examiner rejects the reports of the Appellant, the examiner must provide reasons for doing so; the mere absence of supporting clinical evidence is an insufficient reason; by itself for rejecting his report. If any requested opinion cannot be provided without resort to speculation, the examiner should explain why this is so; and whether the inability to provide the necessary opinion is due to the limits of medical and scientific knowledge or is due to the absence of specific evidence. The examiner should reconcile any opinions with the post-service medical evidence and post-service lay statements and testimony of the Appellant. 2. Schedule the Appellant for a VA examination with a physician with appropriate expertise to ascertain whether his claimed sinus disability is the result of a disease or injury in service. It is imperative that the claims file be made available to and be reviewed by the examiner. The examiner should offer an opinion as to whether it is at least as likely as not (a 50 percent or higher degree of probability) that chronic sinusitis had its onset during his period of service or is otherwise related to the Appellant's period of service; The examiner must provide a rationale for the opinion. The examiner is advised that the Appellant's service treatment records are unavailable. The examiner is advised that the Appellant is competent to report his symptoms and history, and that his reports must be considered in formulating the requested opinion. If the examiner rejects the reports of the Appellant, the examiner must provide reasons for doing so; the mere absence of supporting clinical evidence is an insufficient reason; by itself for rejecting his report. If any requested opinion cannot be provided without resort to speculation, the examiner should explain why this is so; and whether the inability to provide the necessary opinion is due to the limits of medical and scientific knowledge or is due to the absence of specific evidence. The examiner should reconcile any opinions with the post-service medical evidence and post-service lay statements and testimony of the Appellant. 3. Schedule the Appellant for a VA audiometric examination to ascertain whether he currently suffers from bilateral hearing loss disability, as defined by 38 C.F.R. § 3.385, and the etiology of any bilateral hearing loss and tinnitus. It is imperative that the claims file be made available to and be reviewed by the examiner. The examiner should respond to the following: a) whether it is at least as likely as not (a 50 percent or higher degree of probability) that bilateral hearing loss had its clinical onset in service or is otherwise related to the Appellant's period of service, to include in-service noise exposure; b) whether it is at least as likely as not (a 50 percent or higher degree of probability) that tinnitus had its clinical onset in service or is otherwise related to the Appellant's period of service, to include in-service noise exposure. The examiner must provide a rationale for these opinions. The examiner is advised that the Appellant's service treatment records are unavailable. The examiner is advised that the Appellant is competent to report his symptoms and history, and that his reports must be considered in formulating the requested opinions. If the examiner rejects the reports of the Appellant, the examiner must provide reasons for doing so; the mere absence of supporting clinical evidence is an insufficient reason; by itself for rejecting his report. If any requested opinions cannot be provided without resort to speculation, the examiner should explain why this is so; and whether the inability to provide the necessary opinion is due to the limits of medical and scientific knowledge or is due to the absence of specific evidence. The examiner should reconcile any opinions with the post-service medical evidence and post-service lay statements and testimony of the Appellant. 4. Schedule the Appellant for a VA examination with a physician with appropriate expertise to ascertain whether his claimed back disability with sciatica; numbness of the lower extremity; ruptured disc; residuals of neck injury; and, left shoulder disabilities are the result of a disease or injury in service. It is imperative that the claims file be made available to and be reviewed by the examiner. The examiner should identify all disabilities pertaining to the back/lumbar spine, neck/cervical spine, and left shoulder. The examiner should offer an opinion as to the following: a) whether it is at least as likely as not (a 50 percent or higher degree of probability) that a back/lumbar spine disability, to include lumbar strain with right lower extremity radiculopathy had its onset during his period of service or is otherwise related to the Appellant's period of service; b) whether it is at least as likely as not (a 50 percent or higher degree of probability) that a neck/cervical spine disability, to include degenerative joint disease of the cervical spine, had its onset during his period of service or is otherwise related to the Appellant's period of service; c) whether it is at least as likely as not (a 50 percent or higher degree of probability) that a left shoulder disability, to include left shoulder strain, had its onset during his period of service or is otherwise related to the Appellant's period of service. The examiner must provide a rationale for these opinions. The examiner is advised that the Appellant's service treatment records are unavailable. The examiner is advised that the Appellant is competent to report his symptoms and history, and that his reports must be considered in formulating the requested opinions. If the examiner rejects the reports of the Appellant, the examiner must provide reasons for doing so; the mere absence of supporting clinical evidence is an insufficient reason; by itself for rejecting his report. If any requested opinions cannot be provided without resort to speculation, the examiner should explain why this is so; and whether the inability to provide the necessary opinion is due to the limits of medical and scientific knowledge or is due to the absence of specific evidence. The examiner should reconcile any opinions with the post-service medical evidence and post-service lay statements and testimony of the Appellant. 5. Upon completion of the above, readjudicate entitlement to service connection for hemorrhoids; bilateral hearing loss; tinnitus; sinus disability; back disability with sciatica; numbness of the lower extremity; ruptured disc; residuals of neck injury; left shoulder disability; and, acquired psychiatric disorder, to include pursuant to § 3.310. If any of the benefits sought are not granted in full, the Appellant and his representative should be furnished an appropriate supplemental statement of the case and be afforded an opportunity to respond. Thereafter, the case should be returned to the Board for appellate review. The Appellant and his representative have the right to submit additional evidence and argument on the 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 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). __________________________ ____________________________ Michael J. Skaltsounis Dennis F. Chiappetta Acting Veterans Law Judge Veterans Law Judge ______________________________________________ James L. March Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs