Citation Nr: 1329020 Decision Date: 09/11/13 Archive Date: 09/17/13 DOCKET NO. 08-02 189 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Whether new and material evidence has been submitted to reopen a claim of entitlement to service connection for sleep apnea, and if so, whether service connection should be granted. 2. Entitlement to an increased rating for hypertension, currently evaluated as 10 percent disabling. 3. Entitlement to an increased rating for Grave's disease, currently evaluated as 10 percent disabling. 4. Entitlement to an increased rating for rhinitis, current evaluated as noncompensably disabling. 5. Entitlement to an increased rating for hemorrhoids, currently evaluated as noncompensably disabling. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD J. Barone, Counsel INTRODUCTION The Veteran had active service from February 1995 to November 2003. This matter comes before the Board of Veterans' Appeals (Board) from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco Texas. The issues of entitlement to service connection for sleep apnea and increased ratings for Grave's disease and rhinitis are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. In a February 2005 rating decision, the RO denied service connection for sleep apnea. 2. The evidence received since the February 2005 decision is not cumulative or redundant of evidence previously of record, and raises a reasonable possibility of substantiating the claim of entitlement to service connection for sleep apnea. 3. Hypertension is manifested by no more than diastolic pressure predominantly 100 or more or systolic pressure predominately 160 or more; the Veteran requires continuous medication to control his hypertension. 4. The Veteran's hemorrhoids are internal and mild; they are not large or thrombotic, or irreducible with excessive redundant tissue evidencing frequent recurrences. CONCLUSIONS OF LAW 1. The February 2005 rating decision is final. 38 U.S.C.A. § 7104(b) (West 2002); 38 C.F.R. §§ 3.160(d), 20.1103 (2012). 2. New and material evidence has been received to reopen the claim of entitlement to service connection for sleep apnea. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156 (2012). 3. The schedular criteria for an evaluation in excess of 10 percent for hypertension have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.104, Diagnostic Code 7101 (2012). 4. The criteria for a compensable evaluation for hemorrhoids have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.114, DC 7336 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). The Board has determined that the evidence is sufficient to reopen the Veteran's claim of entitlement to service connection for sleep apnea; accordingly, no further discussion of the VCAA is necessary with respect to this claim. Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2012); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. VCAA notice should be provided to a claimant before the initial unfavorable RO decision on a claim. See Pelegrini v. Principi, 18 Vet. App. 112 (2004); Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). On March 3, 2006, the Court of Appeals for Veterans Claims (Court) issued a decision in the consolidated appeal of Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), which held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. The Court held that upon receipt of an application for a service-connection claim, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. Id. at 486. In response to the Veteran's December 2006 increased rating claim, a February 2007 letter informed him of the evidence necessary to support an increased rating. The evidence of record was listed and the Veteran was told how VA would assist him in obtaining additional relevant evidence. He was also advised of the manner in which VA determines disability ratings and effective dates. Subsequent letters advised the Veteran of the status of his claim and provided him with the criteria under which the service-connected disabilities for which he seeks increased ratings are evaluated. The Board finds that the content of the notice provided to the Veteran fully complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) regarding VA's duty to notify. The Veteran has been provided with every opportunity to submit evidence and argument in support of his claim and to respond to VA notices. Further, the Board finds that the purpose behind the notice requirement has been satisfied because the Veteran has been afforded a meaningful opportunity to participate effectively in the processing of his claims. Therefore, the record reflects that he was provided with a meaningful opportunity during the pendency of his appeal such that the preadjudicatory notice error did not affect the essential fairness of the adjudication now on appeal. With respect to VA's duty to assist, VA treatment records have been obtained and associated with the record. VA examinations have been conducted. The Board finds that the examinations were adequate in that they were conducted by neutral, skilled providers who reviewed the record, interviewed the Veteran, and performed appropriate physical examinations prior to providing their conclusions. The Veteran has not otherwise identified any additional evidence or information which could be obtained to substantiate the claim. The Board is also unaware of any such outstanding evidence or information. Therefore, the Board is also satisfied that VA has complied with the duty to assist requirements of the VCAA and the implementing regulations. For the foregoing reasons, it is not prejudicial to the appellant for the Board to proceed to a final decision in this appeal. Analysis New and Material Evidence 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). The 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. New evidence means existing evidence not previously submitted to agency decisionmakers. Material evidence means existing 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 of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). 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). But see Duran v. Brown, 7 Vet. App. 216 (1994) ("Justus does not require the Secretary [of VA] to consider the patently incredible to be credible"). In this case, service connection for sleep apnea was denied in February 2005. The RO specified that service connection was denied because there was no current evidence of sleep apnea. At the time of the February 2005 rating decision, the evidence included service treatment records. They indicate that the Veteran underwent a sleep study in September 2003. Although that study revealed respiratory disturbances, and significant sleep fragmentation, a diagnosis of sleep apnea was not rendered. On VA examination in January 2005, the examiner concluded that there was no evidence of obstructive sleep apnea in the sleep study performed. The evidence added to the record since the February 2005 rating decision includes a December 2007 VA treatment record in which the provider notes that the Veteran was seen to review results of a sleep study. Mild obstructive sleep apnea was assessed. Because the evidence added to the record since the February 2005 rating decision includes that showing current sleep apnea, the Board finds that new and material evidence has been received, and the claim may be reopened. The reopened claim will be addressed in the remand which follows. Ratings Disability ratings are based upon schedular requirements that reflect the average impairment of earning capacity occasioned by the state of a disorder. 38 U.S.C.A. §1155. Separate rating codes identify the various disabilities. 38 C.F.R. Part 4 (2012). In determining the level of impairment, the disability must be considered in the context of the entire recorded history, including service medical records. 38 C.F.R. §4.2 (2012). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, as with the Veteran's claim for an increased rating for the right lateral chest wall scar, the present level of disability is of primary concern. 38 C.F.R. §§ 4.1, 4.2 (2012); see also Francisco v. Brown, 7 Vet. App. 55 (1994). In Hart v. Mansfield, 21 Vet. App. 505 (2007), however, the Court held that "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. In this case the Board has concluded that the disabilities at issue have not significantly changed and that uniform evaluations are warranted for the period considered. An evaluation of the level of disability present must also include consideration of the functional impairment of the Veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. §4.10 (2012). 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 (2012). Hypertension Under 38 C.F.R. § 4.104 , Diagnostic Code 7101, pertaining to hypertensive vascular disease, a 10 percent rating is in order when diastolic pressure is predominantly 100 or more, or; when systolic pressure is predominantly 160 or more, or; when an individual with a history of diastolic pressure predominantly 100 or more requires continuous medication for control. A 20 percent rating is warranted when diastolic pressure is predominantly 110 or more, or; when systolic pressure is predominantly 200 or more. When diastolic pressure is predominantly 120 or more, a 40 percent rating is warranted. A maximum schedular rating of 60 percent is assigned when diastolic pressure is predominantly 130 or more. 38 C.F.R. § 4.104, Code 7101 (2012). The Veteran maintains that his hypertension warrants an evaluation in excess of the currently assigned 10 percent. The record reflects that he has a history of requiring medication for control of his blood pressure. VA treatment records show that in December 2006, the Veteran had blood pressure readings of 153/100 and 132/89. In January 2007, a blood pressure of 128/88 was recorded. On VA hypertension examination in April 2007, blood pressure readings were 128/99, 134/88, and 138/92. In July 2007, the Veteran's blood pressure was 130/94. In September 2007 it was 136/84, and in December 2007 it was 133/85. Blood pressure readings in January 2008 were 133/92 and 132/85. In April 2008 blood pressure readings were 137/98 and 129/87. In June 2008 it was 146/85. In July 2008 the Veteran reported that he had taken his blood pressure at home and it was 140/95. At the time of examination, it was 123/88. In December 2008 it was 141/92. In March 2009 the Veteran's blood pressure was 133/95. In February 2010 the Veteran's blood pressure was 130/90. The Veteran noted that his readings were up and down at home. His medication was increased due to uncontrolled diastolic blood pressure. In March 2010, the Veteran's blood pressure was 132/96 and 134/90. In April 2010 it was 128/80 and 125/80. In September 2010 it was 128/80. On VA examination in January 2011 the Veteran's blood pressure was 132/89. In February 2011 it was 129/82. In January 2012 the Veteran's blood pressure was 132/97, 145/120, and 120/82. Upon careful review of the evidence, the Board concludes that an evaluation in excess of 10 percent for hypertension is not warranted. In order to warrant a 20 percent disability evaluation, the next higher evaluation, the evidence must show diastolic pressure predominately 110 or more or systolic pressure predominately 200 or more. Here, the Board notes that diastolic pressure was 100 on one reading December 2006. However, remaining readings were less than 100; as such, it cannot be stated that diastolic pressure was predominately 110 or more. Moreover, the Veteran's systolic pressure has not been clinically recorded as being 200 or more at any time. Given the numerous readings of record as recorded by health care providers, and how consistent those readings are with respect to systolic pressure having never been record as being 200 or more, the Board finds those readings to be the most credible and probative regarding the severity of the Veteran's hypertension. In sum, the Veteran's blood pressure readings are clearly contemplated by the criteria for a 10 percent evaluation. The Veteran is competent to state that his disability has worsened. However, the medical evidence in this case demonstrates that the Veteran's hypertension is not of sufficient severity to warrant assignment of a higher evaluation. In light of the above discussion, the Board finds that the preponderance of the evidence is against a grant of an evaluation greater than 10 percent for hypertension, and there is no doubt to be resolved. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Hemorrhoids External or internal hemorrhoids are rated pursuant to 38 C.F.R. § 4.114 , DC 7336. A noncompensable evaluation is assigned for mild or moderate hemorrhoids; a 10 percent rating is assigned for large or thrombotic, irreducible hemorrhoids with excessive redundant tissue evidencing frequent recurrences; and a 20 percent evaluation is assigned for hemorrhoids with persistent bleeding and with secondary anemia or with fissures. The Veteran contends that his hemorrhoids should be subject to a compensable evaluation. On VA examination in June 2006, the Veteran's sphincter control was intact. No leakage was noted. The examiner noted that there was bleeding in intermittent episodes, but no recent thrombosis. The rectum and anus were normal. There was no anemia. There were no fissures. The examiner noted small hemorrhoids without thrombosis. The diagnosis was chronic hemorrhoids. In January 2008 the Veteran reported rectal bleeding every day with bowel movements. In a subsequent January 2008 record the Veteran is noted to deny fatigue. He endorsed pain on bowel movements that was relieved following the bowel movement. The Veteran was prescribed a fiber supplement and sitz baths, as well as hydrocortisone suppositories. The report of a February 2008 colonoscopy was negative. On VA examination in January 2011, the examiner noted the Veteran's history was reviewed. He stated that his hemorrhoids had become progressively worse. He endorsed persistent rectal bleeding, anal itching, burning, pain, and swelling. Physical examination revealed internal hemorrhoids with no fistula, stricture, sphincter impairment, or rectal prolapse. The examiner noted that colonoscopy in February 2008 had revealed internal hemorrhoids, and that medical management had been recommended. The diagnosis was internal hemorrhoids. Upon careful review of the record, the Board has determined that a compensable evaluation is not warranted for hemorrhoids. For the assignment of a compensable rating, there must be evidence large or thrombotic, irreducible hemorrhoids with excessive redundant tissue evidencing frequent recurrences. None of this has been demonstrated in any of the clinical data of record. The Veteran's bleeding has been noted by his care providers and examiners, and he has been prescribed suppositories; there is no history or evidence of thrombosis. The Veteran is competent to state that his disability has worsened. However, the medical evidence in this case demonstrates that the Veteran's hemorrhoids are not of sufficient severity to warrant assignment of a higher evaluation. In light of the above discussion, the Board finds that the preponderance of the evidence is against a grant of an evaluation greater than 10 percent for hypertension, and there is no doubt to be resolved. Gilbert. Extraschedular Consideration Ordinarily, the VA Rating Schedule 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). 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. See 38 C.F.R. § 3.321(b)(1) (2012); see also 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 Veterans 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 level of disability and symptomatology and is found to be inadequate, the Board must then determine whether the claimant'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, 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 initial inquiry posed by Thun, the Board has been unable to identify an exceptional or unusual disability picture with respect to the Veteran's service-connected hypertension or hemorrhoids. The medical evidence fails to demonstrate, at any time during the appellate period, symptomatology of such an extent that application of the ratings schedule would not be appropriate. In fact, as discussed in detail above, the symptomatology of the Veteran's disabilities is specifically contemplated under the appropriate rating criteria. Accordingly, the Board finds that the Veteran's disability picture has been contemplated by the ratings schedule. Since the available schedular evaluation adequately contemplates the Veteran's level of disability and symptomatology, the second and third questions posed by Thun become moot. Even still, the record does not show that the Veteran has required hospitalization, or has lost significant periods of work, due to his hypertension or hemorrhoids. In short, the evidence does not support the proposition that the Veteran's service connected disabilities present such an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards and warrant the assignment of an extraschedular rating under 38 C.F.R. § 3.321(b)(1) (2012). ORDER New and material evidence having been submitted, the claim of entitlement to service connection for sleep apnea is reopened. Entitlement to an evaluation in excess of 10 percent for hypertension is denied. Entitlement to a compensable evaluation for hemorrhoids is denied. REMAND Service Connection for Sleep Apnea The Veteran underwent a VA examination in June 2009. The diagnosis was obstructive sleep apnea. The examiner, a pulmonologist, concluded that it was service-connected since the Veteran complained in service. In September 2009 the RO requested an addendum to the examination report. It noted that a rationale to the examiner's conclusion was necessary, as there was no diagnosis of sleep apnea in service. it further pointed out that the first diagnosis was in 2007, four years after release from active service. In October 2009, a VA physician reviewed the claims file. He noted that sleep apnea was not diagnosed in service, and concluded that it was less likely than not that the current obstructive sleep apnea was related to service. He did not discuss the underlying rationale for his conclusion. Rather, he merely provided a recitation of the Veteran's history, and appears to have based his conclusion, at least in part, on the premise that sleep apnea was not diagnosed during service. The Board has determined that the addendum report is not adequate for the purpose of deciding this claim. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that, once VA has provided a claimant with an examination, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided.) Increased Rating for Grave's Disease The Veteran's service-connected Grave's disease is evaluated as 10 percent disabling pursuant to the criteria for hyperthyroidism. Under 38 C.F.R. § 4.119, Diagnostic Code 7900, hyperthyroidism with tachycardia, which may be intermittent, and tremor, or; continuous medication required for control, is rated as 10 percent disabling. Hyperthyroidism with tachycardia, tremor, and increased pulse pressure or blood pressure is rated as 30 percent disabling. Hyperthyroidism with emotional instability, tachycardia, fatigability, and increased pulse pressure or blood pressure is rated as 60 percent disabling. Hyperthyroidism with thyroid enlargement, tachycardia (more than 100 beats per minute), eye involvement, muscular weakness, loss of weight, and sympathetic nervous system, cardiovascular, or gastrointestinal symptoms, is rated 100 percent disabling. 38 C.F.R. § 4.119. Note (1) to Diagnostic Code 7900 provides that, if disease of the heart is the predominant finding, the hyperthyroidism should be rated as hyperthyroid heart disease (Diagnostic Code 7008) if doing so would result in a higher rating than using the criteria above (Diagnostic Code 7900). In this case, the Veteran stated in September 2009 that he had tachycardia, essential tremor, and anxiety related to his Grave's disease. On VA examination in January 2011 the examiner noted that there was no history of hypertension. This is incorrect, as the Veteran is in fact in receipt of service connection for hypertension. There is no discussion in the evidence of whether hypertension is related to Grave's disease, or whether there is increased pulse pressure that is likewise related. The Board further notes that the Veteran is in receipt of service connection for a psychiatric disorder. There is no discussion in the record of whether he has emotional instability that is due to Grave's disease. As such, an examination is necessary to assist the Board in determining the extent and severity of the service-connected Grave's disease. Increased Rating for Rhinitis The Veteran's rhinitis is evaluated pursuant to the criteria for allergic rhinitis. The Board notes that in every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. Under 38 C.F.R. § 4.97, Diagnostic Code 6522, a 10 percent evaluation is warranted for rhinitis where there are no polyps, and there is greater than 50 percent obstruction of nasal passages on both sides or complete obstruction on one side. Where there are polyps, a 30 percent rating is warranted. Here, a January 2011 VA examiner indicated that there were no polyps. There was no discussion of whether there was any obstruction, and if so, the extent of such. Accordingly, the examination report is inadequate for the purpose of deciding the claim, and an additional examination should be conducted. In light of the above discussion, the Board has determined that additional development of the record is required. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA examination to determine the etiology of his current sleep apnea. The claims folder should be forwarded to the examiner for review. The examiner should be specifically requested to review the discussion regarding sleep apnea set forth above. The examiner should be directed to elicit a complete history from the Veteran. All indicated studies should be performed, and their results reported. Following review of the claims file and examination of the Veteran, the examiner should provide an opinion regarding whether it is more likely than not (i.e., probability greater than 50 percent), at least as likely as not (i.e., probability of 50 percent), or less likely than not (i.e., probability less than 50 percent) that the current sleep apnea is related to service. The complete rationale for all opinions expressed should be set forth in the examination report. If the examiner is unable to offer any of the requested opinions, it is essential that the examiner offer a rationale for the conclusion that an opinion cannot be provided without resort to speculation, together with a statement as to whether there is additional evidence that might enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. See Jones v. Shinseki, 23 Vet. App. 382 (2010). 2. Schedule the Veteran for a VA examination to determine the severity of his service-connected Grave's disease. The claims folder should be forwarded to the examiner for review. Any and all studies, tests and evaluations deemed necessary by the examiner should be performed. The examiner should also elicit a complete history from the Veteran. Following interview, examination of the Veteran, and review of the claims file, the examiner should identify the manifestations of the Veteran's Grave's disease. The examiner should specifically indicate whether such manifestations include tachycardia, tremor, increase pulse pressure of blood pressure, emotional instability, or heart disease. If heart disease is present and determined to be related to the Veteran's Grave's disease, the examiner should state whether it is the predominant finding related to Grave's disease. A discussion of the complete rationale for all opinions expressed should be included in the examination report. If the examiner is unable to offer any of the requested opinions, it is essential that the examiner offer a rationale for the conclusion that an opinion cannot be provided without resort to speculation, together with a statement as to whether there is additional evidence that might enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. See Jones v. Shinseki, 23 Vet. App. 382 (2010). 3. Schedule the Veteran for a VA examination to determine the severity of his service-connected rhinitis. The claims folder should be forwarded to the examiner for review. Any and all studies, tests and evaluations deemed necessary by the examiner should be performed. The examiner should also elicit a complete history from the Veteran. Following interview, examination of the Veteran, and review of the claims file, the examiner should identify the manifestations of the Veteran's service-connected rhinitis. The examiner should indicate whether there is greater than 50 percent obstruction of nasal passages on both sides or complete obstruction on one side. A discussion of the complete rationale for all opinions expressed should be included in the examination report. If the examiner is unable to offer any of the requested opinions, it is essential that the examiner offer a rationale for the conclusion that an opinion cannot be provided without resort to speculation, together with a statement as to whether there is additional evidence that might enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. See Jones v. Shinseki, 23 Vet. App. 382 (2010). 4. The Veteran is hereby notified that it is his responsibility to report for any examination, and to cooperate in the development of the claim. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655. 5. Then, after ensuring the examination reports are adequate and undertaking any additional development that is deemed warranted, readjudicate the claims on appeal, with application of all appropriate laws, regulations, and case law, and consideration of any additional information obtained as a result of this remand. If the decision remains adverse to the Veteran, he and his representative should be furnished a supplemental statement of the case and afforded an appropriate period of time within which to respond thereto. 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