Citation Nr: 1328679 Decision Date: 09/09/13 Archive Date: 09/17/13 DOCKET NO. 13-00 033A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for loss of teeth for compensation purposes. 3. Entitlement to service connection for degenerative joint disease of the lumbar spine. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD L. Kirscher Strauss, Counsel INTRODUCTION The Veteran served on active duty from January 1952 to December 1953. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2010 administrative decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida, which denied the Veteran's claims. The Veteran's dental claim includes a claim for entitlement to service connection for loss of teeth for VA outpatient dental treatment purposes. The Regional Office referred that claim to the Orlando VA Medical Center, as noted in the December 2012 statement of the case (SOC). As the VAMC is the current agency of jurisdiction (AOJ), and the Board has not received an appeal from a denial by the AOJ, this claim is not before the Board on appeal. In February 2013, before certification of the appeal to the Board, the Veteran submitted to the RO additional evidence for consideration in connection with the PTSD claim on appeal. A supplemental statement of the case (SSOC) was not issued. However, a waiver of RO jurisdiction for this evidence was received in a written statement dated in April 2013 that is included in the record. Therefore, Board accepts this evidence for inclusion in the record on appeal. See 38 C.F.R. § 20.1304 (2013). The issue of entitlement to service connection for degenerative joint disease of the lumbar spine 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. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. The Veteran participated in combat with the enemy. 2. The most probative evidence of record fails to establish that the Veteran meets the diagnostic criteria for a diagnosis of PTSD. 3. The Veteran asserts that he lost his front teeth in service; he has not suffered tooth loss due to loss of substance of the body of the maxilla or mandible without loss of continuity or disease such as osteomyelitis. CONCLUSIONS OF LAW 1. The criteria for establishing entitlement to service connection for PTSD have not been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2013). 2. The claim for service connection for loss of teeth for compensation purposes is without legal merit. 38 U.S.C.A. §§ 1110, 1712 (West 2002); 38 C.F.R. §§ 3.303, 3.381, 4.150 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. The Veterans Claims Assistance Act of 2000 (VCAA) The Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107 and 5126 (West 2002 & Supp. 2013) and 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2013), describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. The notice requirements of the VCAA require VA to notify a claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, VA will attempt to obtain. 38 C.F.R. § 3.159(b). The requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between a veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id.; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, the issuance of a late notice may be cured by re-adjudication. In this case, in an April 2008 letter the RO provided notice to the Veteran regarding what information and evidence was needed to substantiate his claims for service connection, as well as what information and evidence must be submitted by the Veteran and what information and evidence will be obtained by VA. The letter advised him of how disability evaluations and effective dates are assigned and the type of evidence that impacts those determinations. The case was last adjudicated in December 2012. The record also reflects that VA has made reasonable efforts to obtain relevant records adequately identified by the Veteran, including his post-service VA treatment records, VA examination and medical opinion reports, and lay statements. VA has considered and complied with the VCAA provisions discussed above. The Veteran was notified and aware of the evidence needed to substantiate the claims, the avenues through which he might obtain such evidence, and the allocation of responsibilities between the Veteran and VA in obtaining such evidence. The Veteran was an active participant in the claims process by submitting evidence and argument. Therefore, he was provided with a meaningful opportunity to participate in the claims process and has done so. II. General Relevant Laws and Regulations for Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2013). Service connection may be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To establish service connection for a present disability, there must be: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service." Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Holton v. Shinseki, 557 F.3d 1362 (2009). For a showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." That an injury occurred in service alone is not enough; there must be chronic disability resulting from that injury. Continuity of symptomatology is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. If the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (2013). The Board acknowledges that in the case of any veteran who engaged in combat with the enemy in active service, VA shall accept as sufficient proof of service connection of any disease or injury alleged to have been incurred in or aggravated by such service, satisfactory lay or other evidence of service incurrence or aggravation of such injury or disease, if consistent with the circumstances, conditions, or hardships of such service, notwithstanding the fact that there is no official record of such incurrence or aggravation in such service, and, to that end, shall resolve every reasonable doubt in favor of the veteran. Service connection of such injury or disease may be rebutted by clear and convincing evidence to the contrary. 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d). However, the Board also observes that these provisions deal with the question of whether a particular disease or injury occurred in service; that is, what happened then, and not the question of either current disability or nexus to service, as to both of which competent medical evidence is generally required. In other words, the above-cited provisions do not presumptively establish service connection for a combat veteran; rather, they relax the evidentiary requirements for determining what happened in service. See Brock v. Brown, 10 Vet. App. 155, 162 (1997); Libertine v. Brown, 9 Vet. App. 521, 524 (1996). Initially, the Board notes that the Veteran's service treatment records are unavailable. The National Personnel Records Center (NPRC) reported that the records may have been destroyed in a fire at that facility in 1973. Moreover, additional efforts to obtain any service treatment records from the Veteran or to search for alternative records were unsuccessful. The Board points out that there is a heightened obligation to explain findings and conclusions and to consider carefully the benefit of the doubt rule in cases, such as this, in which records are presumed to have been or were destroyed while the file was in the possession of the government. See Pruitt v. Derwinski, 2 Vet. App. 83, 85 (1992); see also O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). The Board's analysis of the Veteran's service connection claims has been undertaken with this duty in mind. The Veteran's DD Form 214 reflects that he was awarded the Combat Infantry Badge and the Korean Service Medal with two Bronze Stars. Therefore, he is a Combat Veteran. A. PTSD Service connection for PTSD requires medical evidence establishing a diagnosis of the condition in accordance with 38 C.F.R. § 4.125(a); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor actually occurred. If the evidence establishes that the Veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f) (2013). The Veteran's DD Form 214 reflects that he engaged in combat with the enemy and he claimed entitlement to service connection for PTSD due to combat experience in Korea. VA treatment records associated with the electronic Virtual VA claims file reflect that he established care in March 2004, and his wife reported that the Veteran had a one-year history of memory loss and a family history of Alzheimer's disease. The Veteran denied any depression. Subsequent VA treatment records reflect treatment for Alzheimer's dementia with subjective complaints of memory loss. During a primary care visit in May 2008, the Veteran denied any depression or PTSD during a review of systems. A December 2009 VA psychiatry note for "evaluation, brief therapy and medication management of Alzheimer's dementia" reflects that the Veteran reported "doing good." He denied depression or psychotic symptoms, hallucinations, "illusions," flashbacks, or hypervigilance; he reported that sleep was consistent. On mental status examination, his mood was euthymic and affect was broad. The impression was Alzheimer's dementia and the examiner commented that the Veteran presented as mentally stable. During a January 2012 routine medical history and physical, the Veteran denied depression, anxiety, or PTSD during a review of systems. However, his wife had called to request an "anxiety pill" for the Veteran. The Veteran stated that he did not feel too anxious. Reported examination findings noted that the Veteran did "not appear to have any memory problems, nor anxiety at the moment." The assessment included anxiety and Paxil was prescribed. A depression screen was negative in October 2012. The Veteran was afforded a VA PTSD examination in November 2012. He recalled a crew member firing a recoilless rifle at night, being scared by the back blast, and running into a tree and losing all his front teeth. He stated that he was treated in camp and returned to duty. The Veteran reported symptoms of memory loss since 2004. He described "perfect" sleep with no nightmares. He denied having distressing recollections of military service and indicated that he does watch old war movies. He reported good visits with family, good romantic intimacy with his wife, enjoying music, and doing a variety of activities and chores around the house for leisure and to keep busy. The examiner noted that the Veteran was not aware of the nature of the current examination, stating that he had "no idea what [type] of claim was filed." Following a review of the claims file and mental status examination, which revealed poor recall on short- and long-term memory questions, the examining clinical psychologist concluded that the Veteran did not meet the DSM-IV diagnostic criteria for PTSD. The examiner detailed that the Veteran did not persistently reexperience the traumatic event, there was no persistent avoidance of stimuli associated with the trauma or numbing of general responsiveness, and there was no persistent symptoms of increased arousal. The examiner did diagnose dementia of the Alzheimer's type. The examiner opined that based on the records reviewed and the evaluation, the current mental disorder of dementia of the Alzheimer's type was age and health related and not due to military service. In the December 2012 SOC, the RO characterized the Veteran's claim on appeal as "service connection for dementia of the Alzheimer's type (claimed as [PTSD] and nervous problems)" and continued to deny the claim. In his January 2013 substantive appeal, the Veteran clarified that he did not claim entitlement to service connection for an Alzheimer's disability. He asserted that "you stated that I do not have a diagnosis for PTSD, but if you would have reviewed my VA progress notes, you would have seen that there is a diagnosis for PTSD." He indicated that he would provide medical evidence to support his assertion of a diagnosis of PTSD "when available." In a January 2013 letter addressed to a Florida County veteran service officer, a VA psychiatrist, J. R., M.D., stated that the Veteran was a patient at the Orlando VAMC and was in treatment for mental health issues and had provided a copy of his DD-214, which indicated that he was a combat veteran during the war. The psychiatrist stated that during the Veteran's military service, he suffered multiple traumatic stressors including active combat duty where he witnessed the deaths of multiple American and Korean soldiers. He also suffered an event during his combat tour where he was fired upon in a trench and fell and lost several teeth. He is suffering from multiple [PTSD] symptoms including intrusive recollection (e.g., nightmares and flashbacks), avoidant/numbing, and hyperarousal (including hypervigilance and irritability) [that] have impaired his day to day functioning and caused mental disability. It is clear that he has suffered a great mental stress as a result of his military service. The patient meets diagnostic criteria for [PTSD]. Considering the pertinent medical and lay evidence in light of the governing legal authority, the Board finds that service connection for PTSD is not warranted. Initially, the Board acknowledges that the Veteran's lay testimony alone is sufficient to establish the occurrence of the claimed in-service stressor. Here, his DD-214 reflects that he engaged in combat with the enemy, and his claimed stressor, which he reported on VA examination in November 2012, of responding in fear to a back blast from a recoilless rifle, is consistent with the circumstances, conditions, or hardships of his service. Therefore, the element of an in-service stressor is satisfied. 38 C.F.R. § 3.304(f). The Board also acknowledges that the Veteran is competent to describe events that he witnessed or experienced during military service and that he is competent to describe psychiatric symptoms that he may experience. See Barr v. Nicholson, 21 Vet. App. 303 (2007). The only medical opinions to address the question of whether the Veteran has PTSD are from the November 2012 VA examiner and from a VA psychiatrist in January 2013. When reviewing such medical opinions, the Board may appropriately favor the opinion of one competent medical authority over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). However, the Board may not reject medical opinions based on its own medical judgment. Obert v. Brown, 5 Vet. App. 30 (1993); see also Colvin v. Derwinski, 1 Vet. App. 171 (1991). In assessing medical opinions, the failure of the physician to provide a basis for his opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). The Board finds that the opinion of the November 2012 VA clinical psychologist is persuasive evidence against the claim of service connection for PTSD because it was based on a review of the claims file, clinical interview, and mental status examination; and because it is consistent with and fully supported by the medical evidence of record, which does not reflect complaints or diagnosis of PTSD but does document the Veteran's denial of experiencing depression, PTSD, hallucinations, "illusions," flashbacks, hypervigilance, or sleep disturbance due to psychiatric symptoms. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (holding that it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion). In comparison, the Board finds that the opinion of the January 2013 VA psychiatrist, which appears to have been solicited by a county veteran service officer, is entitled to significantly less probative value. First, a review of the VA treatment records associated with the Virtual VA claims file does not reflect that the January 2013 VA psychiatrist has treated the Veteran, and the January 2013 opinion letter does not reflect that a mental status examination was conducted or that the Veteran was physically present for any such examination. As a result, it appears that the conclusion that the Veteran met the diagnostic criteria for PTSD was based solely on reports of subjective symptoms. Second, the psychiatrist's account of current PTSD symptoms of intrusive recollection such as nightmares and flashbacks, avoidance and numbing, and hypervigilance and irritability, is contradicted by and inconsistent with the Veteran's previous denial of such symptoms during routine VA treatment with his primary care physician and psychiatrist and on VA examination in November 2012. Accordingly, the prior consistent statements denying such symptoms, which, notably were made before the claim was denied on the merits (as reflected in the December 2012 SOC) and in the course of seeking routine medical treatment and treatment for Alzheimer's dementia, are afforded greater probative value than the apparent report of PTSD symptoms in January 2013. See Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (statements made for the purposes of medical treatment may be afforded greater probative value because there is a strong motive to tell the truth in order to receive proper care). Finally, while the Board does not doubt that the Veteran was exposed to one or more traumatic stressors during his combat service in Korea, the January 2013 psychiatrist's conclusion that "it is clear that [the Veteran] has suffered great mental stress as a result of his military service" appears to be factually inaccurate. Again, neither his VA treatment records nor the November 2012 VA compensation and pension examination report reflects any communication from the Veteran that he has experienced "great mental stress" due to events in service. In fact, his VA treatment records reflect ongoing treatment and evaluation for Alzheimer's dementia without mention of specific or general military experiences. Moreover, the Board notes that while a VA clinician prescribed Paxil for anxiety upon request of the Veteran's wife in January 2012, the Veteran himself stated that he did "not feel too anxious" and the examiner noted that he did not appear to be anxious on examination. In summary, because the January 2013 medical opinion does not appear to be based on any objective findings and reflects reports of current symptoms that are contradicted by prior statements and medical evidence, the psychiatrist's conclusion that the Veteran meets the diagnostic criteria for PTSD does not appear to be adequately supported. Therefore, the Board finds that the most probative medical evidence of record fails to establish that the Veteran currently has PTSD, despite the presence of a conceded in-service stressor. Congress has specifically limited entitlement to service connection for disease or injury to cases where such incidents have resulted in a disability. See 38 U.S.C.A. § 1110 (West 2002). Accordingly, where, as here, there is no competent medical evidence establishing that the Veteran has current PTSD, the disability for which service connection is sought is not established, and thus, there can be no valid claim for service connection. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In this case, the first essential criterion for a grant of service connection, evidence of a current PTSD disability, has not been met. B. Loss of Teeth for Compensation Purposes Under current legal authority, compensation is only available for certain types of dental and oral conditions, such as impairment of the mandible, loss of a portion of the ramus, and loss of a portion of the maxilla. See 38 C.F.R. § 4.150. Compensation is available for loss of teeth if such is due to loss of substance of body of maxilla or mandible, but only if such bone loss is due to trauma or osteomyelitis, and not to the loss of the alveolar process as a result of periodontal disease, as such loss is not considered disabling. Id. at Note. Treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, and periodontal disease will be considered service connected solely for the purpose of establishing eligibility for outpatient dental treatment and cannot be considered for compensation purposes. 38 U.S.C.A. § 1712; 38 C.F.R. §§ 3.381, 4.150. Considering the pertinent evidence in light of the governing legal authority, the Board finds that service connection for loss of teeth, for compensation purposes, is not warranted. The Veteran contends that he lost his front teeth when he ran into a tree or fell into a hole during combat actions in Korea. He reports that he was taken to a tent hospital for treatment. During a November 2012 VA PTSD examination, he stated that he "got new teeth when he returned" home. As noted, however, replaceable missing teeth are not considered disabling for VA disability compensation purposes. See 38 C.F.R. § 3.381(a); see also 38 C.F.R. § 4.150. Further, there is no evidence and the Veteran has not alleged that he has tooth loss due to loss of body of the maxilla or mandible caused by in-service trauma or osteomyelitis. Although the Veteran had trauma in service, there is no evidence to even suggest that it caused loss of body of the maxilla or mandible, which in turn, caused his tooth loss. As the Veteran seeks service connection for replaceable missing teeth, which were already replaced after service according to his report, and such a condition can only be considered service connected for the purpose of establishing eligibility for outpatient dental treatment-and not for compensation purposes- the claim for service connection for compensation purposes must be denied. Where, as here, the law and not the evidence is dispositive, the claim must be terminated or denied as without legal merit. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). C. Both Service Connection Claims In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claims for service connection for PTSD and loss of teeth for compensation purposes, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b) (West 2002); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). ORDER Entitlement to service connection for PTSD is denied. Entitlement to service connection for loss of teeth for compensation purposes is denied. REMAND The Board has reviewed the evidence of record and finds that additional development is required before deciding the claim for service connection for a low back disability. The Veteran contends that he hurt his back during combat operations in Korea and that he was treated in service for his back. VA treatment records dated from March 2004 and subsequently reflect intermittent complaints of low back pain, with radiation to the right lower extremity beginning in 2008. The claim for service connection was received in July 2010. The Veteran was afforded a VA spine examination in November 2012. He reported that he fell in a hole in Korea in training and combat and hurt his back and lost his tooth, was taken to a tent hospital, and since then it had been the same. Following a review of the claims file, lumbar spine x-ray, and physical examination, the diagnosis was degenerative disease of the lumbar spine. In December 2012, another VA examiner reviewed the CPRS (Computerized Patient Record System) record and considered the information provided by a decision review officer (DRO) regarding the Veteran's status as a combat Veteran. The examiner opined that it would be mere speculation to render an opinion since the Veteran is 80 years old, and degenerative joint disease is a natural progression due to the aging process and not necessarily due to an event that occurred in the [19]50s. The Veteran contends that the December 2012 VA medical opinion was inadequate. The Board agrees that additional medical opinion evidence is required before deciding the claim on appeal. A medical opinion is inadequate where it is noted that the etiology of a disability could not be resolved without resort to speculation, and the examiner does not provide any supporting explanation for that conclusion. Jones v. Shinseki, 23 Vet. App. 382, 390 (2010). The phrase "without resort to speculation" must reflect the limitations of knowledge in the medical community at large and not those of a particular examiner. Id. Additionally, the examiner must identify what facts cannot be determined, for example, whether it cannot be determined from current medical knowledge that a specific in-service injury or disease can possibly cause the claimed condition, or that the actual cause cannot be selected from multiple potential causes. Id. In this case, while the December 2012 VA medical opinion did provide a supporting explanation for the conclusion, indicating that degenerative joint disease is a natural progression due to the aging process, the opinion did not clearly reflect the limitations of knowledge in the medical community at large, or identify what facts could not be determined to reach a more definitive conclusion. Therefore, the AMC/RO should provide the Veteran's entire claims file to an appropriate physician for a supplemental medical opinion. Before arranging for an additional medical opinion, the AMC/RO should ask the Veteran to provide information regarding any treatment he received for a low back disability since separation from service and should obtain any outstanding treatment records from the Orlando VAMC dated from January 2012 to the present that may be related to his claim for a low back disability. See Bell v. Derwinski, 2 Vet. App. 611 (1992). Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). Expedited handling is requested.) 1. The AMC/RO should contact the Veteran and request that he identify the names, addresses and approximate dates of treatment for all health care providers, VA and private, who may possess additional records pertinent to his claim. The AMC/RO should attempt to obtain and associate with the claims folder any medical records identified by the Veteran that are not already of record. Even if the Veteran does not respond, the AMC/RO should obtain from the Orlando VAMC ongoing records of evaluation and treatment for any low back disability dated from January 2012 to the present. 2. Upon completion of the above, the AMC/RO should provide the Veteran's complete claims file and a copy of the remand to an appropriate physician to obtain a medical opinion regarding the etiology of the current degenerative joint disease of the lumbar spine. The physician shall accept that the Veteran incurred a back injury during his active duty combat service in Korea in 1952 and/or 1953. Also, the Veteran's service treatment records are unavailable. The examiner is also requested to provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that the current low back disability began in service as a result of the reported injury or is otherwise medically related to military service, including a back injury sustained when falling into a hole during combat. A complete rationale for any opinion expressed must be provided. If the physician determines that he/she cannot provide an opinion without resorting to speculation, the physician should explain the inability to provide an opinion, identifying precisely what facts could not be determined. In particular, he/she should comment on whether an opinion could not be provided because the limits of medical knowledge have been exhausted or whether additional testing or information could be obtained that would lead to a conclusive opinion. Jones v. Shinseki, 23 Vet. App. 382, 389 (2010). In other words, if the physician cannot determine whether the current back disability is related to the in-service back injury during combat, then the physician should explain why the cause of the current back disability cannot be determined or selected from multiple potential causes, such as the injury in 1952 or 1953 or the natural aging process. 3. The AMC/RO must ensure that the medical opinion report complies with this remand and the questions presented in the request. If the report is insufficient, it must be returned to the examiner for necessary corrective action, as appropriate. 4. After undertaking any other development deemed appropriate the AMC/RO should re-adjudicate the issue on appeal. If the benefit sought is not granted, the Veteran and his representative should be furnished with a supplemental statement of the case and afforded an opportunity to respond before the record is returned to the Board for further review. 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). ______________________________________________ J. A. MARKEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs