Citation Nr: 1324674 Decision Date: 08/02/13 Archive Date: 08/13/13 DOCKET NO. 05-09 484 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to service connection for bilateral hearing loss. 2. Entitlement to service connection for tinnitus. 3. Entitlement to service connection for hypertension. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D. Havelka, Counsel INTRODUCTION The Veteran served on active duty from December 1964 to December 1968 and from January to May 1991. The Veteran also served in the Army National Guard from January 1985 to January 1995 and in the Army Reserve from January 1995 to January 2002. This matter comes before the Board of Veterans' Appeals (Board) on appeal from March 2003 and May 2004 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. In August 2006, the Veteran testified at a hearing at the RO before the undersigned Veterans Law Judge sitting in Washington, DC. A transcript of this testimony is associated with the claims file. The case was previously before the Board in January 2007, May 2009, June 2010, and July 2012, when it was remanded for additional development including examination and medical opinions. The requested development has been completed. The Veteran's appeal was processed, in part, using the Virtual VA paperless claims processing system. Accordingly, any future consideration of this appellant's case should take into consideration the existence of this electronic record. The issue of entitlement to service connection for hypertension is addressed in the REMAND portion of the decision below and is REMANDED to the Department of Veterans Affairs Regional Office. FINDINGS OF FACT 1. Service treatment records do not reveal any complaints, symptoms or diagnosis, of tinnitus during active duty service or any other period of active military service. 2. Service treatment records reveal that the Veteran had normal hearing during his period of active duty service in the Navy from 1964 to 1968; his ears and hearing were normal on separation examination. 3. A January 1985 National Guard enlistment examination revealed audiology findings of a slight level of hearing loss at the 4000 Hertz level of the left ear upon enlistment. 4. Periodic examination during the Veteran's periods of National Guard and Army reserve service reveal some hearing loss upon examination; there are no reports of tinnitus contained in any of the service treatment records. 5. There is no credible evidence linking any current hearing loss or tinnitus disability to the Veteran active duty, to any other period of active military service, or to any noise exposure or acoustic trauma possibly experienced during any period of active duty, ADT or IDT. CONCLUSIONS OF LAW 1. The criteria for service connection for bilateral hearing loss have not been met. 38 U.S.C.A. §§ 101(16), 1110, 1112, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.385 (2012). 2. The criteria for service connection for tinnitus have not been met. 38 U.S.C.A. §§ 101(16), 1110, 1112, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Notice and Assistance Upon receipt of a complete or substantially complete application, VA must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a). The notice requirements apply to all five elements of a service connection claim: 1) veteran status; 2) existence of a disability; 3) a connection between the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006); see also Vazquez-Flores v. Shinseki, 580 F.3d 1270 (2009). The notice must be provided prior to an initial unfavorable decision by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). The notice requirements may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). The RO provided the appellant notice for his claims for service connection for hearing loss and tinnitus in letters dated August 2003 and March 2006. These notification letters substantially complied with the requirements of Quartuccio v. Principi, 16 Vet. App. 183 (2002), identifying the evidence necessary to substantiate a claim, the relative duties of VA and the claimant to obtain evidence, and the requirements of Dingess v. Nicholson, 19 Vet. App. 473 (2006) regarding notification of the laws regarding degrees of disability and effective dates. The claims for service connection were subsequently readjudicated in December 2009 and December 2012. VA has obtained service treatment records; VA examination reports; private treatment records; VA treatment records; assisted the appellant in obtaining evidence; and afforded him the opportunity to present statements and evidence. All known and available records relevant to the issue on appeal have been obtained and associated with the appellant's claims file and he has not contended otherwise. Accordingly, the appellant is not prejudiced by a decision at this time. II. Veteran Status A "veteran" is a person who served in active military, naval, or air service. See 38 U.S.C.A. § 101(2) (West 2002). Pursuant to 38 U.S.C.A. § 101(24), "'active military, naval, or air service' includes active duty, any period of active duty for training (ADT) during which the individual concerned was disabled or died from a disease or injury incurred in or aggravated in line of duty, and any period of inactive duty training during (IDT) which the individual concerned was disabled or died from an injury incurred in or aggravated in line of duty." 38 U.S.C.A. § 101(24) (West 2002). Put another way, service connection may be granted for disability resulting from disease or injury incurred in or aggravated while performing ADT, or for an injury incurred during IDT. See also, 38 C.F.R. § 3.6. The Veteran's discharge papers, DD 214, reveal that he had a period of active duty in the Navy from December 1964 to December 1968. He had approximately 3 years of sea service aboard the USS Raleigh (LPD 1) as a steward. The Veteran subsequently enlisted in the Army National Guard for the period of time from January 1985 to January 1995. His military specialty was a food service specialist, a cook. During his period of National Guard Service he had various discrete periods of ADT and IDT. A DD 214 also reveals that during his period of service in the National Guard he was activated for service in Desert Shield / Desert Storm and had a period of active duty from January to May 1991. Because this is active duty service, he is considered a Veteran with respect to this period of service. Subsequently, he also served in the Army Reserve from January 1995 to January 2002. Again, during this period of time he had various discrete periods of ADT and IDT. Service connection has established for several disabilities incurred during the Veteran's period of time when he was affiliated with the Army Reserve. Service connection been granted for cervical and lumbar spine disabilities which were incurred during a period of IDT on March 9, 1996. Service connection has also been established for coronary artery disease as a result of symptoms which manifested during IDT in October 1999. Accordingly, he is a Veteran with respect to both of these specific periods of IDT service. 38 U.S.C.A. § 101; 38 C.F.R. § 3.6 (2012). The appellant is not a "veteran" for the purposes of the claims for service connection for hearing loss and tinnitus with respect to any other periods of his National Guard and Army Reserve service than those noted above; he in not entitled to any statutory or regulatory presumptions which arise therefrom. He is not entitled to the presumption of soundness, nor is he entitled to the presumption of aggravation of a preexisting injury or disease with respect to any period of ADT or IDT for the period of time from January 1985 to January 2002. 38 U.S.C.A. §§ 1111, 1153 (West 2002); 38.C.F.R. §§ 3.304, 3.306 (2012). III. Service Connection The Veteran seeks service connection for hearing loss and tinnitus. In his March 2005 substantive appeal, VA Form 9, he argued that these conditions are related to his exposure to acoustic trauma during his active duty service in the Navy. At other times he asserted that his claimed hearing loss and tinnitus were related to noise exposure during his service in the Army National Guard, and/or Army Reserve. Generally, service connection may be granted for disability due to a disease or injury that was incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. In addition, service connection may be granted for any disease diagnosed after separation, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In order to establish direct service connection for a disability or to establish service connection based on aggravation in service of a disease or injury which pre-existed service, there must be (1) competent evidence of the current existence of the disability for which service connection is being claimed; (2) competent evidence of incurrence or aggravation of a disease or injury in active service; and (3) competent evidence of a nexus or connection between the current disability and the disease or injury incurred or aggravated in service. Horn v. Shinseki, 25 Vet. App. 231, 236 (2010); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009); cf. Gutierrez v. Principi, 19 Vet. App. 1, 5 (2004) (citing Hickson v. West, 12 Vet. App. 247, 253 (1999)). In many cases, medical evidence is required to meet the requirement that the evidence be "competent". However, when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). For claims for service connection for hearing loss or impairment, VA has specifically defined what is meant by a current "disability" for the purposes of service connection. 38 C.F.R. § 3.385. "[I]mpaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent." 38 C.F.R. § 3.385. The threshold for normal hearing is from zero to 20 decibels, and higher threshold levels indicate some degree of hearing loss. See Hensley v. Brown, 5 Vet. App. 155, 157 (1993). Other organic diseases of the nervous system may be presumed to have been incurred during active military service if they manifest to a degree of 10 percent within the first year following active service. 38 U.S.C.A. §§ 1101, 1112, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). Sensorineural hearing loss is considered an organic disease of the nervous system and is subject to presumptive service connection under 38 CFR 3.309(a). M21-1MR III.iv.4.B.12.a. In this respect, there is no medical evidence showing that a hearing loss disability became manifest to a degree of 10 percent within the first year of the Veteran's separation from active duty in December 1968 or his separation from active duty in May 1991. Accordingly, presumptive service connection is not warranted on a presumptive basis. In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. In this case, the service treatment records corresponding to the Veteran's period of active duty in the U.S. Navy from December 1964 to December 1968 are absent for complaints or findings of hearing loss or tinnitus. Audiometric testing conducted in December 1964 and June 1965 showed that the Veteran's hearing acuity was within normal limits. At his November 1968 service separation medical examination, the Veteran's ears were normal on clinical evaluation. His hearing acuity was 15/15 on whispered voice testing. On entry to active duty in the Navy, the authorized audiological evaluation conducted in December 1964 revealed pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT -5 (10) -5 (5) -5 (5) 0 (10) -5 (0) LEFT 0 (15) -5 (5) -10 (0) -5 (5) -5 (0) Prior to November 1967, audiometric results were reported in standards set forth by the American Standards Association (ASA). Those are the figures on the left of each column and are not in parentheses. Since November 1, 1967, those standards have been set by the International Standards Organization (ISO)-American National Standards Institute (ANSI). In order to facilitate data comparison, the ASA standards have been converted to ISO-ANSI standards and are represented by the figures in parentheses. In June 1965 a physical examination of the Veteran was conducted with respect to screening for submarine duty. On the authorized audiological evaluation, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT -5 (10) -5 (5) -5 (5) 0 (10) -5 (0) LEFT 0 (15) -5 (5) -10 (0) -5 (5) -5 (0) In November 1968, separation examination of the Veteran was conducted. No audiology examination of the Veteran was conducted. Rather, the Veteran's hearing was evaluated as normal, 15/15 on whispered voice testing. No reports of any complaints of hearing loss or tinnitus are contained in the Veteran's active duty service treatment records. There are no medical records related to the Veteran's hearing from 1968 until 1985, a period of almost two decades. In January 1985, the Veteran enlisted in the Army National Guard; he served in the National Guard until October 1995 when he transferred to the Army Reserve. Service treatment records corresponding to his service in the National Guard are also negative for complaints or findings of hearing loss or tinnitus. In January 1985, examination of the Veteran was conducted pursuant to his enlistment in the Army National Guard; clinical evaluation revealed his ears were normal. On a report of medical history completed at the time of his enlistment examination, the Veteran denied a history of hearing loss and ear trouble. On the authorized audiological evaluation conducted during the January 1985 enlistment examination, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 15 5 5 15 LEFT 20 20 15 15 30 These findings reveal that a slight level of hearing loss at the 4000 Hertz level of the left ear was present at that time. However, it is essential to note that this examination was conducted with respect to enlistment in to the National Guard. See Hensley, 5 Vet. App. 155, 157 (1993). The Veteran was not entering into a period of active military service at this time. In January 1989 periodic National Guard medical examination of the Veteran was conducted. Again, the his ears were normal on clinical evaluation. Audiological testing showed pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 10 15 / 10 LEFT 10 10 15 / 10 These audiology test results reveal normal hearing in both ears at this time. While a member of the National Guard, the Veteran had a period of active duty from January to May 1991. Service treatment records corresponding to this period are similarly negative for complaints or findings of a hearing loss disability or tinnitus. At a medical examination conducted in March 1991, his ears were normal. On a report of medical history, the Veteran again denied a history of hearing loss and ear trouble. Audiological evaluation showed pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 20 10 10 5 10 LEFT 15 10 15 10 35 Again, these findings reveal that a slight level of hearing loss at the 4000 Hertz level of the left ear was present at that time. However, such was already noted at the January 1985 National Guard enlistment examination. The Veteran then transferred from the Army National Guard to the Army Reserve; he served in the Army Reserve from January 1995 to September 2002. On an October 1995 medical pre-screening report he denied having ear trouble or hearing loss. In November 1995 his Army Reserve enlistment medical examination was conducted; again his ears were normal on clinical evaluation. On a report of medical history, he denied ear trouble and hearing loss. Audiological evaluation showed pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 0 0 5 10 LEFT 10 0 5 10 40 In March 2000 an "over 40" medical examination, was conducted. Again, the Veteran's ears were normal. On a report of medical history, he continued to deny ear trouble and hearing loss. Audiological evaluation showed pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 10 10 10 15 LEFT 15 10 10 10 15 Service treatment records reveal that he again underwent audiometric testing in June 2002, which showed pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 30 10 20 15 20 LEFT 10 5 5 15 45 The audiogram noted that the Veteran was "routinely noise exposed" and that he used double hearing protection. In February 2002, military retirement medical examination of the Veteran was conducted with respect to his retirement from the Army Reserve. On the report of medical history he again reported having no ear trouble. However, he did check the box indicating a history of hearing loss or wearing a hearing aid. He specifically indicated that "according to a recent hearing test, I have loss in my hearing." In July 2002, the Veteran submitted an original application for VA compensation benefits, seeking service connection for numerous disabilities, including hearing loss and tinnitus. Service personnel records reveal that the Veteran ultimately retired from the Army Reserve in September 2002. In connection with his claim, the Veteran underwent VA medical examination in August 2002. The examiner indicated that the Veteran's claims file was not available for review. She incorrectly noted that the Veteran had had 23 years of "active duty" and was scheduled to retire shortly. The Veteran reported that during his military service, he was exposed to artillery, weapons, diesel engines, explosives, and power tools. He also reported exposure to emergency heaters, which he indicated could blow up very loudly. However, service personnel records reveal that the Veteran's military specialty was as a food service specialist, cook, during his periods of service in the National Guard and Army Reserve. The Veteran also reported a history of intermittent ringing in his right ear since 1997. Audiological testing showed pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 25 20 20 15 20 LEFT 20 15 20 20 50 Speech audiometry revealed speech recognition ability of 94 percent in the right ear and of 96 percent in the left ear. The examiner indicated that given the fact that the Veteran's hearing was being tested prior to discharge from active service, it is as likely as not that his hearing loss began during service. She also indicated that it was as likely as not that the Veteran's tinnitus was related to his hearing loss and his history of noise exposure. The findings of this examination are flawed for the following reasons. First, the examiner did not review any of the evidence in the claims file. Second, the examiner was mistaken with respect to the nature of the Veteran's service in the National Guard and Army Reserve from which he was retiring. Third, while the single 25 decibel reading at the 500 Hertz level of the right ear indicates a degree of hearing loss with respect to the criteria of Hensley, supra, those results did not reveal the presence of a current hearing loss disability. See, 38 C.F.R. § 3.385. In January 2007, the Board remanded the matter for an additional examination and medical opinion, noting that the August 2002 VA medical opinion was based on an inaccurate history of over 20 years of "active service." Pursuant to the Board's remand, the Veteran again underwent VA Compensation and Pension examination in July 2008 at which he complained of difficulty understanding in noisy environments and in groups of people. He reported a minimal history of unprotected noise exposure in the military. He reported his civilian noise exposure was minimal, although evidence of record reveals his civilian employment was a correctional officer. He reported a history of mild, bilateral periodic tinnitus beginning in the middle 1990's. The Veteran indicated that he experienced two episodes of tinnitus yearly, which the examiner indicated was not beyond normally occurring tinnitus. Audiological testing showed pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 30 20 30 30 25 LEFT 25 15 30 30 60 Speech audiometry revealed speech recognition ability of 96 percent in the right ear and of 98 percent in the left ear. These audiology test results reveal the presence of a current hearing loss disability. See, 38 C.F.R. § 3.385. In reviewing the evidence, the examiner noted that the Veteran's hearing was normal during his period of active service in the Navy. He noted that the Veteran's hearing was 15/15 at the time of discharge from active service. Although spoken and whispered voice test were insufficient for rating purposes, the examiner also noted that the Veteran did not report a history of hearing loss or tinnitus at the time of discharge and further noted that he had no hearing profile assigned to him. The examiner noted that current research did not support the concept of delayed onset hearing loss. Therefore, he indicated that any decreased hearing acuity was less likely than not service-connected. He also noted the absence of a notation of tinnitus in the record and stated that it was less likely than not that tinnitus was service connected. The Board remanded again for another VA examination because although the July 2008 VA examiner concluded that the Veteran's hearing loss and tinnitus were not related to his period of active service in the Navy, the examiner did not comment on the relationship, if any, to the Veteran's reported exposure to acoustic trauma in the National Guard and Army Reserve. Another examination was obtained in July 2009 that was conducted by the same audiologist who conducted the July 2008 VA examination. Pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 30 20 30 30 25 LEFT 25 20 30 35 60 Speech audiometry revealed speech recognition ability 98 percent bilaterally. The examiner stated that he remained in agreement with his previous opinion. The Board remanded the claims again because the examiner did not address the relationship, if any, to the Veteran's reported exposure to acoustic trauma in the National Guard and Army Reserve. In July 2010, the same audiologist provided an addendum which essentially indicted that an etiology cannot be identified and to do otherwise is to resort to pure speculation. In August 2012, the most recent VA examination of the Veteran was conducted. Pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 25 20 25 25 35 LEFT 35 20 30 35 65 Speech audiometry revealed speech recognition ability 96 percent in the right ear and 94 percent in the left ear. The examiner stated that the Veteran's hearing loss was not as least as likely as not caused by an event in military service. The examiner stated that hearing was normal during the Veteran's active duty Navy service from 1964 to 1968, and that subsequent hearing tests also revealed normal hearing and that it was not until later in the Veteran's National Guard and Reserve service period that hearing loss was indicated by the hearing tests. While the examiner acknowledged that hearing loss can result from acoustic trauma, the Veteran's periods of ADT and IDT service were too short to experience any significant noise exposure, in light of the Veteran's military specialty as a cook. Moreover, no specific high noise incident was reported or documented. With respect to tinnitus, the Veteran reported hearing a "mild non-descript sound in his left ear once or twice per month for a few seconds." The examiner indicated that this is a normally occuring hearing experience. The examiner indicated that the reported tinnitus was not the result of active duty military service nor was it the result of any noise exposure experience during his Guard or Reserve service. There is no diagnosis of sensorineural hearing loss during the Veteran's active duty service in the Navy from 1964 to 1968 or during his period of active duty from January to May 1991. The medical evidence of record is also clear that the Veteran had a slight hearing loss in his left ear on enlistment in the National Guard in 1985. He is not he in not entitled to any statutory or regulatory presumptions with respect to his National Guard or Army Reserve service. He is not entitled to the presumption of soundness, nor is he entitled to the presumption of aggravation of a preexisting injury or disease with respect to any period of ADT or IDT for the period of time from January 1985 to January 2002. 38 U.S.C.A. §§ 1111, 1153 (West 2002); 38.C.F.R. §§ 3.304, 3.306 (2012). The persuasive evidence of record indicates that the Veteran's claimed bilateral hearing loss and tinnitus are not related to any period of qualifying active military service to include his active duty service, and any period of ADT of IDT in National Guard or Army Reserve service. The preponderance of the evidence is against the claims for service connection for bilateral hearing loss and tinnitus; there is no doubt to be resolved; and service connection is not warranted. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for bilateral hearing loss is denied. Service connection for tinnitus is denied. REMAND The issue of entitlement to service connection for coronary artery disease was granted by a December 2012 RO rating decision, based upon the medical findings in an August 2012 Compensation and Pension examination report. The issue of entitlement to service connection for hypertension remained denied. Unfortunately, the August 2012 Compensation and Pension examination report did not indicate a medical opinion as to whether the Veteran's hypertension was aggravated by the subsequently service-connected coronary artery disease. Service connection is warranted for a disability which is aggravated by, proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Any additional impairment of earning capacity resulting from a service-connected condition, regardless of whether or not the additional impairment is itself a separate disease or injury caused by the service-connected condition, also warrants compensation. Allen v. Brown, 7 Vet. App. 439 (1995). When the medical evidence is inadequate, VA must supplement the record by seeking an advisory opinion or ordering another medical examination. Colvin v. Derwinski, 1 Vet. App. 171 (1991) and Hatlestad v. Derwinski, 3 Vet. App. 213 (1992). Accordingly, the case is REMANDED for the following action: 1. Return the claims file to the examiner who conducted the August 2012 Compensation and Pension examination. If this examiner is not available, the file can be forwarded to another appropriate examiner. The entire claims file (i.e. both the paper claims file and any medical records contained in Virtual VA) should be made available to and be reviewed. Based on the examination and review of the record, the examiner is requested to answer whether it is it at least as likely as not (50 percent or higher degree of probability) that the Veteran's service-connected disabilities, including coronary artery disease, lumbar spine degenerative changes, and/or cervical spine degenerative changes, including any medication prescribed to treat these disabilities, has aggravated the Veteran's claimed hypertension? The examiner is advised that aggravation is defined for legal purposes as a chronic worsening of the underlying condition versus a temporary flare-up of symptoms, beyond its natural progression. If aggravation is present, the examiner should indicate, to the extent possible, the approximate level of severity of the hypertension (i.e., a baseline) before the onset of the aggravation. The examiner must provide a comprehensive report including complete rationale for all conclusions reached. If it is determined that the requested medical opinion cannot be rendered without additional physical examination of the Veteran, then the appropriate examination(s) should be ordered. 2. Readjudicate the Veteran's claim on appeal, with application of all appropriate laws and regulations and consideration of any additional information obtained. Consider his claim for service connection on a direct basis, and secondary to service-connected disabilities. If the decision with respect to the claim remains adverse to the Veteran, he and his representative should be furnished a supplemental statement of the case and afforded a reasonable period of time within which to respond thereto. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ KATHLEEN K. GALLAGHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs