Citation Nr: 1325526 Decision Date: 08/13/13 Archive Date: 08/16/13 DOCKET NO. 09-19 133 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUES 1. Entitlement to service connection for posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for hypothyroidism, to include as secondary to service-connected coronary artery disease or as due to exposure to herbicides. 3. Entitlement to service connection for hypertension, to include as secondary to service-connected coronary artery disease or as due to exposure to herbicides. 4. Entitlement to an initial evaluation in excess of 20 percent for diabetes mellitus. 5. Entitlement to an initial compensable evaluation for bilateral hearing loss disability. 6. Entitlement to an initial evaluation in excess of 10 percent for tinnitus. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD J. Barone, Counsel INTRODUCTION The Veteran had active service from August 1969 to August 1971. This matter comes before the Board of Veterans' Appeals (Board) from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in New Orleans, Louisiana. The Board notes that the Veteran requested a hearing in conjunction with his appeal, but in July 2011 withdrew his hearing request. The issues of entitlement to service connection for hypothyroidism and hypertension, as well as for higher initial ratings for diabetes mellitus, hearing loss, and tinnitus are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDING OF FACT The Veteran does not have a diagnosis of PTSD. CONCLUSION OF LAW PTSD was not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1154(b) (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's 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); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2012); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. VCAA notice should be provided to a claimant before the initial unfavorable RO decision on a claim. See Pelegrini v. Principi, 18 Vet. App. 112 (2004); Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). On March 3, 2006, the Court of Appeals for Veterans Claims (Court) issued a decision in the consolidated appeal of Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), which held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 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. The Court held that upon receipt of an application for a service-connection claim, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. Id. at 486. A letter dated in September 2008, prior to the adjudication of the Veteran's claim, discussed the evidence necessary to support a claim for service connection. The RO requested that the Veteran provide information pertaining to service and describe his claimed stressors. The evidence of record was listed and the Veteran was told how VA would assist him in obtaining additional relevant evidence. This letter also discussed the manner in which VA determines disability ratings and effective dates. Subsequent letters advised the Veteran of the status of his claim. The content of the notice provided to the Veteran fully complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) regarding VA's duty to notify. The Veteran has been provided with every opportunity to submit evidence and argument in support of his claim and to respond to VA notices. Further, the Board finds that the purpose behind the notice requirement has been satisfied because the Veteran has been afforded a meaningful opportunity to participate effectively in the processing of his claims. With respect to VA's duty to assist, a VA examination has been conducted with regard to the Veteran's claim, and a supplementary opinion was sought. The Board finds that the examination, in conjunction with the subsequent addendum are adequate, in that the examination was conducted by a neutral, skilled provider who reviewed the claims file and offered a rationale for his conclusions. The supplementary opinion involved complete review of the claims file, to include conflicting evidence, and included a discussion of the reasoning underlying the examiner's conclusions. In sum, the reports are consistent with the evidence of record and provide an adequate basis upon which to decide this appeal. The Veteran has not otherwise identified any additional evidence or information which could be obtained to substantiate the claims. The Board is also unaware of any such outstanding evidence or information. Therefore, the Board is also satisfied that VA has complied with the duty to assist requirements of the VCAA and the implementing regulations. For the foregoing reasons, it is not prejudicial to the appellant for the Board to proceed to a final decision in this appeal. Analysis Service connection may be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). However, "[a] determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or disease incurred in service." Watson v. Brown, 4 Vet. App. 309, 314 (1993). Entitlement to VA compensation may be granted for disability resulting from disease or injury incurred in or aggravated by active duty. 38 U.S.C.A. §§ 1110 (wartime service), 1131 (peacetime service); 38 C.F.R. § 3.303. To establish a right to compensation for a present disability, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service"-the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Service connection may also be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b) (West 2002). Service connection for PTSD requires medical evidence diagnosing the condition in accordance with VA regulations; a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. If the evidence establishes that the Veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 U.S.C.A. § 1154(b) and 38 C.F.R. § 3.304(d), (f). In this case, the record reflects combat service. Thus, the Board concludes that the evidence establishes the occurrence of the Veteran's claimed combat stressors. The Board observes that effective July 12, 2010, the regulations governing adjudication of service connection for posttraumatic stress disorder (PTSD) were liberalized, in certain circumstances, with respect to the evidentiary standard for establishing the required in-service stressor. For cases pending before VA as of that date, the following regulation applies: If a stressor claimed by a Veteran is related to the Veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of PTSD and that the Veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. For purposes of this paragraph, "fear of hostile military or terrorist activity" means that a Veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the Veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the Veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. 38 C.F.R. § 3.304 (f)(3); see 75 Fed. Reg. 39843 (July 13, 2010). As discussed below, the Veteran does not have a current diagnosis of PTSD; therefore, this amendment does not apply. Service treatment records are negative for any diagnosis, complaint, or abnormal finding pertaining to the Veteran's psychiatric health. On separation examination in July 1971, the Veteran was psychiatrically normal. In August 1971 he certified that he had undergone a separation medical examination more than three working days prior to his departure from place of separation, and to the best of his knowledge, there had been no change in his medical condition. The Veteran submitted his claim in July 2008. He indicated that the disability began in February 1970 and that he had been treated by VA since July 2008. A July 2008 VA psychology note indicates that the Veteran completed a one-hour individual diagnostic interview and psychological testing. The report indicates that the Veteran was the sole informant for his history and that there were no signs of deviant motivation. The provider noted that the Veteran was referred upon positive screen for PTSD during an agent orange examination. The Veteran denied depression and was alert, oriented, coherent, and purposeful. The impression was PTSD, chronic, by history as manifest by trauma, recollections, phobic avoidance, and impairment in life activities for more than one month. A VA examination was carried out in October 2008. The examiner reviewed the Veteran's history. He noted that the examination included a clinical interview, mental status examination, selected scales of the Wechsler Adult Intelligence Scale III, and the Minnesota Multiphasic Personality Inventory-2. He also noted that the Veteran's medical record and claims file were not available. The Veteran reported that he had never been involved in any sort of mental health treatment including counseling or medication. He indicated that he began to have symptoms of emotional distress in the 1970s. He stated that he experienced one or two nightmares every two to three weeks. He indicated that hearing 1960s music reminded him of Vietnam. He stated that he had a buddy that he talked to about once every 10 years about Vietnam. He stated that he avoided pictures and all other reminders of Vietnam. He denied suicidal and homicidal ideation. He denied ever having had a drug or alcohol problem, and also denied having been arrested. With respect to his military history, the Veteran stated that he witnessed a buddy killed. He indicated that following service, he worked as a welder, but stopped working due to heart disease. He noted that he had been married twice, having left his first wife. He related that his second wife of 21 years had died from leukemia. On mental status examination, the Veteran's thought processes were logical coherent, and relevant. He was articulate, verbal, and cooperative. He was oriented, and his affect was spontaneous and good. Verbal comprehension, concentration, and memory were good. The examiner noted that review of the psychological symptoms resulted virtually in the denial of all symptoms other than nightmares. The Veteran denied anxiety, panic, depression, insomnia, crying spells, anhedonia, head pain, stomach pain, racing thoughts, and anger control problems. He denied manic episodes. He denied suicidal and homicidal ideas. The examiner indicated that the Veteran did not seem to have any problem behaviors. With respect to effect of the Veteran's symptoms on social functioning, the examiner noted that he had a good marriage, but that his first wife was afraid of him. The examiner indicated that the Veteran did not seem to have any significant social impairment. He concluded that the Veteran did not fit the criteria for a diagnosis of PTSD. He pointed out that the Veteran denied having any significant symptoms of emotional distress other than nightmares a few times per month. He indicated that the Veteran did not fit the overall criteria for a diagnosis of PTSD. He noted that psychometric testing revealed a high average IQ. He also noted that the MMPI-2 produced a valid response set and that the resultant profile showed an absence of any significant elevations on any of the MMPI scales. He indicated that there were a few scales that were close to the point of significance, including the hypochondriasis scale, the psychasthenia scale, the schizophrenia scale, and the social introversion scale. However, he noted that the PTSD PK scale was far below the point of significance. He concluded that there was no diagnosis for Axis I. In November 2008 the examiner reviewed the claims file and indicated that there was no change in his initial evaluation. In January 2009 the examiner indicated that he had been asked to clarify his findings in light of a July 2008 psychology note giving a diagnosis of PTSD. He pointed out that the Veteran had reported some symptoms of PTSD during the October 2008 interview, but that they were neither significant nor severe enough to cause functional impairment. He noted that the criteria for PTSD was clearly spelled out in the DSM-IV, and indicated that a diagnosis was made when symptoms caused functional impairment. He stated that the Veteran, through the course of the examination denied having any frequent or severe symptoms. He noted that the Veteran denied significant occupational or social impairment, and that the Veteran's statements were corroborated by the fact that he produced a very valid objective MMPI-2. He indicated that it revealed that the Veteran did not have any mental disorder of any type and that specifically he did not fit the criteria for a diagnosis of PTSD. He pointed out that the elevation on the specific scale was far below the point of significance. After careful consideration of the evidence pertaining to this issue, the Board finds that service connection for PTSD is not warranted. In this regard, the Board notes that a key element to establishing service connection is to show that Veteran has the claimed disability. This element may only be shown through evidence of a diagnosis. In this case, the Board acknowledges that a VA outpatient record contains a diagnostic impression of PTSD. However, the provider in July 2008 qualified his impression by noting that it was by history. There is no indication that the diagnosis assigned by the clinical provider was made in full consideration of the DSM-IV criteria. See 38 C.F.R. §§ 3.304(f), 4.125(a). In that regard, the VA provider evaluated the Veteran on an outpatient basis on only one occasion did not provide a discussion of whether the Veteran's symptoms meet the full DSM-IV diagnostic criteria for an accurate diagnosis. On the other hand, the VA examiner conducted a clinical interview, administered psychometric testing, and reviewed the record in reaching his conclusion that the Veteran did not meet the diagnostic criteria under the DSM-IV for a diagnosis of PTSD. In assigning high probative value to the VA examiner's opinion, the Board notes that he had the claims file for review, specifically discussed evidence contained in the claims file to include the July 2008 evaluation, obtained a history from the Veteran, and conducted a complete examination which included focused psychometric testing. There is no indication that the VA examiner was not fully aware of the Veteran's past psychiatric history or that he misstated any relevant fact. The Board thus finds the VA examiner's opinion to be of greater probative value than the Veteran's unsupported statements, and those of the VA clinician who evaluated the Veteran in July 2008. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (noting that factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion.); Neives- Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Board has also considered the Veteran's own assertion that he has PTSD. However, while he is competent to describe symptoms and when they occurred, he is not necessarily competent to identify the specific underlying psychiatric disorder that is the source of those symptoms. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). (explaining in footnote 4 that a Veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). Thus, in determining whether he has PTSD, the Board places far more probative weight on the clinical findings of the VA examiners who conducted a full and comprehensive assessment in October 2008. The Board recognizes that the Court has held that the presence of a chronic disability at any time during the claim process can justify a grant of service connection, even where the most recent diagnosis is negative. McClain v. Nicholson, 21 Vet. App. 319 (2007). However, the Board concludes that the weight of the evidence is against a finding of a PTSD diagnosis conforming to the DSM-IV at any time during the course of the appeal. Therefore, the holding in McClain is inapplicable. Under these circumstances, the Board must conclude that the Veteran has not met the regulatory requirements of entitlement to service connection for PTSD, and that, on this basis, his claim must be denied. ORDER Entitlement to service connection for PTSD is denied. REMAND Service Connection As an initial matter the Board observes that there are two pivotal cases which address the need for a VA examination, Duenas v. Principi, 18 Vet. App. 512 (2004) and McLendon v. Nicholson, 20 Vet App. 79 (2006). In McLendon, the Court held that in disability compensation claims, the Secretary must provide a VA medical examination when there is: (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the Secretary to make a decision on the claim. Id. at 81. In Duenas, the Court held that a VA examination is necessary when the record: (1) contains competent evidence that the Veteran has persistent or recurrent symptoms of the claimed disability and (2) indicates that those symptoms may be associated with his active military service. The Veteran seeks service connection for hypertension and hypothyroidism. He has stated his belief that these disabilities are related to exposure to Agent Orange. In the alternative, his representative indicated in a July 2013 appellate brief presentation that these claimed disabilities might be either due to or aggravated by the Veteran's coronary artery disease. Service connection for coronary artery disease was granted in an April 2011 rating decision, during the pendency of the current appeal. The Board notes that these service connection claims have not yet been adjudicated on a secondary basis. In this case the Board concludes that, as there is competent evidence of hypertension and hypothyroidism and an indication that these disabilities may be related to a service-connected disability, VA examinations are warranted to determine their etiology. Ratings In the July 2013 appellate brief, the Veteran's representative noted that the Veteran had been most recently examined for his diabetes in 2008 and for his hearing loss disability in 2005. He alleged that these disabilities had worsened. With respect to the Veteran's diabetes, he noted that the medication to control that disease had been increased in 2011. VA shall provide a medical examination or obtain a medical opinion when such examination or opinion is necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(d) (West 2002). In the context of an increased rating claim, this duty requires that VA conduct an examination which provides "sufficient detail" as necessary to evaluate a particular disability. 38 C.F.R. § 4.2 (2012); see also Green v. Derwinski, 1 Vet. App. 121, 124 (stating that VA has a duty to provide the veteran with a thorough and contemporaneous medical examination). Moreover, when there is assertion of an increase in the severity of a service-connected disability since the last VA examination, VA should consider whether a more contemporaneous examination is needed to adequately evaluate the disability on appeal. See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); Littke v. Derwinski, 1 Vet. App. 90, 92 (1990); VAOPGCPREC 11-95 (1995). In this case, there is medical evidence that the Veteran's diabetes has increased in severity. Moreover, the most recent audiological examination occurred more than seven years ago. Thus, the Board finds that there is a reasonable basis for new, current examinations of these disabilities. Finally, the Board observes that service connection for tinnitus was granted in a February 2006 rating decision, and a 10 percent evaluation was assigned. The Veteran submitted a notice of disagreement in August 2006, and specified that he disagreed with the rating decision as it pertained to tinnitus. The filing of a notice of disagreement places a claim in appellate status. Therefore, a statement of the case regarding this matter must be issued to the appellant. As such, this issue must be remanded. Manlincon v. West, 12 Vet. App. 239, 240-41 (1999). In light of the above discussion, the Board has determined that additional development is necessary. Accordingly, the case is REMANDED for the following action: 1. Request that the Veteran submit or identify all relevant records not already associated with the claims file. If, after making reasonable efforts to obtain named records the AOJ is unable to secure same, it must notify the Veteran and (a) identify the specific records it is unable to obtain; (b) briefly explain the efforts made to obtain those records; (c) describe further action to be taken with respect to the claim; and (d) inform the Veteran that he is ultimately responsible for providing the evidence. The Veteran must be provided an opportunity to respond. The following development should not be initiated until the action outlined in paragraph 1 is complete. 2. Schedule the Veteran for a VA examination to determine the etiology of his hypertension. The claims folder should be forwarded to the examiner for review. The examiner should be directed to elicit a complete history from the Veteran. All indicated studies should be performed, and their results reported. Following review of the claims file and examination of the Veteran, the examiner should provide an opinion regarding whether it is more likely than not (i.e., probability greater than 50 percent), at least as likely as not (i.e., probability of 50 percent), or less likely than not (i.e., probability less than 50 percent) that the current hypertension began in service or is related to any disease or injury in service. The examiner should also provide an opinion regarding whether it is more likely than not (i.e., probability greater than 50 percent), at least as likely as not (i.e., probability of 50 percent), or less likely than not (i.e., probability less than 50 percent) that the current hypertension is related (caused or aggravated) to any service-connected disability, to include coronary artery disease and diabetes mellitus. The complete rationale for all opinions expressed should be set forth in the examination report. If the examiner is unable to offer any of the requested opinions, it is essential that the examiner offer a rationale for the conclusion that an opinion cannot be provided without resort to speculation, together with a statement as to whether there is additional evidence that might enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. See Jones v. Shinseki, 23 Vet. App. 382 (2010). 3. Schedule the Veteran for a VA examination to determine the etiology of his hypothyroidism. The claims folder should be forwarded to the examiner for review. The examiner should be directed to elicit a complete history from the Veteran. All indicated studies should be performed, and their results reported. Following review of the claims file and examination of the Veteran, the examiner should provide an opinion regarding whether it is more likely than not (i.e., probability greater than 50 percent), at least as likely as not (i.e., probability of 50 percent), or less likely than not (i.e., probability less than 50 percent) that the current hypothyroidism began in service or is related to any disease or injury in service. The examiner should also provide an opinion regarding whether it is more likely than not (i.e., probability greater than 50 percent), at least as likely as not (i.e., probability of 50 percent), or less likely than not (i.e., probability less than 50 percent) that the current hypothyroidism is related (caused or aggravated) to any service-connected disability, to include coronary artery disease and diabetes mellitus. The complete rationale for all opinions expressed should be set forth in the examination report. If the examiner is unable to offer any of the requested opinions, it is essential that the examiner offer a rationale for the conclusion that an opinion cannot be provided without resort to speculation, together with a statement as to whether there is additional evidence that might enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. See Jones v. Shinseki, 23 Vet. App. 382 (2010). 4. Schedule the Veteran for a VA examination to determine the severity of his service-connected diabetes mellitus. Any and all studies, tests and evaluations deemed necessary by the examiner should be performed. The examiner should also elicit a complete history from the Veteran, the pertinent details of which should be included in the examination report. Following interview, examination of the Veteran, and review of the claims file, the examiner should indicate whether the Veteran's diabetes mellitus requires regulation of activities. The examiner should also state whether there are episodes of ketoacidosis of hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider. The examiner should indicate the extent of any complications of the Veteran's diabetes mellitus. A discussion of the complete rationale for all opinions expressed should be included in the examination report. If the examiner is unable to offer any of the requested opinions, it is essential that the examiner offer a rationale for the conclusion that an opinion cannot be provided without resort to speculation, together with a statement as to whether there is additional evidence that might enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. See Jones v. Shinseki, 23 Vet. App. 382 (2010). 5. Schedule the Veteran for a VA examination to determine the severity of his service-connected bilateral hearing loss disability. Any and all studies, tests and evaluations deemed necessary by the examiner should be performed. The examiner should also elicit a complete history from the Veteran, the pertinent details of which should be included in the examination report. The examiner should discuss the effect of the Veteran's hearing loss disability on his occupational functioning and daily activities. A discussion of the complete rationale for all opinions expressed should be included in the examination report. If the examiner is unable to offer any of the requested opinions, it is essential that the examiner offer a rationale for the conclusion that an opinion cannot be provided without resort to speculation, together with a statement as to whether there is additional evidence that might enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. See Jones v. Shinseki, 23 Vet. App. 382 (2010). 6. The Veteran is hereby notified that it is his responsibility to report for any examination, and to cooperate in the development of the claim. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655. 7. Issue a statement of the case on the issue of entitlement to a higher initial rating for tinnitus, pursuant to 38 C.F.R. § 19.26 (2012). If the Veteran perfects his appeal by submitting a timely and adequate substantive appeal, the RO should return the claim to the Board for the purpose of appellate disposition. 8. Then, after ensuring the examination reports are adequate and undertaking any additional development that is deemed warranted, readjudicate the claims on appeal, with application of all appropriate laws, regulations, and case law, and consideration of any additional information obtained as a result of this remand. If the decision remains adverse to the Veteran, he and his representative should be furnished a supplemental statement of the case and afforded an appropriate period of time within which to respond thereto. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ MICHAEL A. PAPPAS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs