Citation Nr: 1333134 Decision Date: 10/22/13 Archive Date: 10/24/13 DOCKET NO. 09-12 071 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for residuals of a right inguinal hernia repair, claimed as trouble voiding. 2. Entitlement to service connection for a back disorder. 3. Entitlement to service connection for a neck disorder. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD T. Adams, Counsel INTRODUCTION The Veteran served on active duty in the Naval Reserves from June 1945 to July 1946, August 1962 to November 1962, June 1963 to November 20, 1963, and November 22, 1963, to March 1964. He also had verified periods of service in the Naval Reserves from June 1945 to July 1949, June 1950 to December 1979 and December 1985 to July 1986. These matters are on appeal from a March 2006 decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. In November 2009, the Veteran withdrew his request for a Travel Board hearing before a Veterans Law Judge. See 38 C.F.R. § 20.702(e) (2013). In a January 2012 decision, the Board denied service connection for a respiratory disorder and recurring cysts, reopened and remanded the claim for bilateral hearing loss, and remanded the claims for a right inguinal hernia and back and neck disorders. Service connection was granted for bilateral hearing loss in in a March 2013 rating decision, so that issue is no longer before the Board. The other issues have been returned to the Board for appellate consideration. In an August 2010 remand, the Board referred the Veteran's claim for service connection for a prostate condition to the Agency of Original Jurisdiction (AOJ). As it does not appear that this issue has been developed for appellate review, the Board again refers the issue to the AOJ for proper development. The Board has reviewed the Veteran's physical claims file, and his electronic file through the "Virtual VA" system, to ensure a complete review of the evidence in this case. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2013). 38 U.S.C.A. § 7107(a)(2) (West 2002). The issue of entitlement to service connection for residuals of a right inguinal hernia repair, claimed as trouble voiding, is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. A back disorder, diagnosed as degenerative osteoarthritis of the lumbar spine, was not documented in service or within one year thereafter, and the preponderance of the evidence is against a finding that this disorder was caused or aggravated by his active service. 2. A neck disorder, diagnosed as degenerative osteoarthritis of the cervical spine, was not documented in service or within one year thereafter, and the preponderance of the evidence is against a finding that this disorder was caused or aggravated by his active service. CONCLUSIONS OF LAW 1. The criteria for service connection for a back disorder have not been met. 38 U.S.C.A. §§ 1131, 5107(b) (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310(a) (2013). 2. The criteria for service connection for a neck disorder have not been met. 38 U.S.C.A. §§ 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist VA has a duty to notify and a duty to assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. §§ 3.159, 3.326(a). Proper notice from VA must inform the claimant and his representative, if any, prior to the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ) of any information and any 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 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). These notice requirements apply to all five elements of a service-connection claim (Veteran status, existence of a disability, a connection between the Veteran's service and the disability, degree of disability, and effective date of the disability). Dingess v. Nicholson, 19 Vet. App. 473 (2006). Information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded must be included. Id. Neither the Veteran nor his representative has alleged prejudice with respect to notice, as is required. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009). None is found by the Board. Indeed, VA's duty to notify has been more than satisfied. The Veteran was notified via a letter dated in June 2005 of the criteria for establishing service connection, the evidence required in this regard, and his and VA's respective duties for obtaining evidence. He also was notified via a letter dated in September 2010 of the criteria for how VA determines disability ratings and effective dates if service connection is awarded. Nothing more was required. Although the Veteran was not provided complete notice until after the initial adjudication of the claims, the Board finds that there is no prejudice to him in proceeding with the issuance of a final decision. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). In this regard, the Board notes that following the provision of the required notice and the completion of all indicated development of the record, the originating agency readjudicated the Veteran's claims. See March 2009 Statement of the Case and March 2009, September 2009, and October 2011 Supplemental Statements of the Case. There is no indication in the record or reason to believe that the ultimate decision of the originating agency on the merits of the claims would have been different had complete VCAA notice been provided at an earlier time. Overton v. Nicholson, 20 Vet. App. 427, 437 (2006) (A timing error may be cured by a new VCAA notification followed by a readjudication of the claim). Regarding VA's statutory duty to assist in claims development, the record also reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records pertinent to the neck and back claims. Pertinent medical evidence associated with the claims files consists of service and VA treatment records and a June 2011 VA examination and opinion. In addition, pursuant to the Board's August 2010 and January 2012 remands, in-patient treatment records from St. Albans were obtained. A February 2012 addendum to the June 2011 VA examination was also obtained as the Board determined that the June 2011 VA opinion was inadequate for adjudication purposes. Consideration has been given to the Veteran's argument, though his representative, in a September 2013 post-remand brief, that the 2012 VA opinions which found that the Veteran's neck and back disorders are not related to his active service, were inadequate because they are based on the rationale that "there a 60 year differential between active service and the current disabilities." The Board does not agree. Here, the February 2012 VA opinion is more than adequate in addressing the medical questions raised in this appeal. There is no unresolved medical question. The June 2011 report of examination shows that all subjective and objective findings necessary for evaluation of the Veteran's neck and back claims were observed and recorded. In the February 2012 VA addendum, the examiner took into account the Veteran's lay history and complaints. The opinions considered all of the pertinent evidence of record, to include the relevant service treatment and post-service treatment records of the Veteran, and provided a complete rationale, relying on and citing to the records reviewed. The opinions were also responsive to the questions posited by the Board. The Board further finds that VA substantially complied with the Board's remand directives in further developing the Veteran's claims. Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141 (1999). Indeed, the medical evidence has been thoroughly developed in this case. The competent and credible evidence includes a June 2011 VA examination and February 2012 opinion which fails to support a finding that any currently diagnosed back and neck disorders are etiologically related to the any period of the Veteran's active military service. Thus, no additional medical examinations or opinions are necessary under the circumstances of this case. Also of record and considered in connection with the appeal are various statements submitted by the Veteran and his representative, on his behalf. Neither the Veteran nor his representative throughout the course of this appeal has made the RO or the Board aware of any other evidence relevant to his appeal that needs to be obtained. Based on the foregoing, the Board finds that all relevant facts have been properly and sufficiently developed in this appeal and no further development is required to comply with the duty to assist the Veteran in developing the facts pertinent to the claims adjudicated herein. Therefore, in view of the foregoing, the Board will proceed with appellate review. II. Legal Principles It is the Board's responsibility to evaluate the entire record on appeal. See 38 U.S.C.A. § 7104(a). The Board has thoroughly reviewed all the evidence in the record. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all of the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence of record shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the veteran). When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the Court of Appeals for Veterans Claims held that an appellant need only demonstrate that there is an "approximate balance of positive and negative evidence" in order to prevail. The Court has also stated, "It is clear that 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. Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303(a) (2013). In general, service connection requires competent and credible evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third elements is through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); see also Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Hickson v. West, 12 Vet. App. 247, 253 (lay evidence of in-service incurrence is sufficient in some circumstances for purposes of establishing service connection); 38 C.F.R. § 3.303(b). However, application of 38 C.F.R. § 3.303(b) is only triggered if the disability in question is one that is listed as a chronic disability under 38 C.F.R. §§ 3.307, 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Certain chronic diseases, including arthritis, may be presumed to have been incurred in or aggravated by service if manifest to a compensable degree within one year of discharge from service. See 38 U.S.C.A. §§ 1101, 1112, (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.307, 3.309 (2013). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2013). Active military, naval, or air service includes any period of active duty for training (ACDUTRA) during which the individual concerned was disabled from a disease or injury incurred or aggravated in the line of duty, and any period of inactive duty training (INACDUTRA) during which the individual concerned was disabled from an injury incurred or aggravated in the line of duty. 38 U.S.C.A. § 101(24) (201) ; see Mercado-Martinez v. West, 11 Vet. App. 415 (1998); see also Paulson v. Brown, 7 Vet. App. 466, 469-70 (1995) ("an individual who has served only on active duty for training must establish a service-connected disability in order to achieve veteran status"); Biggins v. Derwinski, 1 Vet. App. 474, 478 (1991). The Court has held that VA service connection compensation presumptions do not apply with only ACDUTRA or INACDUTRA service. Id. at 477-78. Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted into the record. See Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). The Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1137 (Fed. Cir. 2006). Factors for consideration in assessing credibility include a showing of interest, bias, inconsistent statements, consistency with other evidence, and a lack of contemporaneous medical evidence, although that alone may not bar a claim for service connection. Buchanan, 451 F.3d at 1336-37; Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996), superseded in irrelevant part by statute, Veterans Claims Assistance Act of 2000, Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). III. Analysis At the outset the Board notes that the Veteran's claim for service connection for recurring cysts on his upper back was denied by the Board in January 2012. Thus, the scope of the claim for service connection for disabilities of the back and neck is limited to his orthopedic problems such as arthritis and any additional disorders other than recurring cysts and associated complaints. The Veteran contends that he has back and neck disorders related to "many hours of air time at Berlin Air Lift-West Pac flights from NAS, NY to Vietnam." See, May 2009 statement. He stated that he took aerial photographs in helicopters that had rough landings. He was also aboard helicopters during practice emergency "autogirations" which resulted in many rough landings. He admits that he never reported back or neck pain during special visits to sick bay, but contends that he did mention his complaints of pain during annual examinations. Specifically, he contends that reaching outside of the aircraft while holding very heavy aerial cameras caused severe neck and upper back strain. Review of the Veteran's service personnel records corroborate that he was an aerial photographer, and also corroborate that he flew on numerous training/operational flights, while in the Reserves. The Veteran's STRs reveal that he consistently denied recurrent back pain and are negative for any complaints, treatment, or diagnosis of neck or back disabilities. See Reports of Medical History dated January 1969, December 1971, December 1972, December 1973, January 1975, December 1975, December 1976, December 1977, November 1978, December 1979, December 1980, May 1982, March 1983, December 1984, January 1984, and November 1985. Private hospital records include a November 1981 report which shows that the Veteran was assaulted and injured his neck, kidney area, and sustained a cut over one eye. However, the impression did not include a diagnosed neck injury. VA treatment records include a November 1981 report which indicates that the Veteran was assaulted and kicked in the back and had a frank hematuria. X-rays of the cervical and lumbosacral spine indicated no evidence of fracture or subluxation, but indicated minimal degenerative changes of the cervical spine and lumbar spine. An August 2004 cervical spine X-ray indicated normal cervical curvature. The vertebral bodies were normally developed and in good alignment. There was some narrowing of the intervertebral disc spaces, C5-C6, and C6-C7 with substantial anterior osteophytosis of the vertebral bodies at C6-C7. The spinous processes appeared normal. The retrotracheal soft tissues were not swollen. An X-ray of the thoracic spine disclosed a localized scoliosis with convexity of the left in the upper thoracic area. There were mild degenerative changes and generalized spondylosis throughout the thoracic spine with no focal areas of specific abnormality. A November 2008 report shows an assessment of low back pain/hips and legs pain. At that time, the Veteran denied any recent injury or trauma to his back. A February 2009 report indicates a 10-year history of low back pain and an assessment of low back pain and a history of arthritis. A February 2009 X-ray of the lumbar spine indicated arthritis in the lower thoracic and lumbar 3rd/4th vertebrae levels. An August 2009 MRI lumbar spine showed severe narrowing L4-L5 due to disc bulge and facet and ligamentum flavum hypertrophy. Pursuant to the Board's August 2010 remand, the Veteran was afforded a VA spine examination in June 2011 at which time the examiner noted a history of chronic neck pain since 1992 without known mechanism of injury and chronic low back pain since 1993 with no known mechanism of injury. The examiner diagnosed degenerative osteoarthritis of the cervical spine and lumbar spine with mechanical neck pain. The examiner opined that the degenerative osteoarthritis of the cervical spine and lumbar spine with mechanical neck pain is less likely than not caused by or a result of active service based on the rationale that disc degeneration and accompanying arthritis is a common development. Citing research from a medical journal, the examiner stated that age-related changes are present in 40 percent of adults over 35 years and in almost all individuals over age 50. The examiner stated that the Veteran's disorders were a "stand-alone entity, neither adjunct to nor aggravated by this Veteran's service." In June 2012, the Board determined that the opinion was inadequate for adjudication purposes because the VA examiner appeared to have based this opinion, in part, on a reported onset in approximately 1992 or 1993. The Board noted that while the Veteran consistently denied recurrent back pain throughout his military career, including active and Reserves service, a November 1981 X-ray of the Veteran's cervical and lumbar spine revealed minimal degenerative changes of the cervical and lumbar spine. Therefore, it appeared the Veteran's neck and back conditions had their onset dating to at least 1981, not 1992 or 1993 as reported by the June 2011 VA examiner. Accordingly, the Board remanded the claim for the VA examiner to address the November 1981 X-ray findings and provide an addendum. In February 2012, with regard to the radiographic findings in November 1981, the examiner noted that on November 1981 annual examination the Veteran specifically denied any neck or back pain and physical examination performed at that time was silent for any findings related to cervical or thoracolumbar symptoms. The examiner explained that the November 1981 radiographic findings with respect to chronic cervical and thoracolumbar degenerative spondylosis were incidental findings discovered during an emergency room evaluation for an assault at which time the Veteran complained of having been "punched and kicked," but made no complaint of neck or back pain. The radiographic finding revealed an incidental finding of "minimal degenerative changes of the cervical and lumbar spine." The examiner cited annual examinations performed in May 1982, March 1983, and January 1984 at which time the Veteran specifically denied any neck or back pain and the physical examinations which are silent for any findings related to cervical or thoracolumbar symptoms. The examiner opined that the Veteran's degenerative osteoarthritis of the lumbar spine with mechanical low back pain and degenerative osteoarthritis of the cervical spine with mechanical neck pain are less likely as not due to or a result of active military service. The examiner further opined that "[a]n incidental finding of an asymptomatic condition for which the Veteran was not treated during or within the presumptive period after military service is neither service connectable nor etiologically related to the Veteran's active service." With regard to the Veteran's contention that his neck and back disorders are the result of his time spent on military aircraft, the examiner opined that the degenerative findings are age-related, were not treated during active military service and are a normal and expected outcome due to aging. Activities and injury patterns in the military neither caused nor contributed to the normal expected aging outcome. This is supported by the lack of treatment and silence for complaints. The examiner went on to state that "if the disc disease is not symptomatic, during the interval in question it is not considered a disease such as posttraumatic accelerated disc disease, but rather age-expected outcomes." The Board finds that the claims must be denied. The Veteran was not shown to have neck or back disabilities during service. Rather, the earliest post-service medical evidence of any relevant findings is dated in November 1981. However, in February 2012 the VA examiner explained that the November 1981 radiographic findings with respect to chronic cervical and thoracolumbar degenerative spondylosis were incidental findings discovered during an emergency room at which time the Veteran made no complaint of neck or back pain. This is about 17 years after separation from active duty service. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (a lengthy period without complaint or treatment is evidence that there has not been a continuity of symptomatology, and weigh heavily against the claim). In this regard, the only competent opinion of record is the February 2012 VA opinion stating the following: that the Veteran's degenerative osteoarthritis of the lumbar spine with mechanical low back pain and degenerative osteoarthritis of the cervical spine with mechanical neck pain are less likely as not due to or a result of active military service. As shown more fully below, there is also no persuasive evidence that the Veteran has been experiencing chronic symptoms of neck and back disabilities since service. Put another way, service connection based on the theories of direct onset (38 C.F.R. § 3.303(a)), a presumption of service connection (38 C.F.R. § 3.307, 3.309), or continuity of symptomatology (38 C.F.R. § 3.303(b)) is not established. The Board has fully considered the Veteran's contentions that he had symptoms of neck and back pain during his service and continuity of neck and back symptoms since his service. However, as mentioned earlier, his STRs do not mention complaints of back and neck pain. In addition, the earliest documentary evidence of neck and back disabilities was dated in November 1981, at which time he made no complaints of neck or back pain. Notably, a February 2009 VA treatment record shows that the Veteran only reported a 10-year history of low back pain. The Board finds these statements made in the course of treatment to carry significant weight. Unfortunately, they do not support the claim that the Veteran had continuity of neck or back symptoms since service. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, an opinion as to the etiology and onset of neck and back disorder, diagnosed as degenerative osteoarthritis of the cervical and lumbar spine, and whether these disabilities are etiologically related to the Veteran's active service, falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). Arthritis is not the type of condition/disease that is readily amenable to mere lay diagnosis or probative comment regarding its etiology, as the evidence shows that an X-ray study and other specific findings are needed to properly assess and diagnose the disorder. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); and Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). That is, although the Board readily acknowledges that Veteran is competent to report symptoms such as neck and back pain, there is no indication that the Veteran is competent to etiologically link any such symptoms to his active service. The Veteran has not been shown to possess the requisite medical training, expertise, or credentials needed to render a diagnosis or a competent opinion as to medical causation. Nothing in the record demonstrates that he has received any special training or acquired any medical expertise in evaluating orthopedic disorders. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed.Cir.2012). Accordingly, this lay evidence does not constitute competent medical evidence and lacks probative value. For these reasons, the Board finds that the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for neck and back disabilities on either a direct or presumptive basis. In reaching this conclusion, the Board notes that under the provisions of 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102, a reasonable doubt is to be resolved in the claimant's favor in cases where there is an approximate balance of positive and negative evidence in regard to a material issue. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for a back disorder is denied. Service connection for a neck disorder is denied. REMAND Although the Board sincerely regrets the delay, a review of the evidentiary record reveals that the claims for service connection for residuals of a right inguinal hernia repair, claimed as trouble voiding, must be remanded for further evidentiary development and to ensure due process, for reasons explained below. A review of the record shows that there are relevant outstanding private treatment records which should be requested and obtained. In June 2012, the Veteran submitted a letter from treating private urologist Dr. Parr unaccompanied by any treatment records. VA treatment records dated in April 2000, March 2001, and March 2007 also indicate treatment by Dr. Parr. Accordingly, since it appears that there are outstanding private treatment records that may be relevant to the Veteran's claim, these records should also be obtained. Accordingly, the case is REMANDED for the following actions: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2013). Expedited handling is requested.) 1. The Veteran should be requested to provide the names, addresses and approximate dates of treatment of all non-VA medical care providers who have treated him for residuals of a right inguinal hernia repair, to include Dr. Greg Parr and the Florida Urology Center in Port Orange, Florida. After the Veteran has signed the appropriate releases, those records should be obtained and associated with the claims folder. All attempts to procure records should be documented in the file. If the RO cannot obtain records identified by the Veteran, a notation to that effect should be inserted in the file. The Veteran is to be notified of unsuccessful efforts in this regard, in order to allow him the opportunity to obtain and submit those records for VA review. 2. If the requested records from Dr. Parr and the Florida Urology Center are received, return the claims file and a copy of this remand to the VA examiner who provided the October 2011 VA opinion for an opinion as to whether it is at least as likely as not (i.e., probability of 50 percent or greater), that any voiding dysfunction, regardless of whether it is currently manifest, is etiologically related to the Veteran's active service. In rendering an opinion, the VA examiner should specifically address the Veteran's assertions of symptomatology since 1945. If the October 2011 VA examiner is not available, or if the requested opinions cannot be given without further examination of the Veteran, a new VA examination should be scheduled. If the examiner determines that he or she cannot provide an opinion on the issue at hand without resorting to speculation, the reviewer should explain the inability to provide an opinion, identifying precisely what facts could not be determined. In particular, the examiner should comment on whether an opinion could not be rendered because the limits of medical knowledge have been exhausted or whether additional information could be obtained that would lead to a conclusive opinion. 3. Thereafter, readjudicate the Veteran's claim. If any benefits sought on appeal remains denied, the Veteran and his representative should be provided a supplemental statement of the case, and an appropriate period of time should be allowed for response before the case is returned to the Board. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ Michael J. Skaltsounis Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs