Citation Nr: 1332020 Decision Date: 10/03/13 Archive Date: 10/07/13 DOCKET NO. 07-34 644A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an initial higher evaluation for difficulty swallowing (glossopharyngeal/ninth cranial nerve), rated as noncompensable prior to October 12, 2012, and as 10 percent disabling thereafter. 2. Entitlement to an initial higher disability rating for fecal incontinence, from January 1, 2011, rated as 30 percent disabling prior to January 24, 2012, and as 60 percent disabling thereafter. 3. Entitlement to service connection for a separate evaluation for weakness/numbness of the right upper extremity. 4. Entitlement to service connection for a separate evaluation for a speech impairment (hypoglossal/twelfth cranial nerve). 5. Entitlement to an effective date prior to February 28, 2007 for the grant of special monthly compensation (SMC) for loss of use of creative organ, associated with service-connected erectile dysfunction. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran and his Spouse ATTORNEY FOR THE BOARD J.N. Moats, Counsel INTRODUCTION The Veteran had active service from August 1982 until April 1988. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2007 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida, which in pertinent part, continued a 30 percent disability rating for the Veteran's service-connected multiple sclerosis (MS). The Veteran appeared before the undersigned Veterans Law Judge at a Board hearing held at the RO in November 2008. A transcript of the hearing has been associated with the record. In December 2008 and October 2009, the Board remanded the claim for further development, to include consideration of any manifestations of MS that the Veteran may have. In a January 2011 rating decision, the RO considered various separate evaluations as part of the MS claim. The RO granted service connection for depression (50 percent effective November 30, 2006) and for weakness/numbness of right lower extremity (10 percent effective November 30, 2006). The RO also granted service connection for diminished sensation of the right side of the face, erectile dysfunction, fecal incontinence and swallowing difficulty. The RO rated each of those disabilities as noncompensable, effective November 30, 2006. The RO further denied service connection for weakness/numbness of the right upper extremity (ulnar nerve), a bilateral visual disorder and impairment of speaking ability. In May 2011, the Board issued a final decision on the issues of depression, weakness/numbness of the right lower extremity, neurogenic bladder and erectile dysfunction. The Board also determined the claim for an increased rating for fecal incontinence, for the period prior to February 1, 2011. The remaining issues as listed on the front page of this decision as well as the matters of a compensable evaluation for diminished sensation of the right face, entitlement to a separate evaluation for vision problems and entitlement to SMC were again remanded by the Board for additional development. In February 2013, the Board issued a final decision on the matter of entitlement to an initial higher rating for diminished sensation of the right side of the face and again remanded the remaining issues. In a May 2013 rating decision, the RO granted SMC based on loss of use a creative organ, effective January 9, 2013, and increased the disability rating for fecal incontinence to 60 percent, effective October 12, 2012. Subsequently, in a June 2013 rating decision, the RO granted service connection for open angle glaucoma and increased the disability evaluation for swallowing difficulty to 10 percent, effective January 5, 2012. In a July 2013 rating decision, the RO assigned an effective date of February 28, 2007 for SMC and an effective date of January 24, 2012 for the 60 percent evaluation of fecal incontinence. With respect to the increased ratings awarded by the RO for difficulty swallowing and fecal incontinence, where there is no clearly expressed intent to limit the appeal to entitlement to a specified disability rating, the RO and Board are required to consider entitlement to all available ratings for that condition. AB v. Brown, 6 Vet. App. 35, 39 (1993). The issues therefore remain in appellate status and are characterized as set forth on the front page of this decision. Further, as the RO granted service connection for a separate evaluation for vision symptoms, diagnosed as open angle glaucoma, as well as SMC based on loss of use of a creative organ, these issues are no longer in appellate status. As noted in the prior remand, for the sake of clarity, the Board has separated out the issues as shown on the first pages of this decision, though all the claims stem from the Veteran's original claim for an increased rating for his service-connected MS. The Board notes that, in addition to the paper claims file, there is a paperless, electronic (Virtual VA) claims file associated with the appellant's claims. A review of the Virtual VA claims file does not reveal any additional documents pertinent to the present appeal, other than additional VA medical records dated to March 2013. As noted above, in its May 2011, the Board granted an initial 20 percent disability rating for neurogenic urinary bladder, which was effectuated by the RO in a September 2012 rating decision. In an October 2012 statement as well as subsequent statements, the Veteran indicated that he disagreed with the RO's September 2012 decision. However, as the RO was simply effectuating the Board's decision and the Board's decision is final, the Veteran is unable to appeal this determination to the RO. See 38 U.S.C.A. § 7104; 38 C.F.R. § 20.1100. As such, the Board finds that the Veteran's subsequent statements concerning his disability rating for neurogenic urinary bladder should be treated as a new claim for an increased rating. As this new matter has not been adjudicated by the Agency of Original Jurisdiction (AOJ), it is referred to the AOJ for appropriate action. The Board notes that the Veteran submitted additional evidence after the most recent supplemental statement of the case (SSOC) issued in July 2013. However, in an August 2013 statement, the Veteran waived RO consideration of any additional evidence submitted. 38 C.F.R. § 20.1304(c). 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). The issues of entitlement to an increased rating for difficulty swallowing; entitlement to service connection for separate evaluations for weakness/numbness of the right upper extremity, and a speech impairment; and entitlement to an earlier effective date for the grant of special monthly compensation for loss of use of creative organ 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. FINDING OF FACT From February 1, 2011, the Veteran's service-connected fecal incontinence more nearly approximated extensive leakage and fairly frequent involuntary bowel movements, but without complete loss of sphincter control. CONCLUSION OF LAW Effective February 1, 2011, the criteria for entitlement to a 60 percent disability evaluation, but no higher, for the Veteran's service-connected fecal incontinence, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. Part 4, including §§ 4.7, 4.114, Diagnostic Code 7332 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION VA's Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a 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 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Proper notice from VA must inform the claimant of any information and medical or lay 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. 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim. Accordingly, notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). In the instant case, the Veteran received letters in January 2007, February 2009, November 2009 and March 2013, which notified him of the information and evidence required to substantiate the claim being decided herein and of the division of responsibilities between VA and a claimant in developing an appeal. Moreover, the letters informed the Veteran of what type of information and evidence was needed to establish a disability rating and effective date. The Board acknowledges that, in the present case, complete notice was not issued prior to the adverse determination on appeal. However, fully compliant notice was later issued the claim was most recently readjudicated in the July 2013 SSOC. Accordingly, any timing deficiency has here been appropriately cured. Mayfield, 444 F.3d 1328 (Fed. Cir. 2006). Next, VA has a duty to assist the Veteran in the development of the claims. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The claims file contains the Veteran's post-service reports of VA treatment as well as VA examinations. A review of Virtual VA claims processing system includes additional VA treatment records, which were considered by the RO in the July 2013 SSOC. Moreover, the Veteran's statements in support of the claims, including his hearing testimony, are of record. The Board has carefully reviewed such statements and concludes no available outstanding evidence has been identified. The Board has also perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claim decided herein. Additionally, the Veteran was afforded a VA examination October 2012 to evaluate the severity of his service-connected fecal incontinence. The Board finds that the VA examination is adequate because, as discussed below, it was based upon consideration of the Veteran's pertinent medical history, his lay assertions and current complaints, and because it provides detail sufficient to allow the Board to make a fully informed determination. Barr v. Nicholson, 21 Vet. App. 303 (2007) (citing Ardison v. Brown, 6 Vet. App. 405, 407 (1994)). Furthermore, the Veteran has not asserted, and the evidence does not show, that his symptoms have materially worsened since the most recent October 2012 evaluation. See 38 C.F.R. §§ 3.326, 3.327 (reexaminations will be requested whenever VA determines there is a need to verify the current severity of a disability, such as when the evidence indicates there has been a material change in a disability or that the current rating may be incorrect.); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). The Board accordingly finds no reason to remand for further examination. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. 3.103(c)(2) (2012) requires that any Veterans Law Judge who chairs a hearing fulfill two duties to comply with the VCAA. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Bryant, 23 Vet. App. at 488. Here, during the November 2008 Board hearing, the undersigned Veterans Law Judge adequately explained the claim on appeal and suggested evidence that may support this claim, including evidence that the Veteran might submit that may have been overlooked. The Veteran was also specifically asked questions concerning the severity of his MS symptoms, including fecal incontinence. The Board accordingly concludes that the notice requirements under Bryant were effectively satisfied. To the extent any such notice may have been inadequate, this was effectively cured both by actual knowledge as evidence by statements and questions of the Veteran's authorized representative at the hearing, as well as by the Board providing such explanation of issues and suggesting submission of evidence in the subsequent remands the Board issued to develop this claim. For the above reasons, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). Finally, the Board finds that there was substantial compliance with the Board remand directives. A remand by the Board confers upon the claimant, as a matter of law, the right to compliance with the remand order. Stegall v. West, 11 Vet. App. 268 (1998). Nonetheless, it is only substantial compliance, rather than strict compliance, with the terms of a remand that is required. See D'Aries v. Peake, 22 Vet. App. 97, 104 (2008) (finding substantial compliance where an opinion was provided by a neurologist as opposed to an internal medicine specialist requested by the Board); Dyment v. West, 13 Vet. App. 141 (1999). In particular, in its prior remands, the Board directed the AOJ to obtain additional VA treatment records and afford the Veteran a VA examination. As discussed above, the AOJ obtained VA treatment records and the Veteran was recently afforded a VA examination in October 2012 that is adequate for appellate review. In the most recent February 2013 remand, the Board remanded this issue for consideration of additional evidence and issuance of an SSOC, which was done in June and July 2013. Accordingly, the Board finds that there has been substantial compliance with the Board remand directives and, therefore, no further remand is necessary with respect to the issue decided herein. See Stegall, supra; D'Aries, 22 Vet. App. at 104 (2008). Analysis The present appeal includes the issue of whether a higher rating is warranted for fecal incontinence from February 1, 2011. Again, the Board observes that the RO awarded a 60 percent disability rating, effective January 24, 2012. As such, the Board must determine whether a rating in excess of 30 percent is warranted from February 1, 2011 to January 24, 2012, and a rating in excess of 60 percent is warranted from January 24, 2012. In statements of record, the Veteran has asserted that the 60 percent rating should be awarded effective February 1, 2011. Disability evaluations are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where, as in the instant case, the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). As in the instant case, at the time of an initial rating, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. Id. at 126. Under 38 C.F.R. § 4.114, Diagnostic Code 7332, impairment of sphincter control is evaluated as follows: healed or slight, without leakage (0 percent); constant slight, or occasional moderate leakage (10 percent); occasional involuntary bowel movements, necessitating wearing of pad (30 percent); extensive leakage and fairly frequent involuntary bowel movements (60 percent); and complete loss of sphincter control (100 percent). In pertinent part, a February 1, 2001 VA treatment record noted a new problem in the last year with the Veteran having intermittent leakage with occasional loss of bowel control and accidents. He had to keep a change of clothes and extra diapers with him. In a February 2011 statement, the Veteran reported use of adult incontinence diapers as a result of fecal incontinence not manageable with use of pads. However, the Board found in its prior May 2011 remand that the evidence did not disclose the frequency of bowel incontinence, and remanded for a VA examination to determine the severity of the Veteran's fecal incontinence from the time of that VA examination. A December 2011 VA treatment record again observed that the bowel "had been a real problem in the past year." The Veteran noted three episodes of intermittent fecal incontinence. There was occasional loss of bowel control and accidents. The Veteran kept a change of clothes and extra diapers with him. A January 24, 2012 VA treatment record, the date the RO awarded a 60 percent rating, again reiterated the previous notation concerning the Veteran's bowel incontinence. On remand, the Veteran was afforded a VA examination in October 2012. The Veteran reported that the condition had been progressively worse in the last 18 months to the point of occurring four to five times per week. Rectal incontinence occurred in unpredictable fashion that required constant use of diapers. He used three to four diapers a day because of urinary incontinence as well as rectal. The condition was well documented in past progress notes. Recent examination had disclosed normal rectal sphincter tone. The examiner found that the Veteran had impairment of sphincter control with leakage necessitating wearing a pad with fairly frequent involuntary bowel movements. The examiner observed that involuntary bowel movements were unpredictable as is the volume with full bowel movements about two to three times per week. Physical examination of rectal/anal area was normal with no external hemorrhoids, anal fissures or other abnormalities. The Veteran had normal sphincter note. The examiner found that the Veteran's disability did not impact his ability to work. The examiner observed that the diagnosis of intermittent dysfunction of rectal sphincter control was arrived at on a strictly historical basis, since objectively sphincter tone was normal. He was wearing a diaper during the examination, but the diaper was not soiled at the time of the examination. Initially, the Board finds that based on the evidence of record, a 60 percent disability rating is warranted from February 1 2011. The evidence shows that the Veteran's fecal incontinence more nearly approximates extensive leakage and fairly frequent bowel movements since February 2011 as found at the October 2012 VA examination. Based on VA treatment records and the Veteran's statements, his symptoms have been consistent throughout this period. Thus, when resolving the benefit of the doubt in favor of the Veteran, a 60 percent rating is warranted from February 1, 2011, the period currently on appeal. See 38 U.S.C.A. § 5107 However, the Board finds that a maximum 100 percent rating is not warranted at any point during the course of the appeal from February 1, 2011. There have been any objective finding of complete loss of sphincter control. The October 2012 VA examiner found that the Veteran suffered from leakage necessitating wearing a pad with fairly frequent involuntary bowel movements, which is the criteria for a 60 percent rating. Moreover, on examination, the Veteran had normal sphincter tone. As such, a maximum 100 percent rating is not warranted. In denying a higher rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 4.3, 4.7. Moreover, the Board has also considered whether a higher rating would be available under another diagnostic code. However, the October 2012 VA examination clearly found other abnormalities of the anus and/or rectum. Thus, given the lack of findings of any other symptoms pertaining to the rectum and/or anus, other diagnostic codes are not applicable to the current appeal. The Board has carefully reviewed and considered the Veteran's statements regarding the severity of his fecal incontinence. The Board acknowledges that the Veteran, in advancing this appeal, believes that the disability on appeal has been more severe than the assigned disability rating reflects. Moreover, the Veteran is competent to report observable symptoms. Layno v. Brown, 6 Vet. App. 465 (1994). In this case, however, the competent medical evidence offering detailed specific specialized determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal; the medical evidence also largely contemplates the Veteran's descriptions of symptoms. The lay testimony has been considered together with the probative medical evidence clinically evaluating the severity of the pertinent disability symptoms. In this regard, the Veteran's statements were considered in awarding a 60 percent rating effective from February 1, 2011. Additionally, the Board has also contemplated whether the case should be referred for extra-schedular consideration. In general, the schedular disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. The application of such schedular criteria was discussed in great detail above. To accord justice in an exceptional case where the schedular standards are found to be inadequate, the RO is authorized to refer the case to the Chief Benefits Director or the Director, Compensation and Pension Service for assignment of an extraschedular evaluation commensurate with the average earning capacity impairment. 38 C.F.R. § 3.321(b)(1). An extra-schedular disability rating is warranted if 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 application of the regular schedular standards would be impracticable. Id. The Court has held that the Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance; however, the Board is not precluded from raising this question, and in fact is obligated to liberally read all documents and oral testimony of record and identify all potential theories of entitlement to a benefit under the law and regulations. Floyd v. Brown, 9 Vet. App. 88 (1996). The Court further held that the Board must address referral under 38 C.F.R. §3.321(b)(1) only where circumstances are presented which the Director of VA's Compensation and Pension Service might consider exceptional or unusual. Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). In Thun v. Peake, 22 Vet. App. 111 (2008), the Court clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. Either the RO or the Board must first determine whether the schedular rating criteria reasonably describe the Veteran's disability level and symptomatology. Id. at 115. If the schedular rating criteria do reasonably describe the Veteran's disability level and symptomatology, the assigned schedular evaluation is adequate, referral for extraschedular consideration is not required, and the analysis stops. If the RO or the Board finds that the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology, then either the RO or the Board must determine whether the Veteran's exceptional disability picture includes other related factors such as marked interference with employment and frequent periods of hospitalization. Id. at 116. If this is the case, then the RO or the Board must refer the matter to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for the third step of the analysis, determining whether justice requires assignment of an extraschedular rating. Id. The Board has carefully compared the level of severity and symptomatology of the Veteran's service-connected fecal incontinence with the established criteria found in the rating schedule. The Board finds that the Veteran's symptomatology is fully addressed by the rating criteria under which such disability is rated. In this regard, the Veteran's disability rating contemplates the frequency and extent of the Veteran's involuntary bowel movements. There are no additional symptoms of this disability that is not addressed by the rating schedule. Therefore, the Board finds that the rating criteria reasonably describe the Veteran's disability level and symptomatology of his service-connected fecal incontinence. As such, the Board finds that the rating schedule is adequate to evaluate the Veteran's disability picture. Therefore, the Board need not proceed to consider the second factor, viz., whether there are attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization. Consequently, the Board concludes that referral of this case for consideration of an extra-schedular rating is not warranted. Id.; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). The Court has held that a request for a total disability rating based on individual unemployability (TDIU), whether expressly raised by a Veteran or reasonably raised by the record, is not a separate claim for benefits, but rather involves an attempt to obtain an appropriate rating for a disability or disabilities, either as part of the initial adjudication of a claim or, if the disability upon which entitlement to TDIU is based has already been found to be service-connected, as part of a claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). However, in the instant case, the record shows that the Veteran is still currently employed full time and the October 2012 VA examiner found that this disability did not impact his ability to work; thus, the matter of TDIU need not be further considered. In conclusion, based on the medical evidence of record, a 60 percent rating, but no higher, for the Veteran's fecal incontinence, not warranted from February 1, 2011. ORDER Entitlement to a 60 percent rating, but no higher, for fecal incontinence, effective January 1, 2011, is granted subject to the law and regulations governing the payment of monetary benefits. REMAND Although the Board regrets further delaying appellate review with respect to the remaining issues on appeal, the Board finds that additional development is necessary with respect to these issues. Initially, with respect to the issues of entitlement to an increased rating for difficulty swallowing (glossopharyngeal/ninth cranial nerve), and entitlement to service connection for separate evaluations for weakness/numbness of the right upper extremity, speech impairment (hypoglossal/twelfth cranial nerve), in its prior February 2013 remand, the Board directed the RO to obtain addendum opinions to address the severity and/or etiology of these disabilities. In a June 2013 SSOC, the RO references that VA examinations were done in March and April 2013 with respect to these issues. However, as pointed out by the Veteran's representative in an August 2013, the VA examination report(s) have not been associated with the claims file or Virtual VA. It is unclear from the record whether the RO complied with the Board's February 2013 remand directives. As such, the case must be returned to the RO for association of all examination reports done since the prior February 2013 remand. If such reports are not responsive to the prior remand directives, the Veteran should be afforded new VA examinations addressing all the questions set forth in the prior remand. Where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance. Stegall v. West, 11 Vet. App. 268, 271 (1998). As a final matter, in the July 2013 rating decision, the RO awarded special monthly compensation based on loss of use of creative organ, effective February 28, 2007. That same month, the Veteran submitted a statement disagreeing with the effective date assigned and seeking an earlier effective date of November 2006. As such, the Veteran's statement can be construed as showing disagreement with the effective date assigned and a desire to appeal such date pursuant to 38 C.F.R. § 20.201. However, the RO has not issued a statement of the case with respect to this issue. The Court has held that, where the record contains a notice of disagreement as to an issue, but no statement of the case, the issue must be remanded to the RO to issue a statement of the case, and to provide the veteran an opportunity to perfect the appeal. Manlincon v. West, 12 Vet. App. 238 (1999). 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 RO should take appropriate action pursuant to 38 C.F.R. § 19.26 (2012), to include furnishing the Veteran and his representative with an appropriate statement of the case with respect to the issue of entitlement to an effective date prior to February 28, 2007 for the grant of special monthly compensation based on the loss of use of creative organ. The Veteran and his representative should be advised of need to file a timely substantive appeal if the Veteran desires to complete an appeal as to this issue. 2. The RO should associate all VA examinations reports prepared since the last February 2013 Board remand with the claims file, to specifically include any March and April 2013 reports referred to in the June and July 2013 SSOCs. 3. If such VA examinations reports are not available or are not fully responsive to the Board's February 2013 remand directives, the RO should afford the Veteran a new VA examination with respect to the claims of an increased rating for difficulty swallowing and separate evaluations for right upper extremity weakness/numbness and speech impairment. The claims file must be made available for review in connection with the examination. After examining the Veteran and reviewing the claims file, the examiner is requested to render opinions addressing each of the following questions: a) Does the Veteran have a speech impairment? If so, please clarify which nerve is involved and the specific disorder/disorders diagnosed. b) If any speech impairment is found, is at least as likely as not (50 percent probability or greater) that the disorder(s) was caused by the Veteran's service-connected multiple sclerosis? c) If any speech impairment is found, is at least as likely as not (50 percent probability or greater) that the disorder(s) is aggravated by the Veteran's service-connected multiple sclerosis? d) If any speech impairment is found, is at least as likely as not (50 percent probability or greater) that the disorder(s) is a manifestation of the Veteran's service-connected multiple sclerosis? e) Does the Veteran have a disorder of the right upper extremity? If so, please clarify the diagnosis of the disorder(s). f) If a disorder(s) of the right upper extremity is found, is at least as likely as not (50 percent probability or greater) that the disorder(s) was caused by the Veteran's service-connected multiple sclerosis? g) If a disorder(s) of the right upper extremity is found, is at least as likely as not (50 percent probability or greater) that the disorder(s) is aggravated by the Veteran's service-connected multiple sclerosis? If so, please clarify which nerve is involved. h) If a disorder(s) of the right upper extremity is found, is at least as likely as not (50 percent probability or greater) that the disorder(s) is a manifestation of the Veteran's service-connected multiple sclerosis? i) For the service-connected difficulty swallowing, please clarify: to what degree, if any, does the Veteran have paralysis of the ninth cranial nerve (or other more appropriate nerve if applicable)? A complete explanation must be given for all opinions and conclusions expressed. The examiner is directed to reconcile his or her opinions with any on file that may conflict. 3. When the development requested has been completed, and any other additional development deemed necessary, the issues remaining on appeal should again be adjudicated by the RO on the basis of the evidence of record, including any evidence not previously considered or forwarded directly to the Board. If any benefit sought is not granted, the Veteran and his representative should be furnished a SSOC, and be afforded a reasonable 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 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). ______________________________________________ MARJORIE A. AUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs