Citation Nr: 1334285 Decision Date: 10/29/13 Archive Date: 11/06/13 DOCKET NO. 10-40 483 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUES 1. Prior to October 18, 2010, entitlement to a disability rating in excess of 10 percent for musculoligamentous strain of the left knee with degenerative arthrosis of the medial compartment. 2. Since December 1, 2011, entitlement to a disability rating in excess of 30 percent for left total knee arthroplasty. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD S. B. Mays, Counsel INTRODUCTION The Veteran served on active duty from March 1977 to March 1980. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a June 2010 rating decision of the Lincoln, Nebraska Regional Office (RO), which continued a 10 percent rating for musculoligamentous strain of the left knee with degenerative arthrosis of the medial compartment. After receiving a total left knee arthroplasty on October 18, 2010, the RO assigned a 100 percent (temporary total) rating for convalescence, and continued the 100 percent rating from December 1, 2010. Thereafter the RO assigned a 30 percent rating from December 1, 2011, for left total knee arthroplasty. In November 2010, the Veteran testified before a Decision Review office sitting at the RO, and in September 2011, the Veteran testified before the undersigned Veterans Law Judge via videoconference. Transcripts of those hearings have been associated with the claims file. A request for a total rating based upon individual unemployability (TDIU), whether expressly raised by Veteran or reasonably raised by the record, is not a separate "claim" for benefits, but rather, can be part of a claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). In other words, if the Veteran or the evidence of record reasonably raises the question of whether the Veteran is unemployable due to a service-connected disability for which an increased rating is sought, then part and parcel with the increased rating claim is the issue of whether a TDIU is warranted as a result of that disability. Id. According to September 2011 hearing transcript, the Veteran testified has been employed as a pew installer. There is no subsequent evidence to the contrary. Also, the Veteran himself has not raised the issue of a TDIU. Thus, the matter of a TDIU is not within the Board's jurisdiction. The issue of entitlement to a rating higher than 30 percent for left knee arthroplasty since December 1, 2011, 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. FINDING OF FACT Prior to October 18, 2010, the Veteran's left knee disability was productive of x-ray evidence of severe arthritis but with full extension and flexion to no worse than 120 degrees. CONCLUSION OF LAW Prior to October 18, 2010, the criteria for a rating of 10 percent for service-connected were not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5010, 5257, 5260, 5261 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION In this decision, the Board will discuss the relevant law which it is required to apply. This includes statutes enacted by Congress and published in Title 38, United States Code ("38 U.S.C.A."); regulations promulgated by VA under the law and published in the Title 38 of the Code of Federal Regulations ("38 C.F.R.") and the precedential rulings of the Court of Appeals for the Federal Circuit (as noted by citations to "Fed. Cir.") and the Court of Appeals for Veterans Claims (as noted by citations to "Vet. App."). The Board is bound by statute to set forth specifically the issue under appellate consideration and its decision must also include separately stated findings of fact and conclusions of law on all material issues of fact and law presented on the record, and the reasons or bases for those findings and conclusions. See 38 U.S.C.A. § 7104(d); see also 38 C.F.R. § 19.7 (implementing the cited statute); see also Vargas-Gonzalez v. West, 12 Vet. App. 321, 328 (1999); Gilbert v. Derwinski, 1 Vet. App. 49, 56-57 (1990) (the Board's statement of reasons and bases for its findings and conclusions on all material facts and law presented on the record must be sufficient to enable the claimant to understand the precise basis for the Board's decision, as well as to facilitate review of the decision by courts of competent appellate jurisdiction). The Board must also consider and discuss all applicable statutory and regulatory law, as well as the controlling decisions of the appellate courts. Duties to Notify and Assist As provided by the Veterans Claims Assistance Act of 2000 (VCAA), VA has duties to notify and assist a claimant in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Upon receipt of a complete or substantially complete application for benefits, VA is required to inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will obtain; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). These notice requirements apply to all elements of a claim, including the disability rating and effective date elements. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (2007). This notice should be provided prior to an initial unfavorable decision on a claim by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004) (Pelegrini II). If, however, for whatever reason it was not, or the notice provided was inadequate, this timing error can be effectively "cured" by providing any necessary notice and then readjudicating the claim - including in a statement of the case (SOC) or supplemental SOC (SSOC), such that the intended purpose of the notice is not frustrated and the Veteran is given an opportunity to participate effectively in the adjudication of the claim. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (Mayfield IV); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). The U.S. Supreme Court has found that VCAA notice errors are not presumptively prejudicial, rather, must be determined on a case-by-case basis, and that, as the pleading party attacking the agency's decision, the Veteran, not VA, bears this burden of proof of establishing there is a VCAA notice error and, moreover, above and beyond this, that the error is unduly prejudicial, meaning outcome determinative of the claim. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009). With regard to the notice requirements pertaining to increased-rating claim, there need only be generic notice advising the Veteran of the evidentiary and legal criteria for establishing his entitlement to a higher rating, not also citation to alternative diagnostic codes or potential "daily life" evidence, etc. See Vazquez-Flores v. Shinseki, 580 F.3d 1270, 1277 (2009), overruling Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008). An RO pre-adjudication letter was sent to the Veteran in May 2010 which apprised him of the type of evidence and information needed to substantiate his increased rating claim, and of his and VA's respective responsibilities in obtaining this supporting evidence. The AOJ also advised him as to how disability ratings and effective dates are assigned. Thereafter, the claim was readjudicated by way of a September 2010 SOC and a December 2010 SSOC. VA also has a duty to assist him in fulfilling developing the evidence concerning his claim. This duty includes assisting him in the procurement of records and, when necessary, providing an examination. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The claims file contains the Veteran's service treatment records, as well as his post-service VA medical evaluation and treatment records. He also has had a VA compensation examination assessing the severity of his left knee disability prior to October 18, 2010. Neither the Veteran nor his representative has identified, and the record does not otherwise suggest, any additional existing evidence that is necessary for a fair adjudication of the claim being decided herein that has not been obtained. No further notice or assistance to him with his claims is required. 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). As noted, the Veteran testified before the undersigned VLJ in September 2011. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that the hearing officer's duties under section 3.103(c)(2) are twofold. First, the hearing officer must explain fully the issues still outstanding that are relevant and material to substantiating the claim by explicitly identifying them for the claimant. Id., at 496. Second, the hearing officer must suggest that a claimant submit evidence on an issue material to substantiating the claim when such evidence is missing from the record or when the testimony at the hearing raises an issue for which there is no evidence in the record. Id., at 496-97. During the hearing, the undersigned VLJ identified the issues on appeal and essentially informed the Veteran, in relevant part, that in order for an increased rating to be awarded, the evidence must show an increase in severity. The Veteran asserted that his left knee disability was more severe than 10 percent disabling prior to his left knee arthroplasty. There is no suggestion of any missing evidence pertaining to the initial period on appeal decided here. The Veteran has not alleged that there were any deficiencies in the Board hearing related to the hearing officer's duties under section 3.103(c)(2). See Bryant, 23 Vet. App. at 497-98. Moreover, even assuming that there was such a deficiency, the Board finds that it did not prejudice the Veteran's claim. In Bryant, 23 Vet. App. at 498-99, the Court held that although the hearing officer did not explicitly lay out the material issues of medical nexus and current disability, the purpose of 38 C.F.R. § 3.103(c)(2) had been fulfilled because the record reflected that these issues were developed by VA, and there was no indication that the appellant had any additional information to submit. The Board finds that any deficiency in the September 2011 Board hearing was non-prejudicial. See id. Moreover, as already stated, the Board does not find any deficiency related to the hearing officer's duties under Bryant, and none has been alleged. Legal Criteria - Claim for Higher Rating Disability evaluations are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule), which are based on average impairment in earning capacity. 38 U.S.C.A. § 1155 (West 2002). Evaluations of a service-connected disability require review of the entire medical history regarding the disability. 38 C.F.R. §§ 4.1, 4.2. If there is a question that arises as to which evaluation to apply, the higher evaluation is for application if the disability more closely approximates the criteria for that rating; otherwise, the lower rating is for assignment. 38 C.F.R. § 4.7. Where entitlement to compensation has already been established and increase in disability rating is at issue, present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, the Court has also held that staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2008). 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). The Court has also held that 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 v. Derwinski, 1 Vet. App. 589, 592 (1991). Instead, the Mitchell Court explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance (38 C.F.R. § 4.40), 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 (38 C.F.R. § 4.45). 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. Therefore, in evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. Moreover, the provisions of 38 C.F.R. § 4.59, which relate to painful motion, 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). Under VA regulations, separate disabilities arising from a single disease entity are to be rated separately. See 38 C.F.R. § 4.25; see also Esteban v. Brown, 6 Vet. App. 259, 261 (1994). However, the evaluation of the same disability under various diagnoses is to be avoided. See 38 C.F.R. § 4.14; Fanning v. Brown, 4 Vet. App. 225 (1993). 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). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. See 38 C.F.R. § 4.3. Further, the assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as the Veteran's relevant medical history, his current diagnosis, and demonstrated symptomatology. Any change in diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). According to Diagnostic Code 5003, when the limitation of motion of the specific joint or joints involved is noncompensable (i.e., 0 percent) under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion to be combined, not added, under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm or satisfactory evidence of painful motion. Moreover, under Diagnostic Code 5003, in the absence of limitation of motion, a 10 percent rating is warranted where there is X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. A higher 20 percent rating requires X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations. For purposes of rating disability from arthritis, the knee is considered a major joint. 38 C.F.R. § 4.45(f). Diagnostic Code 5260 provides for the evaluation of limitation of flexion of the knee. See 38 C.F.R. § 4.71a. A noncompensable rating is warranted when leg flexion is limited to 60 degrees. A 10 percent rating is warranted when it is limited to 45 degrees, a 20 percent rating is warranted when it is limited to 30 degrees, and a 30 percent rating is warranted where flexion is limited to 15 degrees. Diagnostic Code 5261 provides for the evaluation of limitation of extension of the knee. See 38 C.F.R. § 4.71a. A noncompensable rating is warranted when leg extension is limited to 5 degrees. A 10 percent rating is warranted when it is limited to 10 degrees, a 20 percent rating is warranted when it is limited to 15 degrees, a 30 percent rating requires extension limited to 20 degrees; a 40 percent rating requires extension limited to 30 degrees; and a 50 percent rating requires extension limited to 45 degrees. Normal range of motion of a knee is from zero degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71 (2013), Plate II. Additionally, the Board must consider whether the Veteran is entitled to separate ratings under Diagnostic Code 5260 (limitation of flexion of the leg) and Diagnostic Code 5261 (limitation of extension of the leg). VAOPGCPREC 9-04 (September 17, 2004), published at 69 Fed. Reg. 59,990 (2004). Specifically, where a Veteran has both a limitation of flexion and a limitation of extension of the same leg, the limitations must be rated separately to adequately compensate for functional loss associated with injury to the leg. Id. Under Diagnostic Code 5257, "other" knee impairment - including recurrent subluxation or lateral instability, warrants a 10 percent rating if resulting in slight disability, a 20 percent rating for moderate disability, and a 30 percent rating if it is severe. The words "slight," "moderate," and "severe," as used in the various diagnostic codes, are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6 (2013). Analysis In a September 2004 rating decision, the RO granted service connection for musculoligamentous strain of the left knee and assigned a 10 percent rating pursuant to Diagnostic Code 5003, effective March 16, 2004. On April 19, 2010, VA received the Veteran's claim of entitlement to an increased rating for his service-connected left knee disability, and the Veteran ultimately appealed the June 2010 rating decision that continued the 10 percent rating. However, during the pendency of the claim, on October 18, 2010, the Veteran underwent left total knee arthroplasty. The RO assigned a temporary total rating from October 18, 2010, forward. Following a period of convalescence, the RO assigned a 30 percent rating from December 1, 2011. The Board adjudicates only the issue of entitlement to a rating higher than 10 percent prior to October 18, 2010. As noted, the issue of entitlement to a rating higher than 30 percent from December 1, 2011, is addressed in the remand portion of this decision. In May 2010, the Veteran underwent a VA compensation examination. The Veteran demonstrated full extension of the left leg to zero degrees and flexion to 120 degrees. He had a normal gait and there were no functional limitations on standing and walking. Varus/valgus testing of the medial collateral ligaments, lateral collateral ligaments, and anterior cruciate ligaments were normal. McMurray's test was negative. Instability of the left knee was not present. X-rays of the left knee showed moderate degenerative changes in all three compartments and possible loose foreign body in the lateral aspect of the knee. In June 2010, the Veteran had a VA orthopedic consultation due to complaints of progressive left knee pain. Examination of the left knee showed no effusion and was stable to varus and valgus stress. His knee had full extension and flexion to 120 degrees. The preponderance of the evidence is against the claim and a rating in excess of 10 percent for his left knee disability prior to October 18, 2010 is not warranted. During this time period, the Veteran's left knee disability was manifested by subjective complaints of pain and stiffness, as well as x-ray evidence of arthritis. However, the arthritis did not involve 2 or more major joints; rather, his service-connected knee disability involves only one major joint. Therefore the criteria for a higher rating under Diagnostic Code 5003 are not met. Additionally, flexion of the Veteran's left leg is not limited to 30 degrees and extension is not limited to 15 degrees to warrant a higher rating under Diagnostic Codes 5260 or 5261. During the May 2010 VA examination and the June 2010 orthopedic consultation, the Veteran's left knee extension was full, and he exhibited flexion to no worse than 120 degrees. There was painful motion during the May 2010 VA examination, but no additional functional loss or loss in range of motion upon repetitive use was shown. See DeLuca, supra. The Board also considered whether a higher or separate rating under Diagnostic Code 5257 is warranted however there is no evidence of any recurrent subluxation or lateral instability in the Veteran's left knee. During the May 2010 VA examination and the June 2010 orthopedic consultation, he was stable to varus and valgus stress. There is no evidence dated from April 19, 2010, the date VA received the Veteran's increased rating claim, to October 18, 2010, the date a temporary total evaluation was awarded, showing compensable limitation of motion or subluxation or instability of the left knee. There is also no evidence of ankylosis of the left knee, or malunion of the left tibia or fibula, thus the criteria for a rating in excess of 10 percent for left knee disability under Diagnostic Codes 5256 and 5262 are not met during the applicable time period. Finally, Diagnostic Code 5258 is not for application as there is no evidence of a dislocated semilunar cartilage in the left knee. Accordingly, the Board finds that the Veteran's left knee disorder does not meet the criteria for a rating in excess of 10 percent under Diagnostic Codes 5256, 5258, and 5262 for the left knee disability during the applicable time period. The Veteran asserts that his left knee disability must have been more severe than 10 percent disabling prior to October 18, 2010, because approximately five months later, he had a total knee replacement. He, as a layperson, is competent to report observable knee symptoms such as pain or stiffness. However, without the appropriate medical training and expertise, he is not competent to provide an opinion on a medical matter, such as the nature and severity of his left knee disability. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). His lay statements must be considered along with the objective medical evidence and findings and in relation to the applicable rating criteria. Thus, although the Veteran's reports of symptoms have been considered, the Board attaches greater probative weight to the clinical findings of skilled, unbiased professionals. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991). Just four months prior to the surgery, in June 2010, the consulting physician described the Veteran's left knee arthritis as severe, but as noted, the knee had full extension and 120 degrees of extension, at worst, and no instability was demonstrated. As a preponderance of the evidence is against the assignment of a rating in excess of 10 percent for the Veteran's left knee disability prior to October 18, 2010, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). In exceptional cases, an extraschedular rating may be provided. 38 C.F.R. § 3.321. The Court has set out a three-part test, based on the language of 38 C.F.R. § 3.321(b)(1) , for determining whether a Veteran is entitled to an extraschedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant's disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extraschedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F. 3d 1366 (Fed. Cir. 2009). The rating criteria contemplate the Veteran's service-connected left knee disability prior to October 18, 2010. The evidence shows that the Veteran's left knee disability during the applicable time period was primarily productive of painful motion, a manifestation that is contemplated in the applicable rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, DC 5010. The rating criteria are therefore adequate to evaluate the Veteran's service-connected disability. Referral for consideration of an extraschedular rating is therefore not warranted. ORDER Prior to October 18, 2010, entitlement to a disability rating in excess of 10 percent for musculoligamentous strain of the left knee with degenerative arthrosis of the medial compartment is denied. REMAND A new VA compensation examination is necessary to determine the current severity of the Veteran's service-connected left total knee arthroplasty. As noted, on October 18, 2010, the Veteran underwent left total knee arthroplasty, and is currently in receipt of a 30 percent rating under Diagnostic Code 5055 December 1, 2011. Under Diagnostic Code 5055 for total knee replacement, a 100 percent rating n is assigned for one year following the implantation of the prosthesis. A 60 percent evaluation is assigned for a prosthetic replacement of the knee joint with chronic residuals consisting of severe painful motion or weakness in the affected extremity. For a prosthetic replacement of the knee joint with intermediate degrees of residual weakness, pain, or limitation of motion, the disability is rated by analogy to Diagnostic Codes 5256 (ankylosis of the knee), 5261 (limitation of extension), or 5262 (impairment of the tibia and fibula). The minimum rating for a prosthetic replacement of the knee joint is 30 percent. The Board notes that, as indicated in the preceding paragraph, the provisions of Diagnostic Code 5055 for total knee replacement do not provide for consideration of Diagnostic Code 5257 (recurrent subluxation or instability), 5260 (limitation of flexion), or any other Diagnostic Code not specifically referenced therein. The Veteran's most recent VA examination of the left knee was conducted in May 2010, prior to his left knee replacement. An updated VA examination is necessary to determine whether his left knee disability warrants a rating in excess of the 30 percent currently assigned. Accordingly, the case is REMANDED for the following action: 1. Contact the Veteran and ask that he identify any outstanding VA and non-VA records pertaining to his left knee disability, status post arthroplasty, that are not already of record. Request copies of any outstanding records of pertinent VA or private medical treatment and associate them with the claims file. 2. Schedule the Veteran for an appropriate VA examination to determine the nature, extent, frequency and severity of the Veteran's left knee arthroplasty. The claims folder should be made available to and reviewed by the examiner. The examiner is asked to: a. Identify all current left knee pathology, status-post knee replacement; b. Conduct all indicated tests and studies, to include range of motion studies expressed in degrees and in relation to normal range of motion, and should describe any pain, weakened movement, excess fatigability, and incoordination present. To the extent possible, the examiner should express any functional loss in terms of additional degrees of limited motion of the Veteran's left knee on repeated use or during flare-ups. If this is not possible, the examiner should so state. c. Provide an opinion concerning the degree of severity of any instability or subluxation of the left knee. The examiner should also determine if the knees lock and if so the frequency of the locking. The examiner should also indicate whether there is ankylosis of the left knee. d. Indicate the nature and extent of any scarring resulting from his left total knee arthroplasty. Provide the measurements of the Veteran's scar(s), and indicate for each scar whether it is deep (associated with underlying soft tissue damage) or superficial, unstable, painful, or causes limitation of motion, and any other symptomatology associated with the scar(s). The examiner is requested to provide a FULLY REASONED EXPLANATION for his or her opinions, based on his or her clinical experience, medical expertise, and established medical principles. 3. After the above has been completed, re-adjudicate the Veteran's claim of entitlement to a rating higher than 30 percent for left total knee arthroplasty since December 1, 2011. If the benefit sought on appeal remains denied, the Veteran and his representative will be issued an appropriate supplemental statement of the case and afforded the opportunity to respond. 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). ______________________________________________ Vito A. Clementi Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs