Citation Nr: 1322357 Decision Date: 07/12/13 Archive Date: 07/18/13 DOCKET NO. 08-32 131 ) DATE ) ) On appeal from the Department of Veterans Affairs Medical and Regional Office Center in Wichita, Kansas THE ISSUES 1. Entitlement to service connection for erectile dysfunction, to include as secondary to residuals of multiple fragment wounds to the abdomen, to include a small bowel perforation, a small bowel resection, and with a retained metal fragment against the abdominal aorta at the level of the L4 vertebral body, and posttraumatic stress disorder (PTSD). 2. Entitlement to a disability rating in excess of 30 percent for the residuals of multiple fragment wounds to the abdomen, to include a small bowel perforation, a small bowel resection, and with a retained metal fragment against the abdominal aorta at the level of the L4 vertebral body. 3. Entitlement to an effective date prior to April 9, 2007, for the award of a 30 percent rating for the residuals of multiple fragment wounds to the abdomen, to include a small bowel perforation, a small bowel resection, and with a retained metal fragment against the abdominal aorta at the level of the L4 vertebral body. REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD J. N. Moats, Counsel INTRODUCTION The Veteran had active service from May 1968 to December 1969. He is the recipient of the Purple Heart. This matter comes to the Board of Veterans' Appeals (Board) on appeal from September 2007 and July 2008 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Wichita, Kansas. The September 2007 rating decision granted the Veteran's claim for an increased rating for the residuals of multiple fragment wounds to the abdomen and assigned a rating of 30 percent, effective April 9, 2007, and the July 2008 rating decision denied the Veteran's claim for erectile dysfunction. This case was previously before the Board in October 2009. At that time, the Board remanded the issues of entitlement to an increased rating for residuals of multiple fragment wound to the abdomen and erectile dysfunction for a Board hearing. The issue of entitlement to an effective date prior to April 9, 2007, for the grant of a 30 percent rating for residuals of multiple fragment wound to the abdomen was remanded in order to provide the Veteran with a statement of the case pursuant to Manlincon v. West, 12 Vet. App. 238 (1999). A statement of the case was issued in March 2010 and the Veteran perfected his appeal in April 2010. In April 2010, the Veteran and his spouse testified at a Board hearing before the undersigned Veterans Law Judge at the RO; a copy of the transcript has been associated with the record. In September 2010, the Board again remanded the issues on appeal for further development. The case has now been returned to the Board for appellate review. The Board notes that, in addition to the paper claims file, there is a paperless, electronic (Virtual VA) claims file associated with the Veteran's claims. A review of the Virtual VA claims file reveals additional evidence not contained in the paper claims file, to include VA treatment records dated through January 2012, which was considered in the March 2012 supplemental statement of the case. The issue of entitlement to service connection for erectile dysfunction is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, D.C. FINDINGS OF FACT 1. For the entire appeal period, the Veteran's residuals of multiple fragment wounds to the abdomen, to include a small bowel perforation, a small bowel resection, and with a retained metal fragment against the abdominal aorta at the level of the L4 vertebral body, are the result of penetrating shrapnel wounds to the abdomen and are manifested by no more than a moderately severe muscle disability, with a retained foreign body, but are not productive of ragged, depressed, or adherent scars, loss of deep fascia or muscle substance, soft flabby muscles in wound area or muscles swelling and harden abnormally in contraction; tests of strength, endurance, or coordinated movements compared with the corresponding muscles of the uninjured side do not show severe impairment of function. 2. A rating in excess of 10 percent for residuals of multiple fragment wounds to the abdomen was denied in a June 2006 rating decision; the Veteran did not initiate appeal from this determination and new and material evidence was not received within one year of the issuance of the decision. 3. The Veteran filed a claim for an increased rating for residuals of multiple fragment wounds to the abdomen that was received by VA on April 9, 2007. 4. Prior to April 9, 2007, it was not factually ascertainable that the Veteran's service-connected residuals of multiple fragment wounds to the abdomen increased in severity so as to meet the criteria for a 30 percent rating. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 30 percent for residuals of multiple fragment wounds to the abdomen, to include a small bowel perforation, a small bowel resection, and with a retained metal fragment against the abdominal aorta at the level of the L4 vertebral body, have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.73, Diagnostic Code 5319 (2012). 2. The June 2006 rating decision that denied a rating in excess of 10 percent for residuals of multiple fragment wounds to the abdomen is final. 38 U.S.C.A. § 7105(c) (West 2002); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2005) [(2012)]. 3. The criteria for an effective date prior to April 9, 2007, for the assignment of a 30 percent disability rating for residuals of multiple fragment wounds to the abdomen, to include a small bowel perforation, a small bowel resection, and with a retained metal fragment against the abdominal aorta at the level of the L4 vertebral body, have not been met. 38 U.S.C.A. § 5110 (West 2002); 38 C.F.R. § 3.400 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Proper notice from VA must inform the claimant of any information and medical or lay 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 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim, including: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. VCAA notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as a statement of the case or supplemental statement of the case, is sufficient to cure a timing defect). In a claim for increase, the VCAA requires only generic notice as to the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). Here, the Veteran was sent letters in June 2007, November 2007, and October 2010 that fully addressed all notice elements of the issues decided herein. The letters provided information as to what evidence was required to substantiate his claims and of the division of responsibilities between VA and a claimant in developing a claim. Moreover, the letters informed the Veteran of what type of information and evidence was needed to establish a disability rating and effective date. The June 2007 letter was sent prior to the initial RO decision in this matter. Although the subsequent letters were issued after the initial decision, the claims were thereafter readjudicated most recently in March 2012. As such, any timing deficiency has here been appropriately cured. Mayfield, 444 F.3d 1328 (Fed. Cir. 2006). Accordingly, no further development is required with respect to the duty to notify. Furthermore, as relevant to the Veteran's effective date claim, the Board observes that the Veteran has appealed with respect to the propriety of the assigned effective date for the 30 percent rating assigned to his residuals of fragment wounds to the abdomen from the award of the increased rating. VA's General Counsel has held that no VCAA notice is required for such downstream issues. VAOPGCPREC 8-2003, 69 Fed. Reg. 25180 (May 5, 2004). In addition, the Board notes that the Court held that "the statutory scheme contemplates that once a decision awarding service connection, a disability rating, and an effective date has been made, § 5103(a) notice has served its purpose, and its application is no longer required because the claim has already been substantiated." Dingess v. Nicholson, 19 Vet. App. 473, 490 (2006). In this case, the Veteran's claim for an increased rating for his residuals of fragment wounds to the abdomen was granted and an effective date was assigned in the September 2007 rating decision on appeal. Therefore, as the Veteran has appealed with respect to the initially assigned effective date for his 30 percent rating, no additional 38 U.S.C.A. § 5103(a) notice is required because the purpose that the notice is intended to serve has been fulfilled. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Next, VA has a duty to assist the Veteran in the development of the claims. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The claims file contains the Veteran's service treatment records, post-service reports of VA treatment and VA examinations. A review of Virtual VA claims processing system reveals additional VA treatment records dated from January 2012, which were considered by the agency of original jurisdiction (AOJ) in the most supplemental statement of the case issued in March 2012. Moreover, the Veteran's statements and Board hearing testimony in support of the claims are of record. The Board has carefully reviewed such statements and testimony and concludes no available outstanding evidence has been identified. The Board has also perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claims. Additionally, the Veteran was afforded VA examinations in July 2007 and December 2010 to evaluate the severity of his service-connected residuals of multiple fragment wounds to the abdomen. The Veteran's representative has asserted that the most recent VA examination was insufficient because it did not address whether the retained metallic fragment caused low back pain. However, as discussed further below, the examiner clearly determined that the Veteran had no functional limitations due to his abdominal wounds. In other words, the examiner specifically found no additional limitations of the back associated with the Veteran's service-connected abdominal muscle injury. In sum, the Board finds that the VA examinations are adequate because, as discussed below, they were based upon consideration of the Veteran's pertinent medical history, his lay assertions and current complaints, and because they provide detail sufficient to allow the Board to make a fully informed determination. Barr v. Nicholson, 21 Vet. App. 303 (2007) (citing Ardison v. Brown, 6 Vet. App. 405, 407 (1994)). Furthermore, the Veteran has not asserted, and the evidence does not show, that his symptoms have materially worsened since the most recent December 2010 evaluation. See 38 C.F.R. §§ 3.326, 3.327 (reexaminations will be requested whenever VA determines there is a need to verify the current severity of a disability, such as when the evidence indicates there has been a material change in a disability or that the current rating may be incorrect); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). The Board accordingly finds no reason to remand for further examination. For the above reasons, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). Additionally, in April 2010, the Veteran was provided an opportunity to set forth his contentions during a hearing before a Veterans Law Judge. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that the decision review officer or Veterans Law Judge who chairs a hearing to fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the April 2010 hearing, the undersigned Veterans Law Judge noted the issues on appeal. Also, information was solicited regarding the functional impact the Veteran's service-connected residuals of multiple fragment wounds to the abdomen disability had on his daily life and employment. The Veteran also provided testimony as to why he felt an earlier effective date was warranted because he had experienced similar symptoms prior to the current effective date and the VA had not discovered that he had a retained metallic fragment until 2007. Therefore, not only were the issues "explained . . . in terms of the scope of the claim for benefits," but "the outstanding issues material to substantiating the claim," were also fully explained. See Bryant, 23 Vet. App. at 497. Moreover, the hearing discussion did not reveal any evidence that might be available that had not been submitted. In this regard, the Veteran testified that he received all of his treatment at the VA and in the subsequent remand, the Board specifically requested the AOJ to obtain all outstanding VA treatment records. Moreover, to the extent any such notice may have been inadequate, this was effectively cured both by actual knowledge as evidence by statements and questions of the Veteran's authorized representative at the hearing, as well as by the Board providing such explanation of issues and suggesting submission of evidence in the subsequent remand the Board issued to develop this claim. As such, the Board finds that, consistent with Bryant, the undersigned Veterans Law Judge complied with the duties set forth in 38 C.F.R. § 3.103(c)(2) and that the Board may proceed to adjudicate the claim based on the current record. Finally, the Board finds that there was substantial compliance with the October 2009 and September 2010 remand directives. A remand by the Board confers upon the claimant, as a matter of law, the right to compliance with the remand order. Stegall v. West, 11 Vet. App. 268 (1998). Nonetheless, it is only substantial compliance, rather than strict compliance, with the terms of a remand that is required. See D'Aries v. Peake, 22 Vet. App. 97, 104 (2008) (finding substantial compliance where an opinion was provided by a neurologist as opposed to an internal medicine specialist requested by the Board); Dyment v. West, 13 Vet. App. 141 (1999). In particular, the October 2009 Board remand directed that the Veteran be afforded his requested hearing before a Veterans Law Judge, which was accomplished in April 2010 and also issue a statement of case with respect to the earlier effective date issues, which was done in March 2010. Additionally, with respect to the issues being decided herein, the Board in September 2010 directed the AOJ to obtain additional VA treatment records and schedule the Veteran for a VA examination. As noted above, additional VA treatment records dated from January 2012 were associated with the Veteran's Virtual VA electronic record and the Veteran was afforded a VA examination in December 2010 that is adequate for appellate review. Accordingly, the Board finds that there has been substantial compliance with the prior Board remand directives and, therefore, no further remand is necessary. See Stegall, supra; D'Aries, 22 Vet. App. at 104 (2008). II. Increased Rating for Residuals of Multiple Fragment Wounds to the Abdomen The Veteran is seeking a rating in excess of 30 percent for his service-connected residuals of multiple fragment wounds to the abdomen. Disability evaluations are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. To evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where an increase in the level of a disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Separate ratings for distinct periods of time, based on the facts are for consideration. Hart v. Mansfield, 21 Vet. App. 505 (2007). The RO has rated the Veteran's disability as 30 percent disabling under Diagnostic Code 5319 for muscle injury. Muscle injuries are evaluated pursuant to criteria at 38 C.F.R. §§ 4.55, 4.56, and 4.73. For rating purposes, the skeletal muscles of the body are divided into 23 muscle groups in 5 anatomical regions. 38 C.F.R. § 4.55(b). The specific bodily functions of each group are listed at 38 C.F.R. § 4.73. The severity of the muscle disability is determined by application of criteria at 38 C.F.R. § 4.56. First, an open comminuted fracture with muscle or tendon damage will be rated as severe, unless (for locations such as the wrist or over the tibia) the evidence establishes that the muscle damage is minimal. 38 C.F.R. § 4.56(a). A through and through injury with muscle damage shall be evaluated as no less than a moderate injury for each group of muscles damaged. 38 C.F.R. § 4.56(b). For VA rating purposes, the cardinal signs and symptoms of muscle disability are loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination and uncertainty of movement. 38 C.F.R. § 4.56(c). Under Diagnostic Codes 5301 to 5323, muscle injuries disabilities are rated as slight, moderate, moderately severe or severe according to criteria based on the type of injury, the history and complaint, and objective findings. 38 C.F.R. § 4.56(d). Diagnostic Code 5319 applies to residuals of injury to Muscle Group XIX, namely the muscles of the abdominal wall. The function of these muscles is support and compression of the abdominal wall and thorax, flexion and lateral motions of the spine, and synergists in strong downward movements of the arm. Under this code, a noncompensable rating is assigned for slight disability, a 10 percent evaluation is assigned for a moderate disability, a 30 percent evaluation is contemplated for a moderately severe disability, and a maximum 50 percent evaluation is contemplated for a severe disability. 38 C.F.R. § 4.56 provides that slight muscle disability is found where there has been a simple wound of the muscle without debridement or infection. Clinical examination would disclose the absence of fascial defect, atrophy or impaired tonus. No impairment of function or metallic fragments retained in muscle tissue would be present. 38 C.F.R. § 4.56. The type of injury associated with a moderate muscle disability is a through and through or deep penetrating wound of short track from a single bullet, small shell or shrapnel fragment, without explosive effect of high velocity missile, residuals of debridement, or prolonged infection. A history with regard to this type of injury should include service department evidence or other evidence of in-service treatment for the wound and consistent complaints of one or more of the cardinal signs and symptoms of muscle disability, particularly lowered threshold of fatigue after average use affecting the particular functions controlled by the injured muscles. Objective findings should include entrance and (if present) exit scars, small or linear, indicating short track of missile through muscle tissue and some loss of deep fascia or muscle substance or impairment of muscle tonus and loss of power or lowered threshold of fatigue when compared to the sound side. 38 C.F.R. § 4.56(d)(2). The type of injury associated with a moderately severe muscle disability is a through and through or deep penetrating wound by a small high-velocity missile or large low-velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intermuscular scarring. A history with regard to this type of injury should include prolonged hospitalization in service for treatment of wound, consistent complaints of cardinal signs and symptoms of muscle disability, and, if present, evidence of inability to keep up with work requirements. Objective findings should include entrance and (if present) exit scars indicating the track of the missile through one or more muscle groups, and indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with the sound side. Tests of strength and endurance compared with sound side should demonstrate positive evidence of impairment. 38 C.F.R. § 4.56(d)(3). The type of injury associated with a severe muscle disability is a through and through or deep penetrating wound by a small high-velocity missile or large or multiple low-velocity missiles, or with shattering bone fracture or open comminuted fracture with extensive debridement, prolonged infection, or sloughing of soft parts, and intermuscular binding and scarring. A history with regard to this type of injury should include prolonged hospitalization in service for treatment of wound, consistent complaints of cardinal signs and symptoms of muscle disability, worse than those shown for moderately severe muscle injuries, and, if present, evidence of inability to keep up with work requirements. Objective findings should include ragged, depressed, and adherent scars indicating wide damage to muscle groups in missile track, and indications on palpation of loss of deep fascia, muscle substance, or soft flabby muscles in wound area. Also, muscles swell and harden abnormally in contraction. Tests of strength, endurance, or coordinated movements compared with the corresponding muscles of the uninjured side should indicate severe impairment of function. If present, the following are also signs of severe muscle disability: (A) X- ray evidence of minute multiple scattered foreign bodies indicating intermuscular trauma and explosive effect of missile; (B) adhesion of scar to one of the long bones, scapula, pelvic bone, sacrum, or vertebrae, with epithelial sealing over the bone, rather than true skin covering in an area where bone is normally protected by muscle; (C) diminished muscle excitability to pulsed electrical current in electrodiagnostic tests; (D) visible or measurable atrophy; (E) adaptive contraction of an opposing group of muscles; (F) atrophy of muscle groups not in the track of the missile, particularly of the trapezius and serratus in wounds of the shoulder girdle; and (G) induration or atrophy of an entire muscle following simple piercing by a projectile. 38 C.F.R. § 4.56(d)(4). Service treatment records showed that the Veteran sustained multiple fragment wounds to the abdomen in April 1969. A laparotomy was performed and perforation of the small bowel, mid jejunum was noted so 3 inches of bowel was resected. A small mesenteric vein was repaired and there was venous enlargement in the mesentery that was improved with removal of a mesenteric hematoma. There was no nerve or artery involvement and the postoperative course was uneventful. The Veteran filed his current claim for an increased rating in April 2007. VA treatment records the year prior to this claim do no specifically address the severity of the Veteran's residuals of multiple fragment wounds to the abdomen. He was afforded a VA examination in July 2007. The claims file was not available for review. However, VA treatment records were considered. The Veteran reported difficulty wearing tight clothing as it caused discomfort on the abdomen. The examiner observed that the Veteran's weight had been fairly stable in the last 12 months with recent weight loss of four pounds. He had been working on weight loss as he was told by his doctor that he was on the edge of sugar diabetes. The Veteran denied any nausea or vomiting. He did report constipated stool every other day and had taken a stool softener in the past. He also indicated that he had diarrhea at least once per week. There was no fistula. On physical examination, the examiner observed that the Veteran wore a belt cinched at the waist. He pointed to the distal end of his scar line and a small indentation was present. The Veteran indicated that this location was where he experienced pain since his surgical repair. The pain was described as like "something trying to get out." State of nutrition was good and lab results were within normal limits. The Veteran complained of abdominal muscle spasms three to four times per week that lasted for 15 to 30 minutes. It was noted that a March 2006 x-ray of the abdomen showed a 5mm metallic density abutting the anterior aspect of abdominal aorta at the level of L4 vertebral body, otherwise unremarkable. The examiner then described the post-operative mid-abdominal scar and observed that the Veteran had a persistent abnormal sensation at distal end of scar. The scar was tender to touch and slightly pale compared to surrounding skin. There was one point of indentation at the distal end of the scar. The scar was stable and slightly hypopigmented with induration depth of 3/4 cm. It was well-healed and flush with surrounding skin. There was no underlying soft tissue damage. Importantly, the scar was non-adherent and no limitations of motion or function were caused by the scar. The diagnosis was status post shell fragment wound injury to the abdomen with exploratory laparotomy and bowel resection 1969; and mid line abdominal scar secondary to 1969 surgery. The examiner indicated that the etiology of diverticulosis and irritable bowel syndrome could not be determined without resorting to mere speculation. In his notice of disagreement, the Veteran reported that he had to take medication for his abdominal muscle spasms. Further, in his substantive appeal, the Veteran requested a 50 percent rating due to extent of muscle damage, surgeries documented in service treatment records and retention of shrapnel in his body. In other statements of record, he primarily described back and left leg pain that was affecting his ability to do his job as a golf professional. Again, he associated this pain with the shrapnel in his back. VA treatment records document that the Veteran had an exploratory laparotomy after the 1969 shrapnel injury with retained shrapnel observed on a March 2006 X-ray. However, examinations of the abdomen showed that it was soft with no tenderness. Moreover, a November 2007 CT of the abdomen was negative. VA treatment records also showed complaints of chronic mechanical low back pain that the Veteran had attributed to his residuals of shell fragment wounds to the abdomen. Importantly, a March 2010 record, showed that degenerative disease was noted on an April 2009 CT scan as well as a pars defect at L5. The examiner indicated that these findings were the cause of the Veteran's pain. There was also no obvious radiculopathy. However, a follow up April 2011 record showed an assessment of mild left lower lumbar radiculopathy. A June 2011 record showed that the Veteran reported abdominal cramps and muscle spasms on both sides of the abdomen. Treatment records also noted that the Veteran worked full time as a manager of a golf course. At the Board hearing, the Veteran testified that he had been complaining of pain for years and in 2007, after a CT scan the found shrapnel in him, which the Veteran asserted was the cause of the pain in his back, stomach and legs. The Veteran provided testimony indicating that he experiences sharp pains in the area of his injuries and problems sleeping. He further indicated that the pain bothered him while playing golf. His wife and he also reported hemorrhoids as well as other bowel and urinary problems, which he attributed to his abdomen injury. The Veteran also described pain and itching due to the scar as well as missing a piece of bone. However, while he indicated not being able to stand for long periods of time due to his back, he provided that he was still able to manage the golf course where he worked. The Veteran's representative asserted that at least a 60 percent rating was warranted. Given the possibility of an increase in severity since the last examination, on remand, the Veteran was afforded another VA examination in November 2010. The claims file was reviewed. The Veteran reported abdominal pain several times a week, which lasted up to 30 to 45 minutes, in the form of abdominal cramping. The episodes had increased since the last VA examination. On physical examination, there was no evidence of malnutrition, anemia or other debility. Abdominal examination showed mild tenderness diffusely throughout both lower quadrants. There were no fistulas or ostomies present. There were also no masses present. The examiner again observed that the Veteran had an abdominal scar. There were diastasis recti when the Veteran performed Valsalva maneuver. There was also an oval scar where the shrapnel fragments entered that measured 1.5 x 0.5 cm. All scars were slightly hypopigmented and nontender. They were superficial with no soft tissue loss or damage. Moreover, no other abnormalities were observed. The scars were smooth, flat with no adherence to underlying tissue. Importantly, the examiner determined that there was no limitation of motion or function due to the scars. The diagnoses were gastroesophageal reflux disease, diverticulitis of the sigmoid colon, internal and external hemorrhoids, and projectile wound to the abdomen with exploratory laparotomy and small bowel resection. The examiner determined that the repair of the Veteran's wounds did not interfere with any strength, endurance or coordinated movements. As the incision was a midline incision, both left and right sides of the abdomen were equal and not affected. The examiner also determined that the Veteran had no limitations of movement due to the abdominal wounds. There were also no focal neurologic manifestations or defects and no radiating pain as a result of this injury to either lower extremity. There were also no associated bowel or bladder impairments. The examiner continued that the Veteran's service-connected disability did not impact the Veteran's ability to work. The Veteran had a history of being substantially gainfully employed since discharge and was still working as a golf course manager. Initially, the Board observes that the Veteran has claimed other problems/symptoms associated with the residuals of his shell fragment wounds to the abdomen, including bowel problems, hemorrhoids and nerve damage to the lower left extremity. However, there has been no medical evidence to support these contentions and the most recent VA examiner, after thoroughly examining the Veteran and reviewing the claims file, clearly determined that there were no functional/neurological impairment or bowel problems associated with the Veteran's service-connected abdominal muscle disability. Moreover, the RO denied a claim for a left lower extremity disability in a June 1997 rating decision and again in a June 2006 rating decision, which was appealed to the Board. The Board upheld the RO's denial in an April 2009 decision. Further, the RO denied service connection for these disabilities in the September 2007 rating decision, which the Veteran did not appeal. As such, these matters are not currently before the Board. The Veteran has also primarily described the shrapnel in his back when discussing his symptoms. However, in a March 2007 rating decision, the RO granted a separate 10 percent rating for shrapnel in the back. The Veteran has also been assigned a separate 10 percent rating for his residual surgical scar. Again, as the Veteran did not appeal the ratings assigned, these issues are also not currently before the Board. With respect to the other oval scar identified at the most recent examination, as the scar was described as superficial and linear, and was considered not painful, unstable or limit function, a separate compensable rating for this scar is not warranted. See 38 C.F.R. § 4.118. In sum, the competent medical evidence does not show that the Veteran has any other separately ratable disabilities associated with his service-connected residuals of multiple fragment wounds. In addition, after thoroughly considering the evidence of record, and with consideration of the totality of the circumstances, the Board finds that a rating in excess of 30 percent is not warranted for the Veteran's residuals of multiple fragment wounds to the abdomen, to include a small bowel perforation, a small bowel resection, and with a retained metal fragment against the abdominal aorta at the level of the L4 vertebral body. While the shell fragment resulted in a retained metallic fragment, there are no cardinal signs or symptoms of a severe muscle disability, such as loss of deep fascia or muscle substance, or impairment of muscle tonus, and an associated loss of power, weakness, lowered threshold of fatigue after average use affecting their functions. Importantly, at both VA examinations, the surgical scar has been described as non-adherent with no underlying tissue damage. Moreover, when specifically requested to address whether the Veteran had any of these symptoms, the November 2010 examiner stated that both sides of the abdomen were equal and not affected and there was no interference with strength, endurance or coordinated movement. Importantly, in response to whether there were any other residuals, particularly with respect to the back, as a result of the Veteran's shell fragment wounds, the examiner clearly stated that the Veteran had no limitations of movement due to the abdominal injury. The Veteran also had no neurological or bladder or bowel impairments. In making these determinations, the VA examiner was aware of the Veteran's lay assertions and medical history. Moreover, the examiner had performed a thorough medical examination of the Veteran's injury. The Board has carefully reviewed and considered the Veteran's statements regarding the severity of his residuals of multiple fragment wounds to the abdomen as well as his contentions of separate impairment of the left lower extremity, hemorrhoids and the bladder and bowel problems. The Board acknowledges that the Veteran, in advancing this appeal, believes that the disability on appeal has been more severe than the assigned disability rating reflects. Moreover, the Veteran is competent to report observable symptoms. Layno v. Brown, 6 Vet. App. 465 (1994). However, he is not competent to associate separate disabilities or symptoms with his abdominal injury as special medical expertise is required because in determining whether these disabilities and/or symptoms are associated with the Veteran's abdominal injury involves a medical subject concerning an internal physical process that extends beyond an immediately observable cause-and-effect relationship. As such, this matter may not be competently addressed by lay evidence, and the Veteran's own opinion is nonprobative evidence. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Further, in this case, the competent medical evidence offering detailed specific specialized determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal; the medical evidence also largely contemplates the Veteran's descriptions of symptoms. The lay testimony has been considered together with the probative medical evidence clinically evaluating the severity of the pertinent disability symptoms. The Board has considered whether staged ratings under Hart, supra, are appropriate for the Veteran's service-connected residuals of multiple fragment wounds to the abdomen, to include a small bowel perforation, a small bowel resection, and with a retained metal fragment against the abdominal aorta at the level of the L4 vertebral body; however, the Board finds that his symptomatology has been stable throughout the appeal period. Therefore, assigning staged ratings for such disability is not warranted. Additionally, the Board has contemplated whether the case should be referred for extra-schedular consideration. In general, the schedular disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. The application of such schedular criteria was discussed in great detail above. To accord justice in an exceptional case where the schedular standards are found to be inadequate, the RO is authorized to refer the case to the Chief Benefits Director or the Director, Compensation and Pension Service for assignment of an extraschedular evaluation commensurate with the average earning capacity impairment. 38 C.F.R. § 3.321(b)(1)). An extra-schedular disability rating is warranted if the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that application of the regular schedular standards would be impracticable. Id. The Court has held that the Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance; however, the Board is not precluded from raising this question, and in fact is obligated to liberally read all documents and oral testimony of record and identify all potential theories of entitlement to a benefit under the law and regulations. Floyd v. Brown, 9 Vet. App. 88 (1996). The Court further held that the Board must address referral under 38 C.F.R. §3.321(b)(1) only where circumstances are presented which the Director of VA's Compensation and Pension Service might consider exceptional or unusual. Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). In Thun v. Peake, 22 Vet. App. 111 (2008), the Court clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. Either the RO or the Board must first determine whether the schedular rating criteria reasonably describe the Veteran's disability level and symptomatology. Id. at 115. If the schedular rating criteria do reasonably describe the Veteran's disability level and symptomatology, the assigned schedular evaluation is adequate, referral for extraschedular consideration is not required, and the analysis stops. If the RO or the Board finds that the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology, then either the RO or the Board must determine whether the Veteran's exceptional disability picture includes other related factors such as marked interference with employment and frequent periods of hospitalization. Id. at 116. If this is the case, then the RO or the Board must refer the matter to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for the third step of the analysis, determining whether justice requires assignment of an extraschedular rating. Id. The Board has carefully compared the level of severity and symptomatology of the Veteran's service-connected residuals of multiple fragment wounds to the abdomen, to include a small bowel perforation, a small bowel resection, and with a retained metal fragment against the abdominal aorta at the level of the L4 vertebral body, with the established criteria found in the rating schedule. The Board finds that the Veteran's residuals of multiple fragment wounds to the abdomen are fully addressed by the rating criteria under which such disability is rated. In this regard, the Veteran's 30 percent rating contemplates his pain and functional loss associated with his muscle injury. Although the Veteran has asserted additional symptoms, as discussed above, these symptoms have not been found to be associated with his service-connected disability. In sum, there are no additional symptoms of his residuals of multiple fragment wounds to the abdomen that are not addressed by the rating schedule. Therefore, the Board finds that the rating criteria reasonably describe the Veteran's disability level and symptomatology of his service-connected disability. As such, the Board finds that the rating schedule is adequate to evaluate the Veteran's disability picture. Therefore, the Board need not proceed to consider the second factor, viz., whether there are attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization. Consequently, the Board concludes that referral of this case for consideration of an extra-schedular rating is not warranted. Id.; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). The Court has held that a request for a total disability rating based on individual unemployability (TDIU), whether expressly raised by a Veteran or reasonably raised by the record, is not a separate claim for benefits, but rather involves an attempt to obtain an appropriate rating for a disability or disabilities, either as part of the initial adjudication of a claim or, if the disability upon which entitlement to TDIU is based has already been found to be service-connected, as part of a claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). However, in the instant case, the record shows that the Veteran is still currently employed full time and, thus, the matter of TDIU need not be further considered. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim for a rating in excess of 30 percent for his residuals of multiple fragment wounds to the abdomen, to include a small bowel perforation, a small bowel resection, and with a retained metal fragment against the abdominal aorta at the level of the L4 vertebral body, for the appeal period. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 4.3, 4.7. III. Earlier Effective Date for Residuals of Multiple Fragment Wounds to the Abdomen The Veteran is also seeking an effective date prior to April 9, 2007 for the grant of a 30 percent disability rating for his service-connected residuals of multiple fragment wounds to the abdomen. As the VA failed to notice that the Veteran had retained shrapnel in his back, he essentially contends that the 30 percent rating should date back to 1970 when he first sought treatment at the VA. The law pertaining to the effective date of a VA claim for increase in disability mandates that unless specifically provided otherwise, the effective date for the increase shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of the application therefor. 38 U.S.C.A. § 5110(a); 38 C.F.R. § 3.400. The pertinent statute then goes on to specifically provide that the effective date of an award of increased compensation shall be the earliest date as of which it is ascertainable that an increase in disability had occurred, if any application is received within one year from such date. 38 U.S.C.A. § 5110(b)(2); 38 C.F.R. § 3.400(o). If the increase became ascertainable more than one year prior to the date of receipt of the claim, then the proper effective date would be the date of claim. In a case where the increase became ascertainable after the filing of the claim, then the effective date would be the date of increase. See generally Harper v. Brown, 10 Vet. App. 125 (1997). Following notification of an initial review and adverse determination by the RO, a notice of disagreement must be filed within one year from the date of notification thereof; otherwise, the determination becomes final. 38 U.S.C.A. § 7105. Applicable regulations provide that if new and material evidence was received during an applicable appellate period following a RO decision (1 year for a rating decision and 60 days for a SOC) or prior to an appellate (Board) decision (if an appeal was timely filed), the new and material evidence will be considered as having been filed in connection with the claim that was pending at the beginning of the appeal period. 38 C.F.R. § 3.156(b); Young v. Shinseki, 22 Vet. App. 461, 466 (2009). Thus, under 38 C.F.R. § 3.156(b), "VA must evaluate submissions received during the relevant [appeal] period and determine whether they contain new evidence relevant to a pending claim, whether or not the relevant submission might otherwise support a new claim." Bond v. Shinseki, 659 F.3d 1362, 1367-68 (Fed. Cir. 2011). "[N]ew and material evidence" under 38 C.F.R. § 3.156(b) has the same meaning as "new and material evidence" as defined in 38 C.F.R. § 3.156(a). See Young v. Shinseki, 22 Vet. App. 461, 468 (2011). Initially, the Board notes that in October 2005, the Veteran filed a claim for a rating in excess of 10 percent for residuals of fragment wounds to the abdomen, which was denied by the RO in a June 2006 rating decision. The Veteran was informed of this decision in a June 2006 letter, but he failed to file a notice of disagreement within one year with respect to the rating assigned. The Veteran filed a statement that same month indicating that he was seeking secondary service connection for hemorrhoids as well as requesting VA to reconsider his claim for left hip, leg, calf, ankle and foot disabilities. However, while the Veteran indicated that he still had shrapnel in his back that was causing problems to his left side, there is nothing in this statement clearly expressing disagreement with the June 2006 rating and showing a desire to appeal the rating assigned pursuant to 38 C.F.R. § 20.201. The RO appropriately treated this statement as a claim for secondary service connection for the disabilities listed and addressed the claim in a subsequent rating decision issued in March 2007. While the Veteran also submitted other statements during the one year period, these statements all address other unrelated disorders. There is no indication in the record of any intent to file a claim for an increased disability evaluation for service-connected residuals of fragment wounds to the abdomen until he filed his current claim, which was received by VA on April 9, 2007. While this statement was also submitted within one year of the previous June 2006 rating decision, it can also not be construed as a valid notice of disagreement as again the Veteran did not express disagreement with that rating decision and a desire to appeal. Rather, he expressly requested an increased rating for his shrapnel wound. Moreover, the claims file does not include any additional new and material evidence addressing the severity of the Veteran's residuals of fragment wounds that was received within one year of the June 2006 rating decision. In other words, there is no evidence of an increase in severity during this period. In his statements of record, the Veteran primarily refers to a retained metallic fracture his spine for which he was granted service-connection in the March 2007. Evidence of this density and any effect on the Veteran's residuals of fragment wounds was already addressed in a prior February 2006 VA examination. In sum, there is no new and material evidence submitted during this period, which would require the RO to reconsider this matter in another rating decision. Therefore, the Veteran did not submit a notice of disagreement within one year of notice of the June 2006 RO rating decision. Moreover, new and material evidence was not submitted within one year of this decision and, in turn, the provisions of 38 C.F.R. § 3.156(b) are not applicable. Accordingly, this decision is final. 38 U.S.C.A. § 7105(c) (West 2002); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2005) [(2012)]. With consideration of the above analysis that the June 2006 rating decision is final, the first claim for an increase for residuals of fragment wounds to the abdomen was received on April 9, 2007. In this regard, the Board notes that, pursuant to 38 C.F.R. § 3.155, any communication or action, indicating an intent to apply for one or more benefits under the laws administered by VA, from a claimant, his or her duly authorized representative, a Member of Congress, or some person acting as next friend of a claimant who is not sui juris may be considered an informal claim. Such informal claim must identify the benefit sought. Upon receipt of an informal claim, if a formal claim has not been filed, an application form will be forwarded to the claimant for execution. If received within 1 year from the date it was sent to the claimant, it will be considered filed as of the date of receipt of the informal claim. In this case, subsequent to the June 2006 rating decision and prior to April 9, 2007, there is no communication from the Veteran or an authorized individual acting on his behalf, to include his representative, evidencing an intent to apply for an increased rating for fragment wounds of the abdomen. In this regard, a June 2006 statement was received subsequent to the June 2006 rating decision in which he indicated that he was seeking secondary service connection for hemorrhoids as well as requesting VA to reconsider his claim for left hip, leg, calf, ankle and foot disabilities. He also indicated that he still had shrapnel in his back that was causing problems to his left side. However, such statement did not request an increase in the abdominal disability. Moreover, while the Veteran also submitted other statements during the time period between the issuance of the June 2006 rating decision and the receipt of the April 2007 claim, these statements all address other unrelated disorders. Pursuant to 38 C.F.R. § 3.157(b), once a formal claim for compensation has been allowed or a formal claim for compensation disallowed for the reason that the service-connected disability is not compensable in degree, receipt of (1) a report of examination or hospitalization by VA or uniformed services, (2) evidence from a private physician or layman, or (3) reports and records from State and other institutions will be accepted as an informal claim for increased benefits or an informal claim to reopen. The Board has considered the applicability of 38 C.F.R. § 3.157(b); however, a report of examination or hospitalization by VA or uniformed services, evidence from a private physician or layman, or reports and records from State and other institutions were not received in the time period between the issuance of the June 2006 rating decision and the receipt of the April 2007 claim. Therefore, the Board finds that the Veteran's claim for an increased rating for his fragment wounds of the abdomen was first received by VA on April 9, 2007, after the previous final denial in June 2006. The general rule, as provided at 38 C.F.R. § 3.400(o)(1), is that the effective date of the award of an increased evaluation is the date of the Veteran's claim, April 9, 2007, or the date entitlement is shown, whichever is later. Therefore, the focus of the Board's review becomes whether it is factually ascertainable that the Veteran experienced an increase in his service-connected residuals of multiple fragment wounds to the abdomen during the year prior to April 9, 2007 to warrant a higher rating. See Quarles v. Derwinski, 3 Vet. App. 129, 135 (1992); see also Harper v. Brown, 10 Vet. App. 125, 126 (1997) (38 U.S.C.A. § 5110(b)(2) and 38 C.F.R. § 3.400(o)(2) are applicable only where the increase precedes the claim (provided also that the claim is received within one year after the increase)). In making this determination, the Board will review the entirety of the evidence of record. See Hazan v. Gober, 10 Vet. App. 511 (1997); Swanson v. West, 12 Vet. App. 442 (1999). The Board has considered whether it was factually ascertainable that the Veteran's service-connected disability had increased in severity in the year prior to April 9, 2007. The medical evidence of record does not specifically reflect treatment for this disability during this period. Moreover, evidence dated after time period, to include the VA examinations in July 2007 and December 2010 as well as additional treatment records, fail to demonstrate a factually ascertainable increase in the severity of such disability prior to April 9, 2007. The Board has also considered the Veteran's lay statements that he had symptoms indicative of a 30 percent rating prior to April 2007, as reported at his April 2010 hearing. However, he testified that such symptoms included back, foot, and leg pain, and that he had retained shrapnel in his back. As indicated previously, the RO denied a claim for a left lower extremity disability in a June 1997 rating decision and again in a June 2006 rating decision, which was appealed to the Board. The Board upheld the RO's denial in an April 2009 decision. Moreover, there is no indication that such disorders are related to the Veteran's abdominal disability and, therefore, cannot serve to support a 30 percent rating pursuant to Diagnostic Code 5319. The Veteran has also primarily described the shrapnel in his back when discussing his symptoms. However, in a March 2007 rating decision, the RO granted a separate 10 percent rating for shrapnel in the back. The Veteran has also been assigned a separate 10 percent rating for his residual surgical scar. As he has been awarded separate compensable ratings for such disabilities, such symptomatology cannot serve to support a 30 percent rating for the Veteran's abdominal disability as such would be tantamount to pyramiding. 38 C.F.R. § 4.14 (pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a Veteran's service-connected disabilities). Therefore, absent any evidence beyond the Veteran's general assertion that his abdominal disability met the criteria prior to April 2007, the Board finds that it was not factually ascertainable that his service-connected disability had increased in severity in the year prior to April 9, 2007, so as to warrant a 30 percent rating pursuant to Diagnostic Code 5319. In conclusion, based on the analysis above, an effective date prior to April 9, 2007, for a 30 percent disability rating for service-connected residuals of multiple fragment wounds to the abdomen, to include a small bowel perforation, a small bowel resection, and with a retained metal fragment against the abdominal aorta at the level of the L4 vertebral body, is not warranted. In denying an earlier effective date, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 4.3, 4.7. ORDER A rating in excess of 30 percent for residuals of multiple fragment wounds to the abdomen, to include a small bowel perforation, a small bowel resection, and with a retained metal fragment against the abdominal aorta at the level of the L4 vertebral body, is denied. An effective date prior to April 9, 2007, for the award of a 30 percent disability rating for residuals of multiple fragment wounds to the abdomen, to include a small bowel perforation, a small bowel resection, and with a retained metal fragment against the abdominal aorta at the level of the L4 vertebral body, is denied. REMAND The Veteran is also seeking service connection for erectile dysfunction. Although the Board regrets further delaying appellate review with respect to this issue, the Board finds that further development is necessary. On remand, the Veteran was afforded a VA examination in December 2010. The examiner determined that the Veteran's erectile dysfunction was less likely as not caused by or a result of injury received during military or caused by or aggravated by his service-connected residuals of multiple fragment wounds or by medication prescribed for this condition. The examiner rationalized that he did not have erectile dysfunction until 1992 to 1993, which was 23 years following his injury. After reviewing the medical literature, the examiner determined that his erectile dysfunction would have occurred immediately if it was due to the injury in Vietnam. Moreover, as the pelvis was not injured, there was no nexus between the Veteran's service-connected injury and onset of erectile dysfunction. However, while the examiner did provide a rationale for why the Veteran's erectile dysfunction was not directly related to the abdominal injury, the examiner failed to offer a detailed rationale as to why the Veteran's medications prescribed for his service-connected disability did not cause or aggravate his erectile dysfunction. In an October 2010 statement, the Veteran indicated that he had been told by his VA doctor that his erectile dysfunction could be caused by the medication he took for his abdominal injury. Moreover, the examiner did cite to certain medical evidence indicating that there could be psychological problems causing erectile dysfunction as well as medications. The Board observes that in a September 2010 rating decision, the RO granted service connection for PTSD. However, the Veteran has not been provided an opinion as to whether his erectile dysfunction could be secondary to his service-connected PTSD. The Court has held that a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008); 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"). Moreover, once VA undertakes the effort to provide an examination for a service connection claim, even if not statutorily obligated to do so, 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). Accordingly, given the lack of rationale provided with respect to the Veteran's medications and the examiner's indication that psychological problems could cause erectile dysfunction, the Board finds that another VA examination should be afforded to the Veteran to determine the nature, extent and etiology of the Veteran's erectile dysfunction. Accordingly, the case is REMANDED for the following actions: 1. The Veteran should be scheduled for an appropriate VA examination to determine the etiology of his erectile dysfunction. It is imperative that the claims file be made available to the examiner for review in connection with the examination, to specifically include these remand instructions. All medically necessary tests should be performed. After reviewing the claims file and examining the Veteran, the examiner should offer an opinion as to the following: a) Whether it is at least as likely as not (a 50% or higher degree of probability) that erectile dysfunction is caused by the Veteran's service-connected PTSD and/or any medications taken for his service-connected disabilities. b) Whether it is at least as likely as not (a 50% or higher degree of probability) that erectile dysfunction has been aggravated by the Veteran's service-connected PTSD and/or any medications taken for his service-connected disabilities. For any aggravation found, the examiner should state, to the best of their ability, the baseline of symptomatology and the amount, quantified if possible, of aggravation beyond the baseline symptomatology by the aggravation. A detailed rationale for all opinions expressed should be provided. 2. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran's claim should be readjudicated based on the entirety of the evidence. If the claim remains denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. The Board intimates no opinion as to the outcome of this case. The Veteran need take no action until so informed. The purpose of this REMAND is to ensure compliance with due process considerations. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). The claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board 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). ______________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs