Citation Nr: 1326767 Decision Date: 08/21/13 Archive Date: 08/29/13 DOCKET NO. 00-22 002 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for a seizure disorder. 2. Entitlement to service connection for a psychiatric disorder, secondary to a seizure disorder. 3. Entitlement to service connection for degenerative joint disease of the spine, secondary to a seizure disorder. 4. Entitlement to service connection for a bilateral knee disorder, secondary to a seizure disorder. 5. Entitlement to service connection for a dental disorder, secondary to a seizure disorder. 6. Entitlement to a total disability rating based upon individual unemployability (TDIU) due to service connected disabilities. REPRESENTATION Appellant represented by: Vietnam Veterans of America WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD K. Kordich, Senior Counsel INTRODUCTION The Veteran served on active duty from February 1965 to May 1965. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2000 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. The August 2000 rating decision found that new and material evidence had not been submitted to reopen a claim for service connection for a seizure disorder; denied service connection claims for depression, degenerative joint disease of the spine, bilateral knee disorder, and for a dental disorder; and determined that entitlement to a total rating due to individual unemployability was not warranted. In July 2001, the Veteran testified before the undersigned Veterans Law Judge at a Board hearing in Washington, D.C. A transcript of this hearing is of record. In January 2002, the Board reopened the claim of entitlement to service connection for a seizure disorder, and remanded the case to the RO for additional development. In August 2003, the Board denied the above-mentioned matters. The Veteran then appealed that decision to the United States Court of Appeals for Veterans Claims (Court). In March 2005, the Court issued an order that granted a joint motion for remand, vacated the Board's August 2003 decision, and remanded the matters to the Board for action in compliance with the motion. The Board thereupon remanded the claims for further development in December 2005. In February 2007, the Board again denied the claims on appeal. The Veteran appealed that decision to the Court, and in December 2008, the Court issued an order, granting a joint motion for remand and vacating the Board's February 2007 decision. The matters were remanded to the Board for action in compliance with the motion. The Board thereupon remanded the claims for further development in April 2009. In May 2010, the Board again denied all of the Veteran's claims on appeal. The Veteran thereafter appealed that decision to the Court, and in April 2011, the Court issued an order, granting a joint motion for remand and vacating the Board's May 2010 decision. The matters were remanded to the Board for action in compliance with the joint motion, and the Board, in turn, remanded the claims for further development in August 2011. The Board again remanded the claims for further development in November 2012. Thereafter, the case was returned to the Board for further appellate review. A review of the Virtual VA paperless claims processing system does not reveal any additional documents pertinent to the present appeal. The issues of entitlement to service connection for a psychiatric disorder, degenerative joint disease of the spine, bilateral knee disorder, and a dental disorder, as secondary to the service connected seizure disorder and a total disability rating based upon individual unemployability (TDIU) due to service connected disabilities 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. FINDINGS OF FACT 1. The Veteran's seizure disorder was not noted on clinical examination at the time of service entrance. 2. The Veteran's seizure disorder clearly and unmistakably pre-existed entry into service. 3. The pre-existing seizure disorder was aggravated by service. CONCLUSION OF LAW The Veteran's seizure disorder was incurred in active military service. 38 U.S.C.A. §§ 1110, 1111, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.306 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000), defines the obligations of VA with respect to the duty to assist and includes an enhanced duty to notify a claimant as to the information and evidence necessary to substantiate a claim for VA benefits. First, VA has a duty to notify the Veteran of any information and evidence needed to substantiate and complete a claim. 38 U.S.C.A. §§ 5102, 5103 (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(b) (2012). Second, VA has a duty to assist the Veteran in obtaining evidence necessary to substantiate a claim. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159(c). As discussed in detail below, sufficient evidence is of record to grant the matter on appeal. Therefore, no further notice or development is needed with respect to this matter. The Board notes that the Veteran was advised in an April 2006 letter of the information and evidence necessary to substantiate the initial rating and effective date in the event his claim was successful. See Dingess v. Nicholson, 19 Vet. App. 473 (2006). Law and Regulations To establish service connection, there must be (1) evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). The determination as to whether these elements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). Under the applicable criteria, service connection may be granted for a disability the result of disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131 (West 2002). A Veteran will be considered to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable (obvious or manifest) evidence demonstrates that an injury or disease existed prior thereto and was not aggravated by such service. Only such conditions as are recorded in examination reports are to be considered as noted. 38 C.F.R. § 3.304(b). A pre-existing disability or disease will be considered to have been aggravated by active service when there is an increase in disability during service, unless there is clear and unmistakable evidence (obvious and manifest) that the increase in disability is due to the natural progress of the disability or disease. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306 (a), (b). Aggravation of a pre-existing condition may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306(b). See Falzone v. Brown, 8 Vet. App. 398, 402 (1995) (holding that the presumption of aggravation created by section 3.306 applies only if there is an increase in severity during service); Akins v. Derwinski, 1 Vet. App. 228, 231 (1991). VA, rather than the claimant, bears the burden of proving that the disability at issue pre-existed entry into service, and that the disability was not aggravated by service, before the presumption of soundness on entrance into active service may be rebutted. 38 C.F.R. § 3.304(b); see Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004); Cotant v. Principi, 17 Vet. App. 116 (2003). Mere history provided by the veteran of the pre-service existence of conditions recorded at the time of the entrance examination does not, in itself, constitute a notation of a pre-existing condition. 38 C.F.R. § 3.304(b)(1); Paulson v. Brown, 7 Vet. App. 466, 470 (1995); Crowe v. Brown, 7 Vet. App. 238, 246 (1995). The presumption of soundness upon entry into service may not be rebutted without "contemporaneous clinical evidence or recorded history" in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). Subsequently, a higher court explained the Miller decision by noting that "[n]othing in the court's opinion suggests that without such evidence the presumption can never be rebutted," emphasizing that any such determination must consider "how strong the other rebutting evidence might be." Harris v. West, 203 F. 3d. 1347, 1351 (Fed. Cir. 2000). As noted, under 38 U.S.C.A. § 1111, the presumption of soundness may be rebutted by clear and unmistakable evidence that a disease or injury existed prior to service and was not aggravated therein. The burden of proof is upon VA to rebut the presumption by producing that clear and unmistakable evidence. See Kinnaman v. Principi, 4 Vet. App. 20, 27 (1993). The determination of whether there is clear and unmistakable evidence that a defect, infirmity, or disorder existed prior to service should be based upon "thorough analysis of the evidentiary showing and careful correlation of all material facts, with due regard to accepted medical principles pertaining to the history, manifestations, clinical course, and character of the particular injury or disease or residuals thereof." 38 C.F.R. § 3.304(b)(1). Temporary or intermittent flare-ups during service of a pre-existing injury or disease are not sufficient to be considered "aggravation in service" unless the underlying condition, as contrasted to symptoms, is worsened. Jensen v. Brown, 4 Vet. App. 304, 306-307 (1993), citing Hunt v. Derwinski, 1 Vet. App. 292 (1991). Under 38 C.F.R. § 3.303(b), an alternate method of establishing the second and third Shedden/Caluza element for certain chronic disabilities listed in 38 C.F.R. § 3.309(a) (2012) is through a demonstration of continuity of symptomatology. See Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); 38 C.F.R. §§ 3.303(b), 3.309(a). In relevant part, 38 U.S.C.A. § 1154(a) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The Board notes that while the conclusions of a physician are medical conclusions that the Board cannot ignore or disregard, see Willis v. Derwinski, 1 Vet. App. 66 (1991), the Board is free to assess medical evidence and is not compelled to accept a physician's opinion. See Wilson v. Derwinski, 2 Vet. App. 614 (1992). A bare conclusion, even one reached by a medical professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). The Court held that the value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion." Bloom v. West, 12 Vet. App. 185, 187 (1999) (a medical opinion based on speculation, without supporting clinical data or other rationale, does not provide the required degree of medical certainty). Thus, a medical opinion is inadequate when it is unsupported by clinical evidence. Black v. Brown, 5 Vet. App. 177, 180 (1995). It is the responsibility of the Board to weigh the evidence, including the medical evidence, and determine where to give credit and where to withhold the same and, in so doing; the Board may accept one medical opinion and reject others. Evans v. West, 12 Vet. App. 22, 30 (1998), citing Owens v. Brown, 7 Vet. App. 429, 433 (1995). But, the Board is mindful that it cannot make its own independent medical determinations, and that it must have plausible reasons, based upon medical evidence in the record, for favoring one medical opinion over another. Evans v. West, supra; see also Rucker v. Brown, 10 Vet. App. 67, 74 (1997), citing Colvin v. Derwinski, 1 Vet. App. 171 (1991). Thus, the weight to be accorded the various items of evidence in this case must be determined by the quality of the evidence, and not necessarily by its quantity or source. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Background The Veteran contends that his seizure disorder had its onset in service, or, alternatively, was permanently aggravated during service, and that as a result of this disorder, he has developed several other disorders. The Veteran's February 1965 service entrance examination was negative for any reference to a seizure disorder. On his February 1965 Report of Medical History, the Veteran noted that he had not had or ever had epilepsy or fits. Later service treatment records indicate that he was diagnosed with chronic grand mal epilepsy which was felt to have existed prior to service and was not permanently aggravated by active duty service. A Medical Board Proceedings report, dated in May 1965, shows that grand mal epilepsy was diagnosed, which was reported to be not completely controlled on anti-convulsive medications. The report also noted that this disorder existed prior to the Veteran's entry into the military. Medical records from the Veteran's private physician, H.J.W., M.D., include a December 1979 letter in which Dr. H.J.W. states that in 1963, the Veteran was shoved into a brick wall and sustained a laceration to the right forehead. About three weeks later, he sustained his first nocturnal epileptic seizure. Nocturnal seizures persisted at the rate of two to three per week until the Veteran was placed on 100 grams of Dilantin three times per day and a half gram of Phenobarbital, starting at about two months after the seizure. The Veteran was practically seizure free for about one month until he dropped Phenobarbital because of excessive morning drowsiness. Thereafter, he had about one nocturnal seizure per month. In 1965, he was taken into the armed services, and he had an increase in the frequency of his seizures. Because of this, he was discharged from service. Dr. H.J.W. noted that the Veteran's seizures increased in number and perhaps in severity following his induction in service. Also, the additional emotional and mental strain of being away from home and in an entirely strange surrounding could have brought about a strain of his nervous system and have caused the acceleration of his condition. The Veteran reportedly required increased medication after active duty service. The Board notes that the Veteran's current treatment records reveal that he takes 500 milligrams of Dilantin per day. An April 1980 medical note from Dr. H.J.W. indicates that the Veteran was seen in June 1963 after he had three grand mal, epileptic type seizures. This was apparently caused by a head injury he had sustained. He was put on Dilantin 150 milligrams, three times per day, and was not seen again until two years later, after he was released from active duty service. At that time (in June 1965), the Veteran related that after he went on active duty service, his seizures became more frequent and required hospitalization on a neuropsychiatric service for a period of time. The Veteran reportedly felt that being in the service caused his condition to become worse. Dr. H.J.W. indicated that he agreed with the Veteran, stating that the stress and worry could have caused deterioration in his condition. Following this, he needed an increase in his drug dosage to obtain control. In June 1968, he was seen and evaluated by L.F.S., M.D. of the University of Virginia Hospital Seizure Service, who helped the Veteran gain control of his seizures. Dr. H.J.W.'s treatment notes, submitted by the Veteran, confirm the Veteran's assertion that he was seen in 1963, was prescribed Dilantin, and was not seen next until 1965. A March 2000 letter from A.T.R., M.D., indicates that physician's conclusion that the three convulsions that the Veteran had in 1963 were post-traumatic seizures due to his head injury, and the fact that he had no seizures for two years while on no medications indicates that he did not have a seizure disorder at the time of entry into the Army. The seizure disorder developed and was diagnosed while the Veteran was in service; therefore, Dr. A.T.R. considered it to be a service-connected disability. An August 2002 VA examination report indicates that the Veteran's epilepsy pre-existed service, and that it was very likely that the epilepsy became worse during military service. The report further noted that exacerbation of a seizure disorder, when an individual is under physical or emotional stress or is extremely tired or sleep deprived, is a very common and well-accepted phenomenon in medical practice. The examiner went on to state that during the few years immediately following service, the Veteran's epilepsy was indeed worse than before military service. At present, the seizure disorder was reportedly well-controlled. The examiner noted that the Veteran appeared to have made an extremely good adjustment, having a family and having maintained full employment until the induction of the computers in the workplace triggered his photosensitive seizures. "[T]hus, it would be pure speculation . . . to state that [the Veteran's] brief military service ha[d] had a permanent impact on his epilepsy." The report of a January 2006 VA neurological examination shows that the Veteran's claims file, including his medical records, were reviewed by the examiner. The Veteran informed the examiner that his history of seizures began at the age of 14 or 15, and added that his seizures increased during his military service. Seizure disorder was diagnosed. The examiner commented that in view of the Veteran's history the disorder was likely a primary generalized epilepsy. The examining neurologist opined that, with a "reasonable degree of medical certainty," the Veteran did in fact have a diagnosable seizure disorder which pre-existed his entry into active military service. He added that, aside from perhaps a "temporary exacerbation" of the seizures while in the service, the seizure disorder, thereafter, was "not aggravated to a permanent degree" by his military service "beyond that which would occur to a natural progression" of this disorder. In June 2009 VA examination, an associate professor of clinical neurology reviewed the claims file and the two prior neurological VA examinations. The physician noted that while the Veteran was a teenager, he suffered at least one and probably more generalized seizures. The historical data indicated that the Veteran's seizures occurred during sleep and most likely represented primary generalized epilepsy. Regardless, the facts indicated that the Veteran had a history of seizures that existed prior to service. He noted that the records also indicated that the Veteran had further seizures while in boot camp, which subsequently led to his discharge. The physician noted that the neurological examinations set forth by the VA examiners were normal. The Veteran's seizures generally had been well controlled. The physician disagreed with the assertion that the Veteran's experiences in boot camp caused or exacerbated his seizure disorder. He, along with the other neurologists of record, believed that this was not supported medically, noting "[i]t is a [sic] well established in the field of epilepsy, that physical stress, emotional stress, lack of sleep and/or irregular eating habits can precipitate a seizure but not cause progression of the underlying electrochemical abnormality." The physician noted, therefore, that he concurred that the Veteran had a pre-existing seizure disorder which perhaps was temporarily exacerbated by military service. However, this did not result in a permanent worsening or progression of the underlying cause of the disability. A statement from A.S., M.D. of the University of Virginia Health System dated July 2011 noted that he had been seeing the Veteran for over 10 years. He accurately summarized the Veteran's medical history with respect to the seizures, and concluded that it was more likely than not that his seizures were caused or permanently aggravated by the events which occurred during his time in the service. Pursuant to the Board's August 2011 remand, the RO obtained a VA examination to ascertain whether there was clear and unmistakable evidence that the Veteran's seizure disorder pre-existed service, and if so, whether there was clear and unmistakable evidence that the Veteran's pre-existing seizure disorder was not aggravated beyond its natural progression during his active duty. At a February 2012 VA examination, the Veteran stated that he had his first seizure at age 13 and the doctor came to his home and prescribed Dilantin. The Veteran indicated he had three seizures that night, and was not hospitalized. He denied continuing medication or having more seizures. He stated that at the age 15 he was pushed into a brick wall and hit his head. There was no treatment for the head injury except laceration suture to the right forehead. The Veteran stated that he had three seizures prior to military service but there was a year period between age 13 and 15. The Veteran entered military service at the age of 17 and stated that while in basic training denied being diagnosed with a seizure disorder and seizure medication was not prescribed. He went to sick call twice for seizures, finished basic training and was sent to his advanced individual training (AIT) school at Fort Jackson, S.C. While at AIT he had another seizure and stated he was locked in a mental hospital for seizures. He indicated he stayed there for a couple of weeks and was taken to a private hospital where he was diagnosed with seizures, prescribed medication, and was later discharged. After leaving the military the Veteran went back to his provider and continued seizure medication. As to the question of whether there was clear and unmistakable evidence that the Veteran's seizure disorder pre-existed service, the examiner answered in the affirmative. As to the question of whether there was clear and unmistakable evidence that the Veteran's pre-existing seizure disorder was not aggravated beyond its natural progression during his active duty, the examiner answered that there was no evidence to suggest military service aggravated the condition beyond its natural progression. The Veteran did not have a dormant epileptic seizure disorder that would have stayed dormant and inactive had he not entered military service. This condition would have manifested itself had the Veteran had not entered the military. The examiner noted that there was no single event in military service aggravating the pre-existing epileptic seizure disorder. He indicated there was no head injury in service and there was no support in the medical literature intimating military service is a trigger for dormant pre-existing seizure disorders. The examiner noted that military service alone is not a risk factor for epilepsy and there is no evidence increased frequency or severity of seizures occurred was a result of military service. Analysis Having considered the evidence of record, the Board finds that the evidence sufficiently establishes that the Veteran's seizure disorder clearly and unmistakably pre-existed service. In particular, the findings in the STRs, the Veteran's own statements in service and thereafter, and the opinions of virtually every VA physician to examine the Veteran show the disorder pre-existed service. Having determined that the Veteran entered service with a seizure disorder, the next step involves determining whether the evidence establishes that the disorder did not undergo aggravation in service. The Board notes the medical evidence shows that the Veteran was free of seizures for at least a year prior to entering active duty and shortly upon entering service was diagnosed with epilepsy and was separated from service. Dr. H.J.W. concluded that the Veteran's seizures increased in number and perhaps in severity following his induction in service, and that the additional emotional and mental strain of being away from home and in an entirely strange surrounding could have brought about a strain of his nervous system and caused the acceleration of his condition. He also agreed with the Veteran's belief that being in service caused the condition to become worse, noting that the stress and worry could have caused deterioration in his condition. Dr. A.S. opined in July 2011, that the seizures were caused or permanently aggravated by events in service. The August 2002 VA examiner report noted that it was very likely that the epilepsy became worse during military service, although the examiner then found that the Veteran ultimately had made an extremely good adjustment; the examiner concluded that the Veteran's brief military service did not have a permanent impact on his epilepsy. The 2002 VA neurological examiner also determined that, given the brief service in the military, and the present status of the Veteran's seizure disorder, it would require pure speculation to state that there was permanent impact on the Veteran's epilepsy. The June 2009 VA neurologist concluded that the Veteran's experiences in boot camp did not cause or exacerbate the seizure disorder, finding no permanent worsening or progression of the underlying cause of the disability. The evidence clearly shows conflicting medical opinions concerning the measurable worsening of the disability during service and whether this worsening constitutes an increase in disability. The Board is unable to find that either the opinions in favor or against the claim lack probative value. Given this and as rebutting the presumption of soundness requires that the evidence undebatably establish the absence of aggravation in service, the Board finds that the Veteran is entitled to the presumption of soundness. Consequently, the evidence shows that the Veteran experienced seizures in service, and has clearly experienced a seizure disorder continuously since service. ORDER Entitlement to service connection for a seizure disorder is granted. REMAND Although further delay is regrettable, the Board finds that additional development is needed to adjudicate the remaining issues on appeal. As to the claims for entitlement to service connection for a psychiatric disorder, degenerative joint disease of the spine, bilateral knee disorder, and dental disorder, these are claimed as secondary to the seizure disorder. The claims were denied because entitlement to service connection for a seizure disorder had not been established. As the Board has granted entitlement to service connection for a seizure disorder in the decision above, a remand is required for consideration of entitlement to service connection for the secondary service connection claims, to be preceded by VA examinations as to whether the seizure disorder either caused or aggravated the psychiatric disorder, degenerative joint disease of the spine, bilateral knee disorder, or dental disorder. 38 C.F.R. § 3.159(c)(4)(i)(C) (2012) (examination warranted where evidence indicates disability may be associated with another service connected disability). A finding of TDIU is dependent upon the impact of service-connected disabilities upon the Veteran's occupational functioning. 38 C.F.R. § 4.16 (2012). Here, there are open questions involving service connection of a disability and potential secondary service connected disabilities arising from the service connected disability, and properly assigned evaluations. The issue of TDIU is inextricably intertwined with these questions. Harris v. Derwinski, 1 Vet. App. 180 (1991) (two issues are "inextricably intertwined" when they are so closely tied together that a final Board decision on one issue cannot be rendered until the other issue has been considered). Remand of the TDIU issue is therefore required pending resolution of the other outstanding issues. Accordingly, the case is REMANDED for the following action: 1. Ask the Veteran to provide the names, addresses, and approximate dates of treatment of all health care providers, VA and private, who have treated him for the claimed disabilities since service. After securing any necessary authorization, request copies of all indicated records which have not been previously secured and associate them with the claims folder. 2. Following the receipt of any records requested above, schedule the Veteran for VA examinations to determine the etiology of any psychiatric disorder, degenerative joint disease of the spine, bilateral knee disorder, or dental disorder. All indicated tests and studies should be performed and all findings reported in detail. The claims folder must be sent to the examiner for review; consideration of such should be reflected in the completed examination report or in an addendum. The examiner should opine as to whether it is at least as likely as not (50 percent probability or more) that any psychiatric disorder, degenerative joint disease of the spine, bilateral knee disorder or dental disorder identified, occurred in service; or was caused, or aggravated by the Veteran's service connected seizure disorder. The examiner must provide a rationale for each opinion. 3. After completing any additional notification and/or development action deemed warranted, review the record again, including any newly acquired evidence, and re-adjudicate the TDIU issue on appeal. The purpose of this REMAND is to obtain additional evidence and ensure that the Veteran is afforded all due process of law. The Board intimates no opinion, either factual or legal, as to the conclusion warranted in this case. No action is required by the Veteran until contacted. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims 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). ______________________________________________ D.C. SPICKLER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs