Citation Nr: 1328513 Decision Date: 09/06/13 Archive Date: 09/16/13 DOCKET NO. 07-30 637 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for IgA deficiency. 2. Entitlement to a compensable initial rating for left knee sprain with Baker's cyst, for the period before June 18, 2009. 3. Entitlement to an initial rating in excess of 10 percent for left knee sprain with Baker's cyst for the period from June 18, 2009. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Joseph R. Keselyak, Counsel INTRODUCTION The Veteran served on active duty from January 2003 to January 2007. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2007 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina, which inter alia, denied service connection for IgA deficiency and granted service connection for residuals of a left knee sprain with an assigned noncompensable initial disability rating, effective January 14, 2007. A timely appeal as to those issues was filed in March 2007. In a July 2009 rating decision, the RO increased the evaluation of the left knee disability involved in the present appeal to 10 percent disabling, effective June 18, 2009. Because the maximum benefit was not granted, the issue of entitlement to a higher evaluation remained on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). The Veteran's appeal also initially included the issues of service connection for celiac disease, service connection for thyroiditis, and service connection for glaucoma. However, the Veteran's claims of service connection for thyroiditis and glaucoma were not preserved for appeal in the Veteran's September 2007 substantive appeal. Further, the Veteran has not indicated that she wishes to continue her appeal as to those issues. The Veteran's claim of service connection for celiac disease was granted in full in a July 2009 rating decision. Under the circumstances, these additional issues are not presently on appeal before the Board. In July 2011 this matter was last before the Board at which time it was remanded to afford the Veteran a hearing before the Board. A videoconference hearing before the Board was scheduled to occur on March 9, 2012. However, via a February 2012 written communication, the Veteran withdrew her request for a hearing before the Board. The issue of entitlement to service connection for IgA deficiency 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. FINDINGS OF FACT Throughout the entire period on appeal, the Veteran's left knee sprain with Baker's cyst has caused pain and limitation of activity, but has not manifested by locking, ankylosis, recurrent subluxation, lateral instability, impairment of the tibia and fibula or genu recurvatum; flexion of the left knee has never been limited to approximately 45 degrees or less and extension has never been limited to approximately 10 degrees or more. CONCLUSIONS OF LAW 1. Prior to June 18, 2009, the criteria for an initial evaluation of 10 percent, but no greater, for left knee sprain with Baker's cyst have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5256-5263 (2012). 2. From June 18, 2009, the criteria for an initial evaluation in excess of 10 percent for left knee sprain with Baker's cyst have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5256-5263 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Notice and Assistance Upon receipt of a complete or substantially complete application for benefits and prior to an initial unfavorable decision on a claim by an agency of original jurisdiction, VA is required to notify the appellant of the information and evidence not of record that is necessary to substantiate the claim. In the notice, VA will inform the claimant which information and evidence, if any, that the claimant is to provide to VA and which information and evidence, if any, that VA will attempt to obtain on behalf of the claimant. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159 (2011); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Notice should also address the rating criteria and effective date provisions that are pertinent to the appellant's claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). In a case such as this, where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service connection claim has been more than substantiated, it has been proven, thereby rendering 38 U.S.C.A. § 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Id.; Dunlap v. Nicholson, 21 Vet. App. 112 (2007). The appellant bears the burden of demonstrating any prejudice from defective notice with respect to the downstream elements. Goodwin v. Peake, 22 Vet. App. 128 (2008). The Veteran has not alleged any prejudice; thus, that burden has not been met in this case. Nevertheless, the Board notes that VA has fully complied with the notice provisions of 38 U.S.C.A. § 5103(a). As part of the Benefits Delivery at Discharge Program (BDD), the Veteran was advised of how to substantiate her claim for service connection, her and VA's respective duties in developing the claim and as to the disability rating and effective date elements of her claim. VA has obtained the Veteran's service treatment records, assisted the Veteran in obtaining evidence, afforded the Veteran physical examinations, and obtained medical opinions as to the severity of her condition. All known and available records relevant to the issues adjudicated on appeal have been obtained and associated with the Veteran's claims file; and the Veteran has not contended otherwise. The United States Court of Appeals for Veterans Claims (hereinafter "the Court") has held that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the VA examinations obtained in this case are adequate. They are predicated on a substantial review of the record and medical findings and consider the Veteran's complaints, symptoms and history. As the examination reports ultimately provide sufficient information such that the Board can render an informed determination, they are adequate. Accordingly, VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issues addressed in this decision has been met. 38 C.F.R. § 3.159(c)(4). VA has complied with the notice and assistance requirements and the Veteran is not prejudiced by a decision on the claim at this time. Laws and Regulations The RO has evaluated the Veteran's left knee disability under 38 C.F.R. § 4.71a, Diagnostic Code 5299-5260 (2012). Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27 (2012). Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2012). Separate rating codes identify the various disabilities. 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability is resolved in favor of the veteran. 38 C.F.R. § 4.3. The VA schedule of ratings will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). 38 C.F.R. Section 3.321(b)(1) provides that, in exceptional circumstances, where the schedular evaluations are found to be inadequate, the veteran may be awarded a rating higher than that encompassed by the schedular criteria. According to the regulation, an extraschedular disability rating is warranted upon a finding that "the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards." Id. The evaluation of the same disability under various diagnoses is to be avoided. Disability from injuries to the muscles, nerves, and joints of an extremity may overlap to a great extent, so that special rules are included in the appropriate bodily system for their evaluation. Both the use of manifestations not resulting from service-connected disease or injury in establishing the service-connected evaluation, and the evaluation of the same manifestation under different diagnoses are to be avoided. 38 C.F.R. § 4.14. Notwithstanding the above, VA is required to provide separate evaluations for separate manifestations of the same disability which are not duplicative or overlapping. See Esteban v. Brown, 6 Vet. App. 259, 261 (1994). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). In addition, an appeal from the initial assignment of a disability rating requires consideration of the entire time period involved, and contemplates "staged ratings" where warranted. See Fenderson v. West, 12 Vet. App. 119 (1999). However, "staged ratings" are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Diagnostic Code 5010 provides that arthritis due to trauma should be rated as degenerative arthritis under Diagnostic Code 5003. 38 C.F.R. § 4.71a. Diagnostic Code 5003 provides that degenerative arthritis that is established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under diagnostic code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a. When there is no limitation of motion of the specific joint or joints that involve degenerative arthritis, Diagnostic Code 5003 provides a 20 percent rating for degenerative arthritis with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations, and a 10 percent rating for degenerative arthritis with X- ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. Note (1) provides that the 20 percent and 10 percent ratings based on X-ray findings will not be combined with ratings based on limitation of motion. When there is limitation of motion of the specific joint or joints that is compensable (10 percent or higher) under the appropriate diagnostic codes, the compensable limitation of motion should be rated under the appropriate diagnostic codes for the specific joint or joints involved. Id. 38 C.F.R. §§ 4.40, 4.45 and 4.59 require the Board to consider a veteran's pain, swelling, weakness, and excess fatigability when determining the appropriate evaluation for a disability using the limitation of motion diagnostic codes. See Johnson v. Brown, 9 Vet. App. 7, 10 (1996); DeLuca v. Brown, 8 Vet. App. 202 (1995). Normal ranges of motion of the knee are to zero degrees in extension, and to 140 degrees in flexion. 38 C.F.R. § 4.71, Plate II. Diagnostic Code 5256 provides ratings for ankylosis of the knee. Favorable ankylosis of the knee, with angle in full extension, or in slight flexion between zero degrees and 10 degrees, is rated 30 percent disabling. Unfavorable ankylosis of the knee, in flexion between 10 degrees and 20 degrees, is to be rated 40 percent disabling. Unfavorable ankylosis of the knee, in flexion between 20 degrees and 45 degrees, is rated 50 percent disabling. Extremely unfavorable ankylosis, in flexion at an angle of 45 degrees or more is to be rated 60 percent disabling. 38 C.F.R. § 4.71a. Diagnostic Code 5257 provides ratings for recurrent subluxation or lateral instability. Slight recurrent subluxation or lateral instability of the knee is rated 10 percent disabling; moderate recurrent subluxation or lateral instability of the knee is rated 20 percent disabling; and severe recurrent subluxation or lateral instability of the knee is rated 30 percent disabling. Id. Separate disability ratings are possible for arthritis with limitation of motion under Diagnostic Codes 5003 and instability of a knee under Diagnostic Code 5257. See VAOPGCPREC 23-97. When X-ray findings of arthritis are present and a veteran's knee disability is rated under Diagnostic Code 5257, the veteran would be entitled to a separate compensable rating under Diagnostic Code 5003 if the arthritis results in noncompensable limitation of motion and/or objective findings or indicators of pain. See VAOPGCPREC 9-98. Diagnostic Code 5258 provides a 20 percent rating for dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. 38 C.F.R. § 4.71a. Diagnostic Code 5259 provides a 10 percent rating for symptomatic removal of the semilunar cartilage. Id. Diagnostic Code 5260 provides ratings based on limitation of flexion of the leg. Flexion of the leg limited to 60 degrees is rated noncompensably (zero percent) disabling; flexion of the leg limited to 45 degrees is rated 10 percent disabling; flexion of the leg limited to 30 degrees is rated 20 percent disabling; and flexion of the leg limited to 15 degrees is rated 30 percent disabling. 38 C.F.R. § 4.71a. See VAOPGCPREC 09-04 (separate ratings may be granted based on limitation of flexion (Diagnostic Code 5260) and limitation of extension (Diagnostic Code 5261) of the same knee joint). Diagnostic Code 5261 provides ratings based on limitation of extension of the leg. Extension of the leg limited to 5 degrees is rated noncompensably (zero percent) disabling; extension of the leg limited to 10 degrees is rated 10 percent disabling; extension of the leg limited to 15 degrees is rated 20 percent disabling; extension of the leg limited to 20 degrees is rated 30 percent disabling; extension of the leg limited to 30 degrees is rated 40 percent disabling; and extension of the leg limited to 45 degrees is rated 50 percent disabling. Id. Diagnostic Code 5262 provides ratings based on impairment of the tibia and fibula. Malunion of the tibia and fibula with slight knee or ankle disability is rated 10 percent disabling; malunion of the tibia and fibula with moderate knee or ankle disability is rated 20 percent disabling; and malunion of the tibia and fibula with marked knee or ankle disability is rated 30 percent disabling. Nonunion of the tibia and fibula with loose motion, requiring a brace, is rated 40 percent disabling. 38 C.F.R. § 4.71a. Diagnostic Code 5263 provides a maximum 10 percent evaluation for genu recurvatum. Id. In claims for VA benefits, VA shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Facts By way of background, a January 2005 service treatment record documents a complaint of left knee pain with radiating tingling and numbness in the left lower extremity to the dorsum of the left foot following a fall on the left knee 1 1/2 years prior. Clinical neurological testing resulted in normal EMG and NCV studies, however. A November 2005 service treatment record documents a complaint of an injured left knee. Examination showed full range of motion and there was no joint line tenderness. McMurray's sign was negative. The popliteal space was tender and a Baker's cyst was assessed. In August 2006, prior to her discharge, the Veteran filed her claim under the BDD program. In December 2006, she was afforded a VA (QTC) examination. At the time of the examination, a history of popliteal pain for 3 years was noted. The Veteran then complained of occasional pain, as well as weakness due to pain and swelling behind the knee. She complained of the occurrence of pain 1 time per month, lasting for 1 week. She described burning and sharp pain that travelled down the back of her leg and at a level of 6/10. She denied incapacitation and there was no functional impairment from the condition. There were signs of decreased sensation of the inferior popliteal fossa, although motor and sensory examination was within normal limits. Objective examination showed flexion to 140 degrees and extension to zero degrees. Joint function was not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination after repetitive use. Anterior and posterior cruciate ligament testing of the left knee was within normal limits, as was testing of the medial and lateral meniscus of the left knee. Gross examination of the muscles was within normal limits. The examiner assessed status-post left knee sprain with residuals. Following this examination, there appears a February 2007 e- mail thread in the claims file noting that clarification was sought on the part of the QTC opinion that noted decreased sensation. The e-mail thread reflects that an assessment of status-post knee sprain with residuals was assessed, with subjective factors of pain and objective factors disclosed by examination. In a March 2007 statement the Veteran related her disagreement with the assigned non-compensable evaluation. She related that she was unable to do many things, e.g. stretch, run, exercise or sit in a chair for a long period of time as the back of her knee would swell. In an April 2007 statement, she reiterated her reasons for disagreeing with the assigned noncompensable evaluation. On June 18, 2009, the Veteran was afforded another VA (QTC) examination. At the time of the examination, the Veteran complained of pain in the left knee occurring 2 times per day and lasting for 2 days. She also complained that the pain was burning and sharp, and travelled down her left leg. She characterized the pain as ranging from 2/10 to 10/10 in severity, elicited by physical activity and occurring spontaneously. She also complained of weakness and swelling, but denied stiffness, heat, redness, giving way, lack of endurance, locking, fatigability and dislocation. She was not receiving any treatment for the condition at the time of the examination and had never had surgery or been hospitalized for the condition. She complained that the condition prevented her from sitting, exercising and walking without pain. Objective examination of the left knee showed tenderness, but no signs of edema, effusion, weakness, redness, heat or guarding of movement. There was no subluxation. Examination also showed no locking pain, genu recurvatum or crepitus. Flexion was to 135 degrees, with pain beginning at 130. Extension was to zero degrees. Pain was noted as having the major functional impact and as the cause of additional imitation of motion, as quantified by the examiner. Joint function was not additionally limited by fatigue, weakness, lack of endurance and incoordination. Anterior and posterior cruciate ligament stability testing was within normal limits, as was testing of the medial and collateral ligaments and the medial and lateral menisci. X- rays were within normal limits. The examiner assessed "Baker's cyst of the left knee" and changed the diagnosis as no evidence of a sprain was found at the time of the examination. In October 2011, the Veteran was afforded another VA examination. At the time of the examination, she complained of weakness, swelling, heat, giving way, lack of endurance and pain. She denied stiffness, redness, locking, fatigability, deformity, drainage, effusion, subluxation and dislocation. She reported flare-ups as often as 7 times per month, lasting for 2 days each time, with pain at a level of 10/10 at worst. During flare-ups, she experienced neither functional impairment nor any limitation of motion of the joint. She reported difficulty with standing and walking, particularly painful prolonged standing, and stiffness with walking. She had not been hospitalized or had surgery for her left knee condition, and denied any incapacitation over the prior 12 months. Objective examination showed no signs of edema, instability, abnormal movement, effusion, weakness, tenderness, redness, heat, deformity, malalignment, drainage, subluxation or guarding of movement. There was no locking, pain, genu recurvatum, crepitus or ankylosis. Flexion was to 120 degrees, with pain at that point. Extension was to 5 degrees, with pain at that point, as well. Joint function was not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination after use. Testing of the medial/collateral ligaments was normal, as was testing of the anterior/posterior cruciate ligaments and the medial/lateral menisci. X-rays were within normal limits and "left knee sprain with Baker's cyst" was assessed. Analysis Based on the foregoing evidence, and after affording the Veteran the benefit of the doubt, the Board finds that the functional loss due to pain associated with the Veteran's left knee disability is sufficient to warrant a rating of 10 percent for the entire period involved in the present appeal. 38 C.F.R. §§ 4.1, 4.2, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260; DeLuca v. Brown, 8 Vet. App. 202 (1995) (Painful motion with the joint or periarticular pathology, which produces disability, warrants the minimum compensation). In this regard, the Board acknowledges that the range of motion findings demonstrated on examination have consistently failed to satisfy the criteria for a compensable rating under the applicable diagnostic code. However, examination has also consistently shown symptoms, such as pain, that the Veteran has competently indicated limited her ability to stand, sit and walk. 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). Accordingly, the Board finds that the overall degree of functional loss is akin to the degree of impairment contemplated by a 10 percent evaluation. Fenderson, supra. The Board has considered whether an evaluation in excess of 10 percent is warranted throughout the entire applicable period. However, the Board points out that Diagnostic Codes 5256, 5257, 5258, 5259, 5262 and 5263 cannot provide for a higher evaluation. As outlined above, ankylosis, recurrent subluxation or instability, and dislocated semilunar cartilage have not been demonstrated on objective examination. No impairment of the tibia and fibula has been demonstrated. Genu recurvatum has not been shown. The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). In considering either Diagnostic Code 5260 or 5261, which provide for evaluation of limitation of flexion and extension, the Board has again also considered the DeLuca factors, such as additional limitation of motion resulting from symptoms such as pain on motion or fatigability. However, even taking such factors into account, the evidence has never shown a significant degree of limitation of flexion or extension, much less flexion limited to approximately 45 degrees or less or extension limited to approximately 10 degrees or more. Accordingly, an evaluation in excess of 10 percent is not warranted. Fenderson, supra. The Board also acknowledges that VA examination in August 2006 noted signs of decreased sensation of the inferior popliteal fossa. Nevertheless, VA examination then and thereafter did not result in the assessment of any associated neurologic abnormality. Notably, EMG and NCV studies conducted in January 2005 were normal and the Veteran has never had surgery due to this condition. Accordingly, the Board does not conclude that a separate evaluation for any neurological residuals. Extraschedular Consideration According to the regulation, an extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1) (2012). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must first determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the service-connected left knee disability is inadequate. A comparison between the level of severity and symptomatology of the Veteran's condition with the established criteria shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. The rating criteria specifically contemplate the Veteran's symptomatology, as well as economic impairment. In short, there is nothing in the record to indicate that the service-connected disability on appeal causes impairment over and above that which is contemplated in the assigned 10 percent rating. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (noting that the disability rating itself is recognition that industrial capabilities are impaired). The Board, therefore, has determined that referral of this case for extra-schedular consideration pursuant to 38 C.F.R. 3.321(b)(1) is not warranted. ORDER Entitlement to a 10 percent evaluation, but no greater, for left knee sprain with Baker's cyst, for the period before June 18, 2009, is granted, subject to the laws and regulations governing the award of monetary benefits. Entitlement to an initial rating in excess of 10 percent for left knee sprain with Baker's cyst for the period from June 18, 2009, is denied. REMAND In furtherance of substantiating her claim for service connection of IgA deficiency, the Veteran was afforded a VA (QTC) examination in December 2006. The examination report documents that the examiner stated that the Veteran had "been suffering from partial IgA deficiency," but that the "current symptoms" were "none" and that the Veteran reported that the condition was asymptomatic. However, in the diagnosis section of the examination report the examiner stated that "there is no diagnosis because there is no pathology to render a diagnosis." In Barr v. Nicholson, 21 Vet. App. 303, 311 (2007), the United States Court of Appeals for Veterans Claims (Court) found that once VA undertakes the effort to provide an examination when developing a service-connection claim, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided. In Stefl v. Nicholson, 21 Vet. App. 120 (2007), the Court found that, "[w]ithout a medical opinion that clearly addresses the relevant facts and medical science, the Board is left to rely on its own lay opinion, which it is forbidden from doing." It is incumbent upon the rating board to return an examination report as inadequate if it does not contain sufficient detail. 38 C.F.R. § 4.2 (2012). The Veteran should be afforded a new VA examination to address her claim for service connection of IgA deficiency. The December 2006 examiner offered contradictory information. On one hand, he related that the Veteran suffered from "partial IgA deficiency," described as asymptomatic. However, on the other hand, he concluded that there was no such diagnosis as there was no pathology to support one. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (if the medical evidence of record is insufficient, the Board is free to supplement the record by seeking an advisory opinion or ordering a medical examination). Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for an appropriate examination to assess the nature and etiology of her claimed IgA deficiency. The entire claims file (i.e., both the paper claims file and any relevant medical records contained in the Veteran's Virtual VA eFolder) should be made available to and be reviewed by the examiner, and it should be confirmed that such records were available for review. After review of the record, and upon examination of the Veteran, the examiner should specifically indicate whether the Veteran currently has IgA deficiency and whether such constitutes an actual disability or is a laboratory finding only. If IgA deficiency is present, and the examiner concludes that such constitutes a disability, as opposed to a laboratory finding, the examiner should offer an opinion as to whether such is at least as likely as not (50/50 probability or better) related to her military service. The examiner is asked to provide the underlying reasons for any opinion expressed. If the examiner is unable to reach an opinion without resort to speculation, he or she should explain the reasons for this inability and comment on whether any further tests, evidence or information would be useful in rendering an opinion. 2. Then, after conducting any additional indicated development, readjudicate the claim currently on appeal. If the benefit sought on appeal remains denied, issue a Supplemental Statement of the Case and provide the appellant and her representative an appropriate period of time to respond before this case is returned to the Board. 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