Citation Nr: 1334002 Decision Date: 10/28/13 Archive Date: 11/06/13 DOCKET NO. 11-01 975 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Philadelphia, Pennsylvania THE ISSUES 1. Entitlement to service connection for chest pains, claimed as irregular heartbeat and heart condition. 2. Entitlement to an initial rating in excess of 10 percent for left anterior cruciate ligament (ACL) reconstruction. 3. Entitlement to an initial rating in excess of 10 percent for recurrent left knee strain. ATTORNEY FOR THE BOARD Laura E. Collins, Associate Counsel INTRODUCTION The Veteran served on active duty from October 2004 to February 2008. These matters are before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued in April 2010 by the Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania, that denied service connection for a heart condition and granted service connection for left ACL reconstruction, assigning an initial 10 percent disability evaluation for the latter, effective February 9, 2009. In November 2012, following the receipt of new evidence (the November 2011 VA examination) the RO issued a rating decision and supplemental statement of the case granting a separate10 percent evaluation for left knee limitation of motion due to pain, effective November 14, 2011 (the date of the examination). The issue of entitlement to service connection for chest pains is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, D.C. FINDINGS OF FACT 1. For the entire appeal period, the Veteran's left ACL reconstruction has been manifested by no more than recurrent slight lateral instability. 2. For the entire appeal period, the Veteran's recurrent left knee strain has been manifested by complaints of locking, with flexion limited to no more than 130 degrees by pain, including on repetition. 3. For the entire appeal period, the Veteran's left ACL reconstruction also has been manifested by mild lateral lower leg numbness. CONCLUSIONS OF LAW 1. Effective February 9, 2009, the criteria for an evaluation of 10 percent, but no higher, for left knee instability have been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.71a, Diagnostic Codes 5257 (2013). 2. Effective February 9, 2009, the criteria for an evaluation of 10 percent, but no higher, for limitation of motion of the left knee have been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5260 (2013). 3. Effective February 9, 2009, the criteria for a separate noncompensable evaluation, for lateral lower leg numbness have been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.124a, Diagnostic Code 8522 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). The Veteran's claim arises from his disagreement with the initial evaluation following the grant of service connection. Once service connection is granted the claim is substantiated, additional notice under this law is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). The duty to assist the Veteran in the development of the claim includes assisting the Veteran in the procurement of service treatment records (STRs), pertinent treatment records, and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Veteran's STRs and VA treatment records have been obtained and considered. The Veteran has not identified any additional outstanding records that VA should seek to obtain on his behalf. The Veteran was provided with VA examinations of the left knee in April 2010 and November 2011. The Board finds that the examinations are adequate in order to evaluate the Veteran's service-connected left knee disability as they include interviews with the Veteran, review of the claims file, x-rays, and full physical examinations. The Veteran has not alleged, nor does the record show, that his service-connected left knee disability has worsened in severity since the most recent examination in 2011. As such, a new examination is not required. See Palczewski v. Nicholson, 21 Vet. App. 174 (2007). The Board finds that all relevant facts have been properly developed, and all reasonable efforts were made by VA to obtain evidence necessary to substantiate the Veteran's claim, and no further assistance to develop evidence is required. Therefore, the Veteran will not be prejudiced as a result of the Board proceeding to the merits of his claim. II. Analysis Disability evaluations are determined by the application of a schedule of ratings, which is based on the average impairment of earning capacity. Separate diagnostic codes (DCs) identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R., Part 4. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. The Veteran's entire history is reviewed when making disability evaluations. See Schafrath v. Derwinski, 1 Vet. App. 589 (1995). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. Where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibits symptoms that would warrant different evaluations during the course of the appeal, the assignment of staged ratings is appropriate. See Fenderson v. West, 12 Vet. App. 119, 126-127 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran is service-connected for left ACL reconstruction which is currently rated 10 percent disabling under 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5257, effective February 9, 2009. He is also separately service-connected for recurrent left knee strain, evaluated as 10 percent disabling under 38 C.F.R. § 4.71a, DC 5260, effective November 11, 2011. He contends that for the entire appeal period, his left knee disabilities have been more severe than the currently assigned ratings and that he is entitled to a higher ratings. A. Instability - Left ACL reconstruction Pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5257, slight recurrent subluxation and lateral instability warrants a 10 percent evaluation. A 20 percent rating requires this be moderate, and a 30 percent evaluation is assigned when it is severe. The rating decision on appeal assigned a 10 percent evaluation under this DC, effective February 9, 2009. The Board finds this assignment is proper, as the 2010 VA examination showed that the Veteran reported giving way and instability. The examiner also noted that the claims file indicated there was residual instability after the surgery. In his January 2011 substantive appeal, the Veteran stated that his knee always gives out on him. However, the medical evidence does not show moderate or severe recurrent subluxation or lateral instability that would warrant a 20 or 30 percent evaluation under DC 5257. In this regard, both the 2010 and 2011 VA examiners found that there was no recurrent subluxation. Additionally, at the November 2011 examination the Veteran did not report subjective instability and all objective instability testing was normal. Therefore, there is no evidence of more than slight instability, and the Board concludes that the Veteran's left knee disability does not warrant a rating in excess of 10 percent under DC 5257 for instability during the appeal period. B. Limitation of Motion - Recurrent left knee strain The Board notes that 38 C.F.R. § 4.71a, DC 5003 establishes, essentially, three methods of evaluating degenerative arthritis that is established by X-rays: (1) when there is a compensable degree of limitation of motion, (2) when there is a noncompensable degree of limitation of motion, and (3) when there is no limitation of motion. Generally, when documented by X-rays, arthritis is rated on the basis of limitation of motion under the appropriate DC for the joint involved. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasms, or satisfactory evidence of painful motion. Read together, DC 5003 and 38 C.F.R. § 4.59 provide that painful motion due to degenerative arthritis established by X-ray is deemed to be limitation of motion and warrants the minimum compensable rating for the joint, even if there is no actual limitation of motion. Lichtenfels v. Derwinski; 1 Vet. App. 484, 488 (1991). In this case, the Veteran has not been diagnosed with arthritis. However, the United States Court of Appeals for Veterans Claims (Court) has held that the provisions of 38 C.F.R. § 4.59 are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). Pursuant to DC 5261, under which limitation of leg extension is evaluated, the following evaluations are assignable: for extension limited to 5 degrees, noncompensable; for extension limited to 10 degrees, 10 percent; for extension limited to 15 degrees, 20 percent; for extension limited to 20 degrees, 30 percent; for extension limited to 30 degrees, 40 percent; for extension limited to 45 degrees, 50 percent. 38 C.F.R. § 4.71a, DC 5261. VA treatment records and examinations show that the Veteran's left knee extension was measured twice during the appeal period. In both instances, it was normal at 0 degrees, with no objective evidence of painful motion. Therefore, the Veteran has no limitation of extension under DC 5261 and a higher rating is not available under this DC. Pursuant to DC 5260, under which limitation of leg flexion is evaluated, the following evaluations are assignable: for flexion limited to 60 degrees, noncompensable; for flexion limited to 45 degrees, 10 percent; for flexion limited to 30 degrees, 20 percent; and for flexion limited to 15 degrees, 30 percent. 38 C.F.R. § 4.71a, DC 5260. VA treatment records and examinations show that the Veteran's left knee flexion was measured twice during the appeal period. At most, it was limited to 130 degrees at the November 2011 VA examination, including on repetition and with painful motion. Based on these measurements, the Veteran's flexion has not been limited to a compensable level during the appeal period. However, when evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). Although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath, supra. The possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing. See 38 C.F.R. §§ 4.40, 4.45; Mitchell. Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. In evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. The relevant evidence of record, which includes the Veteran's lay statements, VA treatment records, and the 2010 and 2011 VA examination reports, show that during the course of the appeal the Veteran's left knee disability has been productive of considerable pain and functional impairment. In a September 2009 lay statement the Veteran reported that he could no longer climb mountains on family hunting trips, could not exercise or play sports like he used to, and had constant pain in his knee that would not go away. The April 2010 VA examiner noted residual pain from the surgery resulting in limited ambulation and exercise. At this examination, the Veteran reported pain, stiffness, weakness, decreased speed of joint motion, and mild weekly flare-ups lasting one to two days caused by overuse. Pain was the most limiting factor during the flare-ups. His standing was limited to an hour, walking was limited to under one mile, and he wore a brace intermittently. Daily activities of exercise, sports, and recreation were moderately limited by the disability. In his May 2010 notice of disagreement, the Veteran stated that the pain affects his everyday life. He cannot stand for long periods of time, which limits his employment opportunities. He was no longer able to play any kind of sports or exercise. In his January 2011 substantive appeal, the Veteran stated that the pain can be overwhelming, his range of motion seems to get worse every year, and he can no longer hunt, fish, or exercise. The November 2011 VA examiner observed that the STRs show functional effects, including residual weakness that prevented the Veteran from running and carrying of heavy loads as required by service. The examiner also reported that the recurrent left knee pain has gradually worsened over subsequent years. The Veteran reported that his left knee was currently intolerant of: excessive, repetitive, or prolonged activity and inactivity; ascending and descending stairs; heavy lifting; and prolonged standing and walking. On physical examination, the 2011 examiner found additional functional loss/impairment of the left knee after repetitive use, including weakened movement, pain on movement, disturbance of locomotion, and interference with sitting, standing, and weight-bearing. He also had pain to palpation. The VA examiner diagnosed recurrent left knee strain. Taking all of the above into consideration, the record nevertheless shows flexion limited to 130 degrees at most. Indeed, repetitive testing conducted in 2011 improved flexion to 135 degrees. Thus, even considering the functional loss due to pain that the Veteran reports, the evidence demonstrates that the criteria for a rating in excess of 10 percent have not been met. Accordingly, Board finds that the Veteran is not entitled to a rating in excess of 10 percent for limitation of flexion due to pain. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The RO assigned an additional 10 percent under DC 5260 effective November 11, 2011, but the Board finds that the Veteran exhibited functional loss due to pain during the entire appeal period. Therefore, the additional 10 percent evaluation shall be effective February 9, 2009. C. Lateral lower leg numbness - Left ACL reconstruction At the 2011 VA examination, the examiner noted that the Veteran had left lateral lower leg numbness as a residual symptom due to the ACL reconstruction surgery in service. Pursuant to 38 C.F.R. § 4.124a, Diagnostic Code 8522, mild paralysis of the musculocutaneous (superficial peroneal) nerve warrants a noncompensable evaluation. A higher rating is only available for moderate (10 percent), severe (20 percent), or complete paralysis (30 percent). The Board assigns an additional noncompensable rating for mild paralysis under DC 8522. The STRs also show documented decreased sensation following the knee surgery, indicating that the symptom has been present throughout the appeal period. Therefore, this additional rating is effective February 9, 2009. However, the medical evidence does not show moderate, severe, or complete paralysis that would warrant a compensable rating under DC 8522. In this regard, there is no complaint, treatment, or diagnosis of moderate or severe paralysis; nor is there any evidence of the weakened eversion of foot required for a rating of complete paralysis. Therefore, there is no evidence of more than mild paralysis, and the Board concludes that the Veteran's left knee disability does not warrant a rating in excess of 0 percent under DC 8522 for left lateral lower leg numbness during the appeal period. D. Other Diagnostic Codes The Board has considered whether it may be appropriate to rate the Veteran's left knee disability under other DCs. Diagnostic Codes 5256, 5262, and 5263 provide ratings for ankylosis, impairment of tibia and fibula, and genu recurvatum, respectively. The medical evidence shows no such impairment. Therefore, a higher rating is not available under these DCs. 38 C.F.R. § 4.71a. Diagnostic Code 5258 provides a 20 percent rating for dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint. While the Veteran reported locking episodes one to three times per month at both examinations, the November 2011 VA examiner specifically noted that there was no meniscal dislocation, meniscal tear, or effusion. Therefore, a higher rating is not available under this DC. 38 C.F.R. § 4.71a, DC 5258. Finally, DC 5259 provides for a 10 percent rating for symptomatic removal of the semilunar cartilage. 38 C.F.R. § 4.71a, DC 5258. The November 2011 VA examiner noted that in November 2006 the Veteran underwent a meniscectomy on his left knee, and that his meniscus (semilunar cartilage) condition resulted in frequent episodes of pain. Therefore, the removal of the Veteran's semilunar cartilage is symptomatic. The evidence shows that the Veteran has experienced the symptom of pain during the appeal period resulting from the surgery. However, the Board has already rated that symptom in connection with DC 5260. Accordingly, that symptom cannot overlap with the symptomatic pain from the removed semilunar cartilage. Therefore, the Board cannot assign a rating under DC 5258, as left knee pain is already contemplated within the symptomatology of the disability rating granted under DC 5260. Therefore, to assign an additional separate rating under these codes would amount to evaluating the same disability under various diagnoses, a practice to be avoided. 38 C.F.R. § 4.14. Based on the foregoing, the Board finds that the Veteran is not entitled to a rating under any other DCs. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert. E. Other considerations The Board finds that the Veteran's symptoms have been stable throughout the appeal period and therefore staged ratings are not appropriate. Hart. The Board has also considered whether an extra-schedular rating is warranted, noting that if an exceptional case arises where ratings based on the statutory schedules are found to be inadequate, consideration of an "extra-schedular" evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities will be made. 38 C.F.R. § 3.321(b)(1). The Court has held that the determination of whether a claimant is entitled to an extraschedular rating under § 3.321(b) is a three-step inquiry, the responsibility for which may be shared among the RO, the Board, and the Under Secretary for Benefits or the Director, Compensation and Pension Service. Thun v. Peake, 22 Vet. App. 111 (2008). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. This means that initially there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is adequate, and no referral is required. If the criteria do not reasonably describe the claimant's disability level and symptomatology, a determination must be made whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. § 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). See id. When the analysis of the first two steps reveals that the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step - a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. However, in this case, the rating criteria reasonably describe the claimant's disability level and symptomatology. The Veteran essentially exhibits limitation of flexion, lateral lower leg numbness, locking, and recurrent slight lateral instability, all of which are contemplated in the rating criteria. Additionally, the Board has considered and assigned an additional 10 percent evaluation for functional limitation due to pain. Moreover, there are additional rating criteria to be considered should the knee impairment produce additional symptoms. As such, with the Veteran's disability picture contemplated by the rating schedule, no referral for an extra-schedular consideration is required. Finally, the Court has held that entitlement to a total disability rating for compensation based on individual unemployability due to service-connected disabilities (TDIU) is an element of all appeals for a higher rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). Entitlement to a TDIU is raised when a Veteran: (1) submits evidence of a medical disability; (2) makes a claim for the highest rating possible; and (3) submits evidence of unemployability. As there is no evidence of unemployability due to the Veteran's left knee disability, the question of entitlement to a TDIU is not raised. ORDER A rating in excess of 10 percent for instability of the left knee is denied. The separate 10 percent rating for limitation of flexion of the left knee is granted effective February 9, 2009, subject to the law and regulations governing the payment of VA monetary benefits. A separate noncompensable rating for mild paralysis of the left lateral lower leg is granted, effective February 9, 2009, subject to the law and regulations governing the payment of VA monetary benefits. REMAND The Veteran seeks service connection for symptoms that he has claimed as irregular heartbeat and heart condition. For the reasons that follow, his claim must be remanded. The symptoms for which the Veteran seeks service connection have been described as follows. Beginning during service and continuing to the present, he has attacks of pain in his left chest that radiate down his left arm. During these attacks, he has shortness of breath and when he tries to breathe, it sends sharp pain down his arm. The attacks last for 5 to 8 seconds, and he has to stop what he is doing because of the pain. At his April 2010 VA heart examination, he reported attacks occurring three times per month, but it happened more often during service. The Veteran stated in his substantive appeal that this was not due to an anxiety attack but was due to a heart condition. However, physicians have been unable to diagnose any heart condition. At the April 2010 VA examination, chest x-ray, METs estimate, and physical examination were all normal. The EKG showed sinus bradycardia but no diagnosis was evident. There was no evidence of arrhythmia or heart condition. The VA examiner diagnosed atypical chest pain, non-cardiac in nature. The medical evidence does, however, indicate that there may be a psychiatric etiology for the symptoms for which the Veteran seeks service connection. STRs dated October 2004 show that during basic training he was diagnosed with and treated for adjustment disorder with anxious and depressed mood, which was noted to have resolved during training. In August 2005, at the age of 19, he complained of chest pain with shortness of breath for the past three months. He rated the pain at a 7 out of 10, beginning in the left chest and radiating down the left arm for 5 to 6 seconds. He reported approximately 20 episodes in the past three months. He could not correlate the pain to any activity, exertion, or meals. On examination one week after the most recent episode, his heart was without rubs, gallops, or murmurs. The diagnosis was atypical chest pain with the notes: "consider anxiety attack," and "previous history of anxiety in boot camp." VA's duty to assist includes a duty to provide a medical examination or to obtain a medical opinion where it is deemed necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). Further, the Board may order an examination when the record shows that the Veteran has a current disability, indicates that this disability may be associated with the Veteran's active service, and does not contain sufficient evidence for the Board to make a decision on the issue. 38 U.S.C.A. § 5103A(d)(2). If the record indicates that there may be a nexus between the current disability and any service related incident, then the Board may order an examination. McLendon v. Nicholson, 20 Vet. App. 79 (2006). In this case, the record shows that the Veteran has the current condition of recurring chest pains with shortness of breath and that he has experienced this since service. The record also indicates that these symptoms may be related to anxiety attacks. The Board finds that this is sufficient to indicate that there may be a nexus between the current symptoms and the symptoms in service. Therefore, a remand is necessary in order to obtain an opinion. Additionally, the Veteran has contended that his chest pains may be due to asbestos exposure. In his original claim application, he stated that in October 2006 he was clearing out tile in one of the old barrack rooms and the contractor later said that they had been exposed to asbestos. This theory was not addressed in the rating decision on appeal. Thus, on remand, the RO should address this theory of entitlement. The Veteran indicated that all of his treatment has been through the Lebanon VA Medical Center (VAMC). The most recent VA treatment record associated with the claims file are dated April 2010. Any relevant outstanding treatment records from that facility should be obtained on remand. Finally, the Board notes that the address in the Veterans Benefits Management System is different from the address to which documents have been mailed for the last two years. Correspondence must be sent to the proper address. Accordingly, the case is REMANDED for the following actions: 1. Obtain any relevant treatment records from the Lebanon VAMC dated after April 2010. 2. Schedule the Veteran for a VA psychiatric examination. The examiner should review the claims file and note that review in the report. All appropriate tests and studies should be conducted. After examining the Veteran, the examiner should: Identify any current psychiatric disabilities found to be present; and offer an opinion as to whether any such disability had its onset in service, particularly addressing whether the chest pain complaints were early manifestations of any current psychiatric disability. The examiner should describe all findings in detail and provide a complete rationale for all opinions offered. The examiner should also acknowledge the Veteran's statements as to the onset and recurrence of his chest pain symptoms since service. If the examiner is unable to provide the requested opinions without resort to speculation, the reasons for that should be explained, noting particularly whether it is the limits of medical knowledge that prevents providing the opinion or missing facts. If it is missing facts, the information that is necessary to provide a non-speculative opinion should be described to the extent possible. If the examiner recommends any additional consultations with other specialties, schedule the Veteran for any such recommended examinations. 5. After undertaking any additional development deemed appropriate, readjudicate the claim, including addressing the Veteran's theory of entitlement due to asbestos exposure. If the benefit sought remains denied, the Veteran must be furnished a supplemental statement of the case and be given an opportunity to respond before the claims file is returned to the Board for further appellate consideration. In sending this or any other document to the Veteran, his correct address should be confirmed since the one in the Veterans Benefits Management System electronic file appears to differ from the one to which documents have been mailed. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the Court for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ MICHAEL E. KILCOYNE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs