Citation Nr: 1328492 Decision Date: 09/06/13 Archive Date: 09/16/13 DOCKET NO. 10-26 976 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUES 1. Evaluation of chronic sprain of the dorsal spine, currently evaluated as 10 percent disabling. 2. Entitlement to service connection for a respiratory disorder. ATTORNEY FOR THE BOARD Hallie E. Brokowsky, Counsel INTRODUCTION The Veteran served on active duty from July 2000 to July 2006. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2009 decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Denver, Colorado. The Board notes that, pursuant to her request in her June 2010 substantive appeal, the Veteran requested a hearing before the Board; however, in April 2013, the Veteran withdrew the Board hearing request. As such, the Board will proceed with its review on the present record. See 38 C.F.R. § 20.704(d), (e) (2012). The Virtual VA claims file has been reviewed. The issue of entitlement to service connection for a respiratory disorder is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDING OF FACT Chronic sprain of the dorsal spine is manifest by pain and spasm without abnormal gait or spinal contour. Functional flexion is better than 60 degrees and the combined range of motion is better than 120 degrees. CONCLUSION OF LAW The criteria for a disability rating in excess of 10 percent for chronic sprain of the dorsal spine are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The United States Court of Appeals for Veterans Claims (Court) issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the 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, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. In this case, the agency of original jurisdiction (AOJ) issued a notice letter, dated in June 2009, to the Veteran. This letter explained the evidence necessary to substantiate the Veteran's initial claim for service connection and the downstream issue of an increased rating, as well as the legal criteria for entitlement to such benefits. The letter also informed her of her and VA's respective duties for obtaining evidence. The AOJ decision that is the basis of this appeal was decided after the issuance of an initial, appropriate VCAA notice. As such, there was no defect with respect to timing of the VCAA notice. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). VA also has a duty to assist a veteran with the development of facts pertinent to the appeal. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). This duty includes the obtaining of "relevant" records in the custody of a Federal department or agency under 38 C.F.R. § 3.159(c)(2), as well as records not in Federal custody (e.g., private medical records) under 38 C.F.R. § 3.159(c)(1). VA will also provide a medical examination if such examination is determined to be "necessary" to decide the claim. 38 C.F.R. § 3.159(c)(4). The claims file contains the Veteran's available service treatment records, reports of VA and private post-service treatment, and the Veteran's own statements in support of her claim The Veteran was afforded VA examinations responsive to the initial claim for service connection and the subsequent claim for an increased rating. The Board has reviewed the examination reports, and finds that they are adequate for the purpose of deciding the issues on appeal. The examination reports contain all the findings needed to rate the Veteran's service-connected chronic sprain of the dorsal spine, including history and clinical evaluation. The Veteran's appeal for higher evaluation for chronic sprain of the dorsal spine, is distinguished from the facts in Proscelle v. Derwinski, 2 Vet. App. 629, 633 (1992), where no VA examination was provided during the rating claim, and a veteran specifically stated that his disability "has increased in severity [such] that I rate a higher disability," constituting at least both some assertion by the veteran and some evidence of worsening of disability since the last VA examination. Proscelle, 2 Vet. App. at 632. In the Veteran's case currently on appeal to the Board, there is no evidence of worsening of the Veteran's disability since the 2012 VA examinations, including no assertion by the Veteran of worsening since the last VA examination. The Veteran here does not assert that her chronic sprain of the dorsal spine has worsened since the May 2012 VA examination; she merely asserts entitlement to a higher disability evaluation. The Veteran has not submitted evidence of worsening, and the evidence of record, including the medical evidence reflecting on the severity of the disability on appeal, does not suggest that this disability worsened since the most recent VA examination, or since the most recent VA treatment records. As there is no evidence of worsening since the last VA examination, a remand for a new VA examination is not warranted, and is not required by the VCAA. See Palczewski v. Nicholson, 21 Vet. App. 174, 182 (2007) (mere passage of time does not require VA to provide a new medical examination); VAOPGCPREC 11-95 (interpreting that a new examination is appropriate when there is an assertion of an increase in severity since the last examination). The Veteran has been afforded adequate examinations on the issue decided herein. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Additionally, the Veteran has not alleged that any examination is inadequate to decide the claim being adjudicated herein, so the examinations are presumed to have been adequate. See Sickels v. Shinseki, 643 F.3d 1362 (Fed. Cir. 2011) (holding that the Board is entitled to presume the competence of a VA examiner and the adequacy of the opinion). Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion has been met. 38 C.F.R. § 3.159(c)(4). The Board has reviewed the Veteran's statements and medical evidence of record and concludes that there is no outstanding evidence with respect to the Veteran's claim. For these reasons, the Board finds that the VCAA duties to notify and assist have been met. Legal Criteria for Increased Disability Evaluation Disability evaluations are determined by application of the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. An evaluation of the level of disability present must also include consideration of the functional impairment of the Veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be staged. Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods during the appeal period where the service- connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, the disability ahs not significantly changed and a uniform evaluation is warranted. In addition, when assessing the severity of a musculoskeletal disability that, as here, is at least partly rated on the basis of limitation of motion, VA must also consider the extent that the veteran may have additional functional impairment above and beyond the limitation of motion objectively demonstrated, such as during times when his symptoms are most prevalent ("flare-ups") due to the extent of his pain (and painful motion), weakness, premature or excess fatigability, and incoordination. DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995); see also 38 C.F.R. §§ 4.40, 4.45, 4.59. Analysis for Increased Disability Evaluation Lumbosacral and cervical spine disabilities are rated under the General Rating Formula for Rating Diseases and Injuries of the Spine ("general rating formula"). 38 C.F.R. § 4.71a, DCs 5237-5242. Intervertebral disc syndrome (IVDS) is rated under the Formula for Rating IVDS Based on Incapacitating Episodes, whichever method results in the higher rating when all disabilities are combined under 38 C.F.R. § 4.25. See 38 C.F.R. § 4.71a, DC 5243. According to the general rating formula, a 10 percent evaluation is to be assigned for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or combined range of motion of the thoracolumbar spine greater than 120 degrees, but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent evaluation is to be assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent evaluation is to be assigned for forward flexion of the thoracolumbar spine 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine. A 50 percent evaluation is to be assigned for unfavorable ankylosis of the entire thoracolumbar spine. For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, entire thoracolumbar spine, or entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. 68 Fed. Reg. 51,443, Note (5) (Aug. 27, 2003). The Formula for Rating IVDS Based on Incapacitating Episodes provides for ratings from 10 to 60 percent based on the frequency and duration of incapacitating episodes, defined in Note 1 as a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. The maximum 60 percent schedular rating is warranted for incapacitating episodes having a total duration of at least 6 weeks during the previous 12 months. The Notes following the General Rating Formula for Diseases and Injuries of the Spine provide further guidance in rating diseases or injuries of the spine. Note 1 provides that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be rated separately under an appropriate diagnostic code. Note 2 provides that, for VA compensation purposes, the combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees and of the thoracolumbar spine is 240 degrees. Note 4 provides that range of motion measurements are to be rounded to the nearest five degrees. Note 5 defines unfavorable ankylosis as a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Note 6 provides that disability of the thoracolumbar and cervical spine segments are to be rated separately, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. The Veteran's chronic sprain of the dorsal spine is evaluated as 10 percent disabling pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5237. The Veteran was afforded a VA examination in August 2009, in connection with her initial claim for compensation. According to the report, the Veteran complained of constant pain between her shoulder blades, difficulty getting comfortable to sleep, difficulty taking full breaths, stiffness, and spasms; she denied radiation of pain, paresthesias, and bladder or bowel incontinence. She reported that driving for more than an hour increases her pain, that she avoids lifting heavy objects, and that her backpack for school aggravates her pain; she did not report any issues at her part-time job. She can sit for an hour with back support and for 10 minutes without support; there is no limitation on standing or walking. She reported that she has flare-ups once a month, lasting from 2 days to over 2 weeks, with an average of 4-5 days; treatment is massage, Icy Hot, or a heating pad. Examination of the spine showed no kyphoscoliosis, no tenderness of the cervical or lumbar spine. There was tenderness from the fourth thoracic vertebra to T-10, almost T-12 level; she also had tenderness on palpation bilaterally in that area. There was no swelling. Range of motion was forward flexion to 90 degrees, with a slight pulling sensation in the mid-back; extension was from zero (0) to 40 degrees without pain, lateral flexion was to 30 degrees bilaterally with complaint of pain in the mid-dorsal area, and rotation was to 80 degrees with complaint of pain in the mid-dorsal area at the end of motion. Repetitive motion testing did not change the range of motion; no loss of motion was observed due to pain, weakness, impaired endurance, incoordination, or instability. Deep tendon reflexes were active and equal. There was no evidence of muscle weakness or sensory loss; her gait was normal. X-rays showed normal alignment of the thoracic spine, with normal vertebral body height and normal disc height; there was no osteophytosis or bone lesions. The diagnosis was chronic strain of the mid-dorsal spine with symptoms of constant pain. The Veteran was afforded a VA examination in May 2012. According to that report, the Veteran complained of back pain and spasm, worse with prolonged sitting. She also complained that her back pain and spasms interrupt her sleep. She described her symptoms as constant, with flare- ups a couple of times per month, lasting a day at a time; with flare-ups, she has to decrease her physical activity. Range of motion showed forward flexion to 90 degrees, extension to at least 30 degrees, lateral flexion to at least 30 degrees bilaterally, and rotation to at least 30 degrees bilaterally. The Veteran's range of motion was not additionally limited by pain and she was able to perform repetitive use testing, albeit with pain on movement. The Veteran had bilateral thoracic paraspinal muscle tenderness, with guarding and/or muscle spasm, but without abnormal gait or spinal contour. There was no evidence of muscle atrophy and deep tendon reflexes of the ankles were 2+. Sensory examination was normal and there was no evidence of radiculopathy or intervertebral disc syndrome. The Veteran does not use any assistive devices. X-rays did not show arthritis. The Veteran has been assigned a 10 percent evaluation for her dorsal spine disability. The 10 percent evaluation contemplates pain on motion. 38 C.F.R. § 4.59 (2012). It is also consistent with flexion better than 60 degrees, with muscle spasm and localized tenderness, but without abnormal gait or spinal contour. In order to warrant a higher evaluation, there must be the functional equivalent of limitation of flexion to 60 degrees or less, a combined range of motion not greater than 120 degrees or abnormal gait or contour, or muscle spasm or guarding severe enough to result in abnormal gait or abnormal spinal contour. Here, the Veteran has complained of pain, decreased ability to lift heavy objects, and sleep impairment. After a review of the lay and medical evidence, the Board finds that an evaluation in excess of 10 percent is not warranted. 38 C.F.R. § 4.7. The evidence of record indicates that the Veteran's chronic sprain of the dorsal spine was productive of pain with combined range of motion of the thoracolumbar spine of 240 degrees at the May 2012 VA examination; this is much better than motion limited to 120 degrees. The Veteran's thoracolumbar strain was productive of no worse than forward flexion to 90 degrees at her August 2009 VA examination; extension was to 40 degrees and lateral rotation and flexion were to at least 30 degrees. Likewise, she had normal gait and negative straight leg testing. Reflexes and strength testing were normal. X-rays showed normal vertebral body height and alignment, without evidence of bone lesions or osteophytosis. Clearly, this examination demonstrated that she did not have abnormality of the spinal contour. She had pain on motion, spasm, and tenderness to palpation, but no additional limitation of motion due to pain. Thus, applying the facts to the criteria set forth above, the Veteran remains entitled to no more than a 10 percent evaluation for her service-connected chronic sprain of the dorsal spine under the General Rating Formula for Diseases and Injuries of the Spine. The Board has considered whether additional functional impairment due to factors such as pain, weakness and fatigability demonstrate additional limitation of motion or function to warrant a higher rating. See 38 C.F.R. §§ 4.40, 4.45, 4.59 and DeLuca at 206-07. The Board finds that the Veteran's subjective complaints of pain, stiffness and spasm have been contemplated in the current rating assignment. The August 2009 and May 2012 VA examination reports indicate that the Veteran complained of pain and spasm, but physical examination did not demonstrate any additional limitations in response to pain, including incoordination, weakness, or fatigability. Even when we consider the pleadings regarding pain, stiffness and spasm as credible, neither the lay nor medical evidence suggests that flexion is functionally limited to 60 degrees or that the combined range of motion is functionally limited to 120 degrees. Her reports of pain, stiffness and spasm are credible, but do not provide a basis for a higher evaluation. See Mitchell, supra. In essence, the Board finds that the lay and medical evidence are not significantly dissimilar. However, neither the lay nor medical evidence provide a basis for a higher evaluation. Rather, the evidence establishes that remaining functional flexion is better than 60 degrees, the remaining combined range of motion is better than 120 degrees and that there is no abnormality of gait or spinal contour. Further, the evidence does not show favorable or unfavorable ankylosis of the entire thoracolumbar spine during either of the rating periods on appeal. The evidence establishes that the Veteran's chronic sprain of the dorsal spine has not been productive of incapacitating episodes. Although the Veteran reported experiencing flare-ups at the VA examinations, there is no indication that the flare-ups required bed rest by a physician and treatment by a physician. Moreover, at the May 2012 VA examination, the Veteran explicitly denied that she had incapacitating episodes requiring bed rest by a physician and treatment by a physician. With consideration of the provisions of Note (1) of the General Rating Formula for Diseases and Injuries of the Spine, the Board notes that there is no objective evidence of record for the entire rating period on appeal which demonstrates that the Veteran experiences any neurologic symptomatology. The neurological examinations at these examinations did not show decreased strength or sensation in any of the extremities due to her service-connected chronic sprain of the dorsal spine. As the Veteran does not have any neurological deficits, it is not for consideration here. Extraschedular Considerations As to consideration of referral for an extraschedular rating, such consideration requires a three-step inquiry. See Thun v. Peake, 22 Vet. App. 111 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The first question is whether the schedular rating adequately contemplates the Veteran's disability picture. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. If the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, then the second inquiry is whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as governing norms. If the Veteran's disability picture meets the second inquiry, then the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether an extraschedular rating is warranted. The discussion above reflects that the symptoms of the Veteran's chronic sprain of the dorsal spine is fully contemplated by the applicable rating criteria. As shown above, the criteria include symptoms, each of which were addressed in the VA examination reports and which provided the basis for the disability rating that has been assigned. The Veteran has no complaints other than pain and spasm as a result of her disability, which was clearly considered in the range of motion testing that was carried out and which serves as the basis for her assigned disability rating for her chronic sprain of the dorsal spine. In any event, the evidence does not reflect that there has been marked interference with employment, frequent hospitalization, or that the Veteran's symptoms have otherwise rendered impractical the application of the regular schedular standards. The Veteran alleged that chronic sprain of the dorsal spine interferes with her ability to focus at school, but she did not indicate that she had to miss any time from work or her classes due to her chronic sprain of the dorsal spine. According to the Veteran, her chronic sprain of the dorsal spine causes pain, which is distracting, but has no other impact as an employee or student. Therefore, referral for consideration of extraschedular ratings for the chronic sprain of the dorsal spine is not warranted. 38 C.F.R. § 3.321(b)(1). In the absence of exceptional factors associated with chronic sprain of the dorsal spine, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). ORDER Entitlement to a disability evaluation in excess of 10 percent for chronic sprain of the dorsal spine is denied. REMAND Under the VCAA, VA must provide an examination when there is competent evidence of a disability (or persistent or recurrent symptoms of a disability) that may be associated with an in-service event, injury, or disease, but there is insufficient information to make a decision on the claim. 38 U.S.C.A. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). Lay statements can satisfy each of these elements in certain circumstances, and the threshold for finding that the disability (or symptoms of a disability) may be associated with service is low. Waters v. Shinseki, 601 F.3d 1274, 1277 (Fed. Cir. 2010); McLendon, 20 Vet. App. at 83. The Veteran has not been provided with a VA examination in order to address whether she has a respiratory disorder related to her active military service, including her service-connected chronic sprain of the dorsal spine. The Board acknowledges that the VA examination reports and the Veteran's statements indicate that the Veteran has complaints of chest pain, difficulty breathing, and soft tissue damage such that she is unable to expand her chest cavity and lungs. The Board acknowledges that the Veteran's service treatment records do not show any respiratory complaints related to her service-connected four-wheeler accident. The Board also acknowledges that the August 2009 VA examination report stated that the Veteran had chest expansion from 33 centimeters to 86 centimeters, with normal air entry and without rales, rhonchi, or wheezes; however, the VA examination did not provide information as to what chest expansion is considered normal, nor did the VA examination indicate if there was any damage to the Veteran's chest or lungs as a result of the accident. Additionally, at an October 2009 VA mental health examination, the VA examiner noted that the Veteran reported experiencing chest pressure and a crushing feeling of her chest in intimate situations and when trying to sleep; the VA examiner diagnosed the Veteran with an anxiety disorder. As such, it is unclear whether the Veteran's respiratory symptoms are a manifestation of the Veteran's already service-connected anxiety disorder or service-connected chronic sprain of the dorsal spine, or whether the Veteran's respiratory symptoms are indicative of a separate disorder. VA adjudicators may consider only independent medical evidence to support their findings; they may not rely on their own unsubstantiated medical conclusions. If the medical evidence of record is insufficient, VA is always free to supplement the record by seeking an advisory opinion, or ordering a medical examination to support its ultimate conclusions. See Colvin v. Derwinski, 1 Vet. App. 171 (1991). Accordingly, the Board finds that the Veteran should be afforded a VA examination regarding her claim for service connection for a respiratory disorder. See 38 U.S.C.A. § 5103A(d)(1); 38 C.F.R. § 3.159(c)(4) (VA has an affirmative duty to obtain an examination of the claimant at VA health-care facilities if the evidence of record does not contain adequate evidence to decide a claim). Accordingly, the case is REMANDED for the following action: 1. The Veteran should be afforded a VA examination to determine the nature and etiology of any respiratory disorder that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file. The examiner should indicate whether it is as least as likely as not (50 percent probability or more) that any respiratory disorder is caused or aggravated by service-connected disabilities or is related to service. The provider is advised that the Veteran is competent to report symptoms, treatment, and injuries, and that her reports must be taken into account, along with the other evidence of record, in formulating the requested opinions. A complete rationale should accompany each opinion provided. 2. If, upon completion of the above action, the benefit sought remains denied, the case should be returned to the Board after compliance with requisite appellate procedures. 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). ______________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs