Citation Nr: 1328727 Decision Date: 09/09/13 Archive Date: 09/17/13 DOCKET NO. 09-12 396 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUES 1. Entitlement to an increased rating for sarcoidosis with thoracotomy, currently rated as 30 percent disabling. 2. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for tuberculosis (TB), to include on a secondary basis, and if so, whether the reopened claim should be granted. 3. Entitlement to service connection for bilateral leg disability other than degenerative joint disease/bursitis of the knees and bilateral greater trochanteric bursitis. 4. Entitlement to service connection for bilateral carpal tunnel syndrome (CTS). 5. Entitlement to service connection for left ulnar neuropathy. 6. Entitlement to service connection for headaches, to include on a secondary basis. 7. Entitlement to service connection for sleep apnea. REPRESENTATION Appellant represented by: Military Order of the Purple Heart of the U.S.A. ATTORNEY FOR THE BOARD D. Schechter, Counsel INTRODUCTION The Veteran served on active naval duty from February 1969 to October 1972. This appeal comes before the Board of Veterans' Appeals (Board) from a January 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Indianapolis, Indiana. When this case was before the Board in February 2011, it was decided in part and remanded in part. While the case was in remand status, the issues of entitlement to service connection for erectile dysfunction and tinnitus were resolved by a May 2012 rating decision granting service connection for those disabilities. The issue of entitlement to service connection for bilateral leg disability was partially resolved by a September 2012 rating decision granting service connection for left and right hip trochanteric bursitis and a December 2012 rating decision granting service connection for bilateral knee degenerative joint disease/bursitis . The issues of entitlement to service connection for TB, left ulnar neuropathy, headaches and bilateral leg disability other than bilateral knee degenerative joint disease/bursitis and bilateral greater trochanteric bursitis are addressed in the REMAND that follows the ORDER section of this decision. FINDINGS OF FACT 1. The manifestations of the Veteran's sarcoidosis more nearly approximate pulmonary involvement with persistent symptoms requiring chronic low dose (maintenance) or intermittent corticosteroids, than pulmonary involvement requiring systemic high dose (therapeutic) corticosteroids. 2. The Veteran's sarcoidosis is not productive of any significant impairment of pulmonary functioning. 3. The RO denied a claim of entitlement to service connection for TB in a rating decision issued in September 1999; the Veteran did not appeal the denial or submit any pertinent evidence within the appeal period. 4. Evidence added to the record after the appeal period includes evidence that is not cumulative or redundant of the evidence previously of record and relates to an unestablished fact necessary to substantiate the claim for entitlement to service connection for TB. 5. CTS has not been present at any time during the pendency of the Veteran's claim. 6. Sleep apnea has not been present at any time during the pendency of the Veteran's claim. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 30 percent for the Veteran's sarcoidosis with thoracotomy scar have not been met for any portion of the rating period. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 38 C.F.R. § 4.97, Diagnostic Codes 6846-6600. (2012). 2. As new and material evidence has been received, the criteria for reopening the claim for entitlement to service connection for TB are met. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156 (2012). 3. The criteria for service connection for bilateral CTS are not met. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2012). 4. The criteria for service connection for sleep apnea are not met. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Claim to Reopen Legal Criteria Generally, a claim which has been denied in an unappealed RO decision or an unappealed Board decision may not thereafter be reopened and allowed. 38 U.S.C.A. §§ 7104(b), 7105(c) (West 2002). An exception to this rule is 38 U.S.C.A. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. Moreover, new and material evidence received prior to the expiration of the appeal period, or prior to the appellate decision if a timely appeal has been filed, will be considered as having been filed in connection with the claim which was pending at the beginning of the appeal period. 38 C.F.R. § 3.156(b). New evidence is defined as existing evidence not previously submitted to agency decision makers. Material evidence means evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence previously of record, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The Court recently interpreted the language of 38 C.F.R. § 3.156(a) as creating a low threshold, and viewed the phrase "raises a reasonable possibility of substantiating the claim" as "enabling rather than precluding reopening." The Court emphasized that the regulation is designed to be consistent with 38 C.F.R. § 3.159(c) (4), which, "does not require new and material evidence as to each previously unproven element of a claim." Shade v. Shinseki, No. 08-3548 (U.S. Vet. App. Nov. 2, 2010). For the purpose of establishing whether new and material evidence has been submitted, the credibility of the evidence, although not its weight, is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). Factual Background and Analysis The Veteran originally claimed that service connection for pulmonary tuberculosis was warranted because it was secondary to his service-connected sarcoidosis. The claim was denied in a September 1999 rating decision because the evidence failed to show that the tuberculosis was secondary to the Veteran's service-connected sarcoidosis. The Veteran did not appeal the September 1999 rating decision or submit any pertinent evidence within the appeal period. The evidence received subsequent to the appeal period includes the report of an April 2011 VA respiratory diseases examination stating that the Veteran, "actually had military TB by report... radiographs are not available." This evidence is not cumulative or redundant of the evidence previously of record and relates to an unestablished fact necessary to substantiate the claim. Accordingly, it is new and material, and reopening of the claim for service connection for TB is warranted. As explained below, the Board has determined that further development is required before the reopened claim is decided. II. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2012), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. The Board also notes the United States Court of Appeals for Veterans Claims (Court) has held that the plain language of 38 U.S.C.A. § 5103(a) (West 2002), requires that notice to a claimant pursuant to the VCAA be provided 'at the time' or 'immediately after' VA receives a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). The timing requirement enunciated in Pelegrini applies equally to the initial-disability-rating and effective-date elements of a service-connection claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The record reflects that the Veteran was provided all required notice in a letter mailed in June 2007, prior to the initial adjudication of the claims. The Board also finds VA has complied with its duty to assist the Veteran in the development of the claims adjudicated herein. In this regard, the record reflects that all pertinent available medical evidence identified by the Veteran has been obtained, to include private and VA outpatient treatment records. In addition, the Veteran has been afforded appropriate VA examinations in connection with the claims decided herein. The Appeals Management Center (AMC) also substantially complied with the Board's February 2011 remand directives. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999). The Veteran has not asserted, and the evidence of record does not show, that his sarcoidosis has increased significantly in severity since the most recent examination. Neither the Veteran nor his representative has identified any outstanding evidence that could be obtained to substantiate any of the claims. The Board is also unaware of any such evidence. Accordingly, the Board will address the merits of the claims on appeal. III. Burdon of Proof Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary 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 (West 2002); 38 C.F.R. §§ 3.102, 4.3 (2012); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. IV. Increased Rating for Sarcoidosis Legal Criteria Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2012). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during active service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2012). A 30 percent rating is warranted for sarcoidosis if there is pulmonary involvement with persistent symptoms requiring chronic low dose (maintenance) or intermittent corticosteroids. A 60 percent rating is warranted when there is pulmonary involvement requiring systemic high dose (therapeutic) corticosteroids for control. A 100 percent rating is warranted when there is cor pulmonale; or cardiac involvement with congestive heart failure; or progressive pulmonary disease with fever, night sweats, and weight loss despite treatment. 38 C.F.R. § 4.97, Diagnostic Code 6846. According to the note that follows Diagnostic Code 6846, active disease or residuals of sarcoidosis may also be rated as chronic bronchitis pursuant to Diagnostic Code 6600 or extra-pulmonary involvement under the specific body system involved. 38 C.F.R. § 4.97, Diagnostic Code 6846. Under Diagnostic Code 6600, which governs ratings of chronic bronchitis, a 30 percent rating is warranted when pulmonary function tests (PFTs) show FEV1 of 56 to 70 percent predicted, FEV1/FVC of 56 to 70 percent, or DLCO (SB) of 56 to 65 percent predicted. A 60 percent rating is warranted when there is FEV1 of 40 to 55 percent predicted, FEV1/FVC of 40 to 55 percent, or DLCO (SB) of 40 to 55 percent predicted or maximum oxygen consumption of 15 to 20 ml/kg/min (with cardiorespiratory limit). A 100 percent rating is warranted for FEV-1 less than 40 percent predicted, FEV1/FVC less than 40 percent, DLCO (SB) less than 40 percent predicted, maximum exercise capacity less than 15 ml/kg/min oxygen consumption (with cardiac or respiratory limitation), cor pulmonale (right heart failure), right ventricular hypertrophy, pulmonary hypertension (shown by echo or cardiac catheterization), episodes of acute respiratory failure, or requires outpatient oxygen therapy. Under 38 C.F.R. § 4.96 (Special provisions regarding evaluation of respiratory conditions), ratings under Diagnostic Codes 6600 through 6817 and Diagnostic Codes 6822 through 6847 will not be combined with each other. Rather, a single rating will be assigned under the diagnostic code which reflects the predominant disability with elevation to the next higher evaluation only where the severity of the overall disability warrants such elevation. See 38 C.F.R. § 4.96(a). When 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 is assigned. 38 C.F.R. § 4.7. It is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified; findings sufficiently characteristic to identify the disease and the disability therefrom are sufficient; and above all, a coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21 (2012). Factual Background and Analysis In accordance with 38 C.F.R. §§ 4.1, 4.2 (2012) and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed all evidence of record pertaining to the history of the service-connected sarcoidosis. The Board has found nothing in the historical record which would lead to the conclusion that the current evidence of record is not adequate for rating purposes. Moreover, the Board is of the opinion that this case presents no evidentiary considerations which would warrant an exposition of remote clinical histories and findings pertaining to either disability. In this regard the Board notes that where entitlement to compensation has already been established and an increase in the disability is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Veteran was afforded a VA respiratory diseases examination in May 2007. He reported that he experienced chest pain intermittently, which was at times associated with exertion and that he experienced chest pain and heaviness at times when walking up one flight of stairs. He stated that waling one block or climbing one flight of stairs caused him to experience shortness of breath. He described his dyspnea on exertion as causing him to stoop over and stop and rest for 10 minutes before proceeding. Upon neurological consultation in October 2006, the Veteran reported fatigue as well as excessive daytime sleepiness, with nighttime sleep disturbance. While the neurologist suspected sleep apnea, he also suspected the Veteran's sarcoidosis as playing a role in these symptoms. Subsequently, on a VA sleep study conducted in August 2012, sleep apnea was not found. Thus, the case presents evidence of fatigue and dyspnea on exertion, both potentially due to sarcoidosis. However, the Veteran was afforded a VA pulmonary function test in March 2011, and a VA pulmonary examination for compensation purposes in April 2011. As the April 2011 examiner noted, the pulmonary function test results were normal, and at the examination the Veteran reported that he could walk as far as he wanted. He reportedly had never taken medication for his sarcoidosis. The April 2011 examiner further noted that while there were scant radiographic findings, the examiner attributed these to residuals of the Veteran's pulmonary tuberculosis, rather than to his sarcoidosis. The examiner concluded that the Veteran's sarcoidosis was in remission. The Board finds the conclusions of the April 2011 examiner to be well-informed by review of the evidence of record and examination of the Veteran, as well as by the Veteran's own assertions, and to be based on sound reasoning. The Board also finds that the weight of the evidence is to the effect that the difficulties with exertion previously reported by the Veteran, to the extent present during the rating period, are not attributable to the Veteran's sarcoidosis, which, by the weight of the evidence including particularly the findings of the April 2011 examiner and the March 2011 pulmonary function test, is in remission without discernible residuals (beyond those already separately rated). In any event, the evidence shows that the sarcoidosis has not required any corticosteroid treatment. It is clear that the manifestations of the disability are not in excess of those contemplated by the assigned rating of 30 percent under Diagnostic Code 6846. Moreover, the findings on pulmonary function testing were normal so the disability would not warrant a higher rating it were rated as bronchitis under Diagnostic Code 6600. While the Board has duly considered the Veteran's assertions and acknowledges that he is competent to describe his symptoms, he is not competent to attribute those symptoms to a particular disorder. The Board also has considered whether there is any other schedular basis for granting this claim, but has found none. In particular, the Board notes that the evidence does not show that the thoracotomy scar is productive of any symptoms or impairment warranting a separate compensable rating. Consideration has been given to assigning a staged rating; however, at no time during the period in question has the disability warranted a higher rating. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Finally, the Board has considered the doctrine of reasonable doubt but has determined that it is not applicable to this claim because the preponderance of the evidence is against the claim. V. Claims for Service Connection Legal Criteria Service connection may be granted for a disability resulting from injury or disease incurred in or aggravated by active service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Service connection may be granted for disability which is proximately due to or the result of service-connected disability. 38 C.F.R. § 3.310(a). Additional disability resulting from the aggravation of a nonservice-connected disability by a service-connected disability is also compensable under 38 C.F.R. § 3.310(a). Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Sleep Apnea The record contains evidence of sleep disturbance and medical evidence showing that the presence of sleep apnea was suspected but it does not contain medical evidence showing a confirmed diagnosis of sleep apnea in service or thereafter. The Veteran underwent a sleep study and was afforded a VA examination for compensation purposes in August 2012. The examiner noted that the sleep study did not show that the Veteran has sleep apnea. The examiner stated that the Veteran did not currently have sleep apnea and that he had never had sleep apnea. The Veteran and his wife have described his problems with sleep and the Board has no reason to doubt their credibility. Never the less, as lay persons, they are not competent to attribute the Veteran's symptoms to sleep apnea. In view of the negative sleep study, the August 2012 VA examination report indicating that the Veteran has never had sleep apnea, and the absence of any medical evidence confirming the presence of sleep apnea in service or thereafter, the Board must conclude that service connection is not warranted for this claimed disability. In so concluding, the Board has considered the doctrine of reasonable doubt but has determined that it is not applicable to this claim because the preponderance of the evidence is against the claim. Bilateral CTS Upon private neurological evaluation in 2006, while CTS was first differentially assessed based on "soft signs" and the Veteran's complaints of shooting pains from the wrists, EMG testing in November 2006 produced no evidence of CTS. Similarly, upon VA neurological examination for compensation purposes in March 2011, EMG testing was negative for median nerve neuropathy. That examiner diagnosed hand paresthesias, but no CTS. The evidentiary record as a whole does not otherwise provide findings or diagnoses of CTS. While the Veteran is competent to report on symptoms such as hand or wrist pain or paresthesia, he does not possess the expertise required to attribute his symptoms to CTS. Jandreau. As discussed above, the medical evidence shows that CTS has not been present during the period of this claim. Therefore, this claim must also be denied. In reaching this decision, the Board has considered the doctrine of reasonable doubt but has determined that it is not applicable to this claim because the preponderance of the evidence is against the claim. ORDER An increased rating for sarcoidosis with thoracotomy scar is denied. The Board having determined that new and material evidence has been presented, reopening of the claim for service connection for TB is granted. Service connection for sleep apnea is denied. Service connection for bilateral CTS is denied. REMAND Further development is required before the Board decides the claims for service connection for TB, bilateral lower extremity disability, left ulnar neuropathy, and headaches. A. Service Connection for TB The Veteran was afforded a VA respiratory examination in April 2011. The examiner suspected that the Veteran had current residuals of TB, but the examiner did not provide an opinion concerning the etiology of any TB or residuals of TB present during the period of the claim. Therefore, another VA examination with opinion is required. B. Service Connection for Bilateral Lower Extremity Disability (other than the already service-connected degenerative joint disease/bursitis of the knees and bilateral greater trochanteric bursitis) While examinations were obtained addressing knee and hip disabilities, and ultimately service connection for disabilities of the knees and hips has been granted, the Veteran's claim is broader, encompassing pain and swelling of both the legs and feet. Examination and readjudication of the remaining portion of the claim is required, in fulfillment of the Board's prior remand instructions. Stegall v. West, 11 Vet. App. 268 (1998). C. Service Connection for Left Ulnar Neuropathy The record of a consultation by a private neurologist in October 2006 shows that the Veteran complained of intermittent sharp pains in the wrists that shoot into the metacarpals. The neurologist reported examination findings of "soft signs of possible bilateral carpal tunnel syndrome and probable bilateral cubital tunnel syndrome." The neurologist also suspected musculoskeletal arthritic involvement. However, following EMG testing in November 2006, the neurologist found evidence of mild left ulnar neuropathy, but no evidence of right ulnar neuropathy or carpal tunnel syndrome. The Veteran was afforded a VA neurological examination for compensation purposes in March 2011 addressing the claimed left ulnar neuropathy. EMG testing was conducted, and the examiner interpreted the findings as a normal, with no evidence or median or ulnar neuropathy. On this basis the examiner diagnosed hand paresthesias with no EMG findings. Unfortunately, the March 2011 examiner did not note the prior EMG findings supportive of the presence of left ulnar neuropathy, and did not address the apparent discrepancy between those prior findings and current findings. The examiner also did not address the etiology of the identified hand paresthesias. Therefore, the examination report is inadequate for adjudication purposes, and a new examination is warranted. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). D. Service Connection for Headaches The Veteran was afforded a VA neurological examination for compensation purposes in March 2011. The examiner opined that the Veteran's headaches were not caused or aggravated by the Veteran's service-connected sarcoidosis or his service-connected hypertension. The examiner explained that the medical literature did not support a causal link between sarcoidosis and headaches. The examiner further supported the opinion, regarding causation related to hypertension, as follows: While hypertension is commonly thought to result in headache this is not necessarily true. Hypertension usually has no symptoms. It is therefore no cause of the headaches, nor does it aggravate his headaches. The Board finds this medical rationale discounting a causal link to hypertension to be both unsound logically, and not addressing the appropriate standard of proof. Merely because hypertension is usually asymptomatic does not speak to whether it is asymptomatic for this Veteran, and merely because hypertension does not necessarily cause headaches does not support the conclusion that hypertension is not causing headaches for this Veteran. Additionally, the March 2011 examiner failed to consider the February 2007 assessment of the Veteran's private treating neurologist. The private neurologist diagnosed right occipital neuralgia, and noted that the Veteran's hypertension was among potential contributors and triggers for his headaches. While a June 2012 VA examination addendum opinion also address the Veteran's headaches, this opinion only addressed etiology as directly related to service. The Board finds the March 2011 examination report inadequate for adjudication purposes. A new examination is thus warranted to address questions of secondary causation. Accordingly, this case is REMANDED to the RO or the Appeals Management Center (AMC), in Washington, D.C., for the following actions: 1. The RO or the AMC should undertake appropriate development to obtain any outstanding records pertinent to the Veteran's claims. 2. Then, the Veteran should be afforded a VA examination by a physician with sufficient expertise to determine the etiology of any TB or residuals of TB present during the period of the claim. The claims files and any pertinent evidence in Virtual VA that is not included in the claims files must be made available to and reviewed by the physician. Any indicated studies should be performed. Following the examination of the Veteran and a review of his pertinent history, the examiner should first address whether active or inactive TB or residuals of TB have been present at any time during the pendency of the claim. If so, the examiner should state an opinion as to whether there is a 50 percent or better probability that the disability originated while the Veteran was serving on active duty or is otherwise etiologically related to his active service. The examiner should consider all relevant evidence, including in particular the PPD conversion upon medical board examination in service in August 1972 and the INH prophylaxis then administered, as well as the finding of active TB in 1997 with hospitalization and chemotherapy at that time. The physician must provide the supporting rationale for all opinions expressed. If the physician is unable to provide any required opinion, he or she should explain why the opinion cannot be provided. 3. The Veteran should be afforded a VA examination by a physician with sufficient expertise to determine the nature and etiology of any lower extremity disorders present during the period of the claim (other than the already service-connected bilateral knee degenerative joint disease/ bursitis and bilateral greater trochanteric bursitis). The claims files and any pertinent evidence in Virtual VA that is not included in the claims files must be made available to and reviewed by the physician. Following the examination of the Veteran and a review of his pertinent history, for each identified lower extremity disorder, the examiner should state an opinion as to whether there is a 50 percent or better probability that the disorder originated in service, is otherwise etiologically related to service, or was caused or permanently worsened by the Veteran's sarcoidosis and/or hypertension. The physician must provide the supporting rationale for all opinions expressed. If the physician is unable to provide any required opinion, he or she should explain why the opinion cannot be provided. 4. The Veteran should be afforded a VA examination by a physician sufficient expertise ( other than the one who conducted the VA neurological examination of the Veteran for compensation purposes in March 2011) to determine the nature and etiology of any left ulnar neuropathy present during the period of the claim. The claims files and any pertinent evidence in Virtual VA that is not included in the claims files must be made available to and reviewed by the physician. Following the examination of the Veteran and a review of his pertinent history, the examiner should state an opinion with respect to any left ulnar neuropathy present during the period of the claim as to whether there is a 50 percent or better probability that the disorder originated during service, is otherwise etiologically related to service, or was caused or permanently worsened by the Veteran's sarcoidosis. The physician must provide the supporting rationale for all opinions expressed. If the physician is unable to provide any required opinion, he or she should explain why the opinion cannot be provided. 5. The Veteran should be afforded a VA examination by a physician sufficient expertise to determine the nature and etiology of any headache disorder present during the period of the claim. The claims files and any pertinent evidence in Virtual VA that is not included in the claims files must be made available to and reviewed by the physician. Following the examination of the Veteran and a review of his pertinent history, the examiner should state an opinion with respect to any headache disorder present during the period of the claim as to whether there is a 50 percent or better probability that the was caused or permanently worsened by the Veteran's hypertension. The physician must provide the supporting rationale for all opinions expressed. If the physician is unable to provide the required opinion, he or she should explain why the opinion cannot be provided. 6. The RO or the AMC should also undertake any other development it determines to be warranted. 7. Then, the RO or the AMC should readjudicate the Veteran's claims. If the benefits sought on appeal are not granted to the Veteran's satisfaction, he and his representative should be provided a Supplemental Statement of the Case and afforded the requisite opportunity to respond before the case is returned to the Board for further appellate action. By this remand, the Board intimates no opinion as to any final outcome warranted. The Veteran need take no action until he is otherwise notified, but he may furnish additional evidence and/or argument during the appropriate time frame. See Kutscherousky v. West, 12 Vet. App. 369 (1999). This REMAND must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or the Court 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). ______________________________________________ Shane A. Durkin Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs