Citation Nr: 1334877 Decision Date: 10/31/13 Archive Date: 11/06/13 DOCKET NO. 08-34 730 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida THE ISSUE Propriety of the reduction of the disability rating for non-Hodgkin's lymphoma from 100 percent to 0 percent, effective from October 1, 2007 to December 15, 2008, and from February 1, 2010 to present. REPRESENTATION Appellant (the Veteran) is represented by: Veterans of Foreign Wars of the United States WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD L. Cramp, Counsel INTRODUCTION The Veteran had active service from October 1965 to January 1969. This appeal comes before the Board of Veterans' Appeals (Board) from a June 2007 rating decision of the RO in St. Petersburg, Florida. In July 2010, the Veteran and his spouse presented testimony at a Board hearing, chaired by the undersigned Veterans Law Judge, sitting at the RO. A transcript of the hearing is associated with the claims file. In August 2010, the Board remanded this appeal for additional evidentiary development. It has since been returned to the Board for further appellate action. During the remand, the RO assigned a 100 percent rating for non-Hodgkin's lymphoma effective from December 15, 2008 to February 1, 2010, with a 0 percent rating assigned effective February 1, 2010. The Board has characterized the issue as reflecting this change. In reviewing this case the Board has not only reviewed the physical claims file, but also the file on the "Virtual VA" system to insure a total review of the evidence. In the August 2010 decision, the Board referred an issue back to the RO for appropriate action. The Board noted that, in a May 2008 rating decision, the RO denied service connection for a scar associated with the Veteran's non-Hodgkin's lymphoma, stating that the Veteran had failed to identify the location of the scar; however, a review of the file showed that he underwent surgery in April 2004 for excision of a pelvic mass; and, at his hearing in July 2010, the Veteran indicated that the scar is down the middle of his chest and into the abdominal area. It does not appear that any action has resulted from the previous referral. Accordingly, the issue is again REFERRED to the RO for appropriate action. FINDING OF FACT The reduction of the rating for non-Hodgkin's lymphoma from 100 percent to 0 percent, effective from October 1, 2007 to December 15, 2008, and from February 1, 2010 to present, was based on actual improvements in the level of disability, and during these times periods, the disease was in remission, with residuals separately evaluated. CONCLUSION OF LAW Reduction of the disability rating for non-Hodgkin's lymphoma from 100 percent to 0 percent effective from October 1, 2007 to December 15, 2008, and from February 1, 2010 to present was proper and the criteria for restoration of a 100 percent rating during those periods are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.105, 3.159, 3.343, 3.344, 4.1-4.14, 4.117, Diagnostic Code 7715 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION Service connection for non-Hodgkin's lymphoma was granted by way of a December 2005 rating decision. An initial 100 percent rating was assigned pursuant to 38 C.F.R. § 4.118, Diagnostic Code 7715, effective November 12, 2004. Diagnostic Code 7715 provides for the assignment of a 100 percent rating for non-Hodgkin's lymphoma with active disease or during a treatment phase. A note to the rating criteria provides that, if there has been no local recurrence or metastasis, rate on residuals. The Veteran was advised at the time of the December 2005 decision that the disability would be the subject of a future review examination. The Veteran underwent a review examination in March 2007. The review examination found that non-Hodgkin's lymphoma was in remission with no residuals. Following the review examination, the RO proposed reducing the disability evaluation from 100 to 0 percent. In an April 2007 notice letter, the Veteran was informed of the proposal to reduce the disability rating from 100 percent to 0 percent. In a June 2007 rating decision, the RO reduced the rating for non-Hodgkin's lymphoma from 100 percent to 0 percent, effective October 1, 2007, and this appeal ensued. The Board remanded this appeal in August 2010 for additional development due to concerns about the adequacy of the March 2007 examination. In an October 2011 rating decision, pursuant to a September 2010 VA medical opinion, the RO determined that there had been a recurrence of non-Hodgkin's lymphoma in 2008. The RO assigned a 100 percent rating effective December 15, 2008 and a 0 percent rating effective February 1, 2010. After a review of the all of the evidence in this case, the Board finds that reduction of the disability rating for non-Hodgkin's lymphoma from 100 percent to 0 percent was proper, and a restoration of the 100 percent rating is not warranted. There is no question that a disability may be reduced; however, the circumstances under which rating reductions can occur are specifically limited and carefully circumscribed by regulations promulgated by the Secretary. Dofflemyer v. Derwinski, 2 Vet. App. 277, 280 (1992). VA law requires that, when a reduction in evaluation of a service-connected disability is deemed to be warranted, and such reduction will result in a decrease in payment of compensation benefits being made, a rating proposing the reduction will be prepared setting forth all material facts and reasons. The beneficiary will be notified and furnished detailed reasons for the reduction and given 60 days for presentation of additional evidence to show that compensation payments should be continued at the current level. See 38 U.S.C.A. § 5112; 38 C.F.R. § 3.105(e). Additionally, under 38 C.F.R. § 3.105(i), the advance written notice concerning a proposed rating reduction must inform the beneficiary that he has a right to a predetermination hearing, provided that a request for such a hearing is received by VA within 30 days from the date of the notice. Here, the rating reduction resulted in a decrease in the combined rating from 100 percent to 10 percent; therefore, the provisions of 38 C.F.R. § 3.105(e) are applicable; however, the Veteran does not contend, and the evidence does not reflect, any failure in compliance with the procedural requirements for rating reductions. A proposed rating was issued by the RO in April 2007, prior to the reduction. In that decision, the RO set forth the material facts and reasons for the proposed reduction, noting that the Veteran's lymphoma was in remission. In a letter accompanying the rating decision, the Veteran was given 60 days for presentation of additional evidence to show that compensation payments should be continued at the current level. That letter also informed him that he had a right to a predetermination hearing, provided that a request for such a hearing was received by VA within 30 days from the date of the notice. The Veteran responded to the proposal to reduce his rating by letter received in June 2007. He did not request a hearing. He submitted additional medical records, which were considered by the RO. Nevertheless, the RO reduced the rating to 0 percent in a June 2007 rating decision. As the Veteran was notified of the proposed reduction and afforded the opportunity to attend a hearing and submit additional evidence, the Board finds that the procedural requirements for a rating reduction were met. The substantive requirements for reduction of ratings in effect for five years or more are set forth at 38 C.F.R. § 3.344(a) and (b). However, since the 100 percent evaluation was granted in December 2005, effective November 12, 2004, and reduced to 0 percent in June 2007, effective October 1, 2007, it had not been in effect for five years. As such, the provisions of 38 C.F.R. § 3.344(a) and (b) are not directly applicable in this case. With respect to disabilities that are likely to improve (i.e., those in effect for less than five years), re-examinations disclosing improvement in disabilities will warrant a rating reduction. 38 C.F.R. § 3.344(c). However, it is necessary to ascertain, based upon a review of the entire recorded history of the condition, whether the evidence reflects an actual change in disability and whether examination reports reflecting change are based upon thorough examinations. In addition, it must be determined that an improvement in a disability has actually occurred and that such improvement actually reflects an improvement in the Veteran's ability to function under the ordinary conditions of life and work. See Brown v. Brown, 5 Vet. App. 413, 420-421 (1993) (citing 38 C.F.R. §§ 4.1, 4.2, 4.10 and 4.13); 38 C.F.R. 3.344(c). Rating reductions are contrasted with increased rating claims. A rating reduction may not be based solely on a determination that the schedular criteria for the lower rating are more appropriate. Rating reductions necessarily involve a comparative analysis of the evidence utilized to establish the level of disability prior to the proposed reduction, and the evidence which serves as the basis for the proposed reduction. The evidence of record must demonstrate improvement in the level of disability and that such improvement will likely continue. After a review of the all of the evidence in this case, the Board finds that reduction of the rating for non-Hodgkins lymphoma from 100 percent to 0 percent, effective October 1, 2007, was proper, and a restoration of the 100 percent rating from October 1, 2007 is not warranted. In so finding, the Board notes that the evidence indicates that the level of disability had improved at the time of the reduction, and that such improvement was reasonably likely to continue. While the VA examination upon which the decision to reduce was based did not include a claims file review, this error was remedied in obtaining a supplemental opinion based on claims file review in September 2011. The September 2011 report reflects that the complete claims file was reviewed. See Tucker v. Derwinski, 2 Vet. App. 201 (1992). In Tucker, the Veterans Court reasoned that determinations as to whether there is an actual change in disability, rather than a temporary fluctuation in symptoms, and whether an improvement in a disability actually reflected an improvement in a veteran's ability to function under the ordinary conditions of life and work, are in part medical determinations which require an examination that is informed by a review of a veteran's medical history. Although the appellant in Tucker argued that the reduction in his disability rating based on an inadequate examination rendered the reduction void ab initio, the Veterans Court did not adopt this position, but held that VA adjudicators committed error when they chose to substitute their own opinion for that of a doctor instead of obtaining an adequate medical opinion. Here, the Board has complied with the holding in Tucker by obtaining an opinion based on file review. In addition, the Board finds that both the March 2007 and September 2011 reports demonstrate an actual improvement in the non-Hodgkins lymphoma that was likely to continue. The September 2011 report includes the opinion that the Veteran went into clinical remission around October of 2004. After that, he received a number of Rituxan treatments to maintain the remission status. He may have relapsed about December of 2008, based upon a PET scan report. The final note of June 2009 again finds him in remission status. In reaching the opinion that there was a remission as early as October 2004, the VA physician noted that a private progress note dated July 15, 2004 indicates that the Veteran was treated with Rituxan for 4 weekly treatments, the last one given on June 9, 2004. At this time, his platelet count was normal at 254,000. The private physician indicated that no further treatment with Rituxan was necessary at that time, but that the Veteran should receive maintenance Rituxan approximately 6 months later in January of 2005, and that he would be under the care of another physician in the interval. PET and CT reports of October 22, 2004 indicated significant improvement in the previously noted soft tissue mass in the left perinephric space. PET demonstrated interval resolution of a previously noted abnormal uptake. According to the VA physician, at this point, it would be reasonable to say that the Veteran was in remission. The VA physician also noted that a report dated February 22, 2005 indicates that the Veteran received 4 treatments with Rituxan between January 14, 2005 and February 15, 2005 and the plan was to resume in July 2006. A note dated March 10, 2007 reveals that the Veteran was receiving Rituxan once a week until 6 months ago. These treatments were for maintenance of remission status. A note by a private physician refers to a PET scan done at January 22, 2007 which showed abnormal uptake in the stomach, which was consistent with a normal variant or also seen in H. pylori infection. On December 30, 2008 a PET/CT scan ordered by the Veteran's private physician demonstrated intensely positive small lymph nodes in the right axilla and subpectoral region. The report referred to a PET scan dated October 2, 2007, which showed no active lymphoma. The VA physician believed that this indicated that the Veteran relapsed out of remission status in December 2008. The Veteran was seen by an oncologist on May 17, 2009 and a PET scan was performed in the Miami VA demonstrating a small right inguinal lymph node with mild metabolic activity. VA blood chemistries dated August 23, 2011 had a total protein of 6.7 and an albumin of 4.5 suggesting the IgM gammopathy was not significantly present, and that lymphoma did not appear to be active at this time. A CBC dated November 18, 2008 was almost normal with a wbc of 4,100, a hematocrit of 36.6, and a platelet count of 163,000. The VA physician reasoned that this type of low grade lymphoma often goes into clinical remission with treatment but rarely is cured. It often recurs a number of times, and for that reason, maintenance treatment with Rituxan along with continuing observation is recommended. Although in clinical remission, most often a patient continues to harbor a barely detectable residual tumor burden which manifests from time to time. Often these patients do have demonstrable immune disorders and immune dysfunction, as was the case here. Initially, the Veteran appears to have had immune thrombocytopenia and a monoclonal gammopathy. Both responded to treatment, the platelet count returned to normal range and has been there since the initial treatments in 2004. The monoclonal IgM gammopathy was significant but the physician did not see subsequent measurements. The VA chemistries suggest that the IgM gammopathy is much less, but are not conclusive that the gammopathy is eliminated. Based on the findings of the VA physician, the Board finds that the determinations of the RO that the non-Hodgkin's lymphoma was in remission at the time of the reduction, that it subsequently came out of remission in December 2008, and that it entered remission again in July 2009, are correct and are supported by the record. The Board acknowledges the difficulty in reconciling the VA physician's statement that non-Hodgkin's lymphoma is a disability which by its nature often goes into clinical remission with treatment, and often recurs a number of times, with the Board's finding, as dictated by VA law, that there has been an improvement in the level of disability and that such improvement will likely continue. However, in the case of non-Hodgkin's lymphoma, the rating criteria are specific as to the basis for determining that there has been an improvement in the disability warranting a reduction, the criteria specify that such improvement is shown, and that reduction is warranted, when there is no longer active disease or when the treatment phase has ended. Thus, the criteria contemplate the situation present in this case. The evidence addressing these criteria is unequivocal. To find that a possibility of recurrence prohibits a reduction would render this portion of the rating criteria of no meaning or effect. As there was no active disease at the time of the reductions, and the Veteran was no longer in treatment phase, but was in a maintenance phase, as found by the VA physician, reductions in 2007 and 2010 were appropriate, and the disease was at those times to have been rated on residuals. Regarding residuals, the Veteran is separately rated for facial scars associated with basal cell carcinoma and esophageal candida, both residuals of non-Hodgkin's lymphoma. Service connection was specifically denied for claimed gastritis and hypertrophic actinic keratosis. The Veteran has asserted that various other complaints are also residuals which warrant a disability rating. In the October 2005 VA examination, during the active phase of the Veteran's non-Hodgkin's lymphoma, the Veteran complained primarily of fatigue. The examiner found that his activities of daily life were not affected and that the disease did not interfere with his occupation other than his being tired easily. At the time of a March 2007 VA examination, also during a period when the Veteran was compensated at the 100 percent level, but which served as the basis for the rating reduction, the examiner listed various side effects of the medication used to treat non-Hodgkin's lymphoma. However, it is quite difficult to discern which symptoms were actually present and which of the symptoms were simply listed as known to be associated with the medication used to treat non-Hodgkin's lymphoma. In a section which appears to list symptoms known to be associated with the medication are listed: headache, fatigue, nausea, dry mouth, muscle pain, "[b]one or joint damage," bladder inflammation, and dry eyes. In a section titled "[current symptoms]" are noted fever, chills, night sweats, fatigue, malaise, weakness, headaches, nausea, constipation, and pruritis. In a section titled "[other symptoms]" are listed shortness of breath, "[b]one or joint pain," blurred vision, and memory loss. The Board notes that the imprecise nature of the reference to "[b]one or joint pain" and "[b]one or joint damage" without identifying the bones or joints affected and/or the nature of the damage leads the Board to conclude that this and other symptoms listed in the corresponding sections are not specifically associated with the Veteran, but are listed as generally recognized to be associated with the medication. Although the Board acknowledges that the design of the examination report makes it virtually impossible to determine the intent of the examiner. Regarding the section listing current symptoms, while these appear to be symptoms reported by the Veteran, there is no indication from the examiner as to which symptoms, if any, she believes to be associated with the Veteran's non-Hodgkin's lymphoma. Most telling regarding the extent of impairment, the examiner found no significant effects on the Veteran's occupation. Regarding activities of daily life, she found only mild impairment regarding chores, and no impairment regarding shopping, exercise, sports, recreation, traveling, feeding, bathing, dressing, toileting, and grooming. The RO requested clarification of the examiner's findings in April 2007, noting that the examiner had found the disease to be active, but had also noted normal blood test results. In an addendum, the examiner reported that the Veteran's blood chemistry and blood count were normal and that the disease was in remission. At this time, the examiner specifically listed the symptoms associated with the Veteran's non-Hodgkin's lymphoma as chills, night sweats, and fatigue after 2 hours of normal activities of daily life occurring every 2 weeks. However, it is not clear whether these symptoms were present during the remission, and thus subject to a separate rating, or only during the active phase when a 100 percent rating was assigned. A May 2008 private treatment record reveals that the Veteran was feeling good and denied fevers, chills, sweats, bone pains, or any other problems. A June 2008 private treatment record reveals that the Veteran reported he was doing well and denied any major problems or symptoms including fevers, chills, sweats, weight loss, or bone pains. The Veteran reported that he had recently gotten drunk and had a trauma to his right hip and left flank with significant ecchymosis. A December 2008 private treatment record reveals that the Veteran was doing well with no new problems or symptoms. A February 2010 private treatment record reveals complaints of aches and pains, sinusitis, fatigue, night sweats, dry eyes, itchy eyes, difficulty hearing, joint pains, tachycardia, swelling of the legs, shortness of breath, occasional irritable bowel symptoms, heart burn, frequent urination, joint pains, arthralgias, myalgias, rash, dry skin, itching, nail changes, dizziness, numbness, memory loss, and hot flashes. It was noted that the Veteran remained fully active. The examiner made no finding as to which if any of the reported symptoms were associated with non-Hodgkin's lymphoma. A June 2010 private treatment record reveals that the Veteran was doing well with no new problems or symptoms. He complained of feeling tired and having an occasional cough. An August 2010 private treatment record reveals an assessment of low grade non-Hodgkin's lymphoma with no evidence of disease recurrence. The Veteran was found to have no problems or symptoms other than occasional cough and occasional sweats. A September 2010 VA examination includes notations in the report of medical history that there is no history of dizziness, syncope, fatigue, dyspnea, fever, night sweats, lightheadedness, weakness, or headaches. Then, under the section covering current general symptoms, following what appears to be a pre-printed list of examples (chills, night sweats, frequent infections, other), the examiner listed general muscle cramps. As with the March 2007 examination, the examiner did not clearly associate this symptom with the Veteran's non-Hodgkin's lymphoma, and the examiner's ultimate finding that the disease was in remission and that there were no effects of the disease on the Veteran's usual daily activities leaves such an association in doubt. The examiner reported that, during remissions of non-Hodgkin's lymphoma, the Veteran's health was fair, and that there were at that time no signs of active lymphoma. As noted in the Introduction, the Board remanded this issue in August 2010 in part to seek medical guidance as to the presence of residuals and their description. A VA physician addressed the Veteran's assertions as to residuals in the September 2011 opinion. While the physician acknowledged that some of the claimed symptoms may have been present initially, at the time of diagnosis, and in relation to some of the treatments, he found that symptoms of weakness, fatigue, flu like symptoms, chills, fever, night sweats, eye infections, diarrhea, shoulder problems, heart problems, cystic formations in the face, muscle cramps, pain in the left foot, and blistering were non specific and not adequately documented to conclude any relation to the diagnosis or treatment of the lymphoma. The Board emphasizes that a finding by a clinician that symptoms are not adequately documented does not imply that the clinician does not believe the Veteran's assertions. The Board accepts the physician's reasoning at face value, i.e., that there is an insufficient evidentiary basis to establish an etiological relationship between the Veteran's various complaints and his non-Hodgkin's lymphoma. The VA physician clearly acknowledged the Veteran's complaints, and there is no suggestion that any were disbelieved. The Board acknowledges that the Veteran disagrees with the findings of the VA physician. His assertions, including his hearing testimony, have repeatedly emphasized the effect of fatigue and his belief that this is related to his non-Hodgkin's lymphoma. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), identifying an etiological relationship between the symptoms claimed in this case and a disease entity such as non-Hodgkin's lymphoma 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). The Board finds the opinion of the VA physician on this point to be more persuasive than the Veteran's assertions that his various physiologic complaints are etiologically related to his non-Hodgkin's lymphoma. Accordingly, the Board concludes that there are no additional nonservice-connected residuals to be rated during the periods of remission of non-Hodgkin's lymphoma. The Veteran generally disagrees with the basis for the reduction. He has asserted that complete remission is determined when all signs of the disease have disappeared, and that he will never be in complete remission because the disease can reappear at any time and that his doctor has informed him that complete remission cannot be determined until at least five years after treatment. The Board finds that this mischaracterizes the requirements for continuation of a 100 percent rating. Complete remission and cure of the underlying disease are not required to reduce a 100 percent rating. The criteria contemplate that a 100 percent rating will only be assigned with active disease or during a treatment phase. If a recurrence of the disease is shown such that treatment is again necessary, a 100 percent rating would again be warranted, however, only for the duration of the active or treatment phase of the disease. This is entirely consistent with and contemplated by the rating criteria. On the VA Form 9, the Veteran objected to the fact that, upon each subsequent recurrence, he would have to follow the time-consuming process of reopening the claim. The Board simply notes that the law and regulations governing VA disability compensation require not only that there is underlying entitlement to the compensation sought, but that requests for increased compensation based on an increase in disability are presented through claims, formal and informal, including receipt of records of outpatient or hospital treatment under 38 C.F.R. § 3.157 (2013). In short, the inconvenience of filing a claim is not a basis to restore the 100 percent rating, but is a situation entirely contemplated by VA law. The Board has considered whether the Veteran's appeal includes an increased rating claim for non-Hodgkin's lymphoma, and concludes that it does not. The rating schedule for non-Hodgkin's lymphoma does not include intermediate ratings for the disease, but includes only a 100 percent rating during active and treatment phases and a 0 percent rating during remissions. The instruction to separately rate residuals during phases of remission is in some sense a means of providing intermediate ratings during these periods. As discussed above, the Veteran is separately service connected and rated for various residuals of non-Hodgkin's lymphoma. There are no active appeals as to these ratings. Based on the opinion expressed in the September 2011 report, there are no additional residuals that are not already service connected. To summarize the Board's findings here, when viewed in the context of all of the evidence of record at the time of the reductions in 2004 and 2010, the Board finds that the remissions in the active phase of the disease and the switch from treatment phase to maintenance phase represent real improvements in the Veteran's ability to function under the ordinary conditions of life and work. To the extent contemplated by the rating criteria, those improvements were expected to continue. Accordingly, the Board finds that the corresponding reductions were proper, and that restoration of the 100 percent rating from October 1, 2007 to December 15, 2008 and from February 1, 2010 is not warranted. The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Here, the issue on appeal did not arise from an "application" as contemplated in 38 U.S.C.A. § 5103(a). Rather, the RO adjudicated the issue on its own in light of an anticipated VA review examination. Thus, the issue on appeal here is not subject to the VCAA notification requirements. The Board also notes that the notification provisions of 38 C.F.R. § 3.105 were followed in regard to the rating reduction. The notice provided to the Veteran under these provisions informed him of the type of evidence necessary to substantiate a continuance of the 100 percent rating for non-Hodgkin's lymphoma and of the necessity that he either submit or adequately identify such evidence. Thus, to the extent that VCAA notice requirements are applicable, the notice provided under 38 C.F.R. § 3.105 was adequate to fulfill those requirements. When conducting a hearing, a VA hearing officer, to include a Veterans Law Judge, must suggest that a claimant submit evidence on any issue material to substantiating the claim when the record is missing any evidence on that issue or when the testimony at the hearing raises an issue for which there is no evidence in the record. See Bryant v. Shinseki, 23 Vet. App. 488 (2010); 38 C.F.R. § 3.103 (2011). The hearing officer also must suggest the submission of evidence when testimony during the hearing indicates that it exists (or could be reduced to writing) but is not of record. Here, during the hearing, the symptomatology believed by the Veteran to be associated with his non-Hodgkin's lymphoma was discussed in detail, and testimony concerning his level of impairment was elicited. The Veterans Law Judge inquired as to the effect of the claimed symptoms on the Veteran's daily life. Such actions supplement the VCAA and comply with 38 C.F.R. § 3.103. The Board is also satisfied VA has made reasonable efforts to obtain relevant records and evidence. Specifically, the information and evidence that has been associated with the claims file includes the Veteran's service treatment records, post-service VA treatment records and all private treatment records identified by the Veteran, as well as the Veteran's written assertions and personal hearing testimony. While the Veteran testified that he was on "social security," this was not due to disability, but due to age eligibility. In addition, the Veteran was afforded several VA examinations to address whether there had been remission of his non-Hodgkins lymphoma. The RO supplemented these examinations with an expert medical opinion in September 2011. The Board finds that this evidence is adequate because it addresses the evidence in the claims file in detail, it addresses the questions of whether and when there were remissions, and it addresses the residuals claimed by the Veteran to be associated with his non-Hodgkins lymphoma. As noted above, this appeal involves a remand by the Board for additional evidentiary development. A remand by the Board confers on the claimant, as a matter of law, the right to compliance with the remand orders. Stegall v. West, 11 Vet. App. 268, 271 (1998). While substantial compliance is required, strict compliance is not. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) citing Dyment v. West, 13 Vet. App. 141, 146-47 (1999). In this case, the RO substantially complied with the Board's August 2010 remand instructions by asking the Veteran to sign the appropriate releases permitting VA to obtain his medical records from his private physician. In September 2010, the Veteran identified treatment from six private providers. The Board specified in its remand instructions that records from Dr. Behrmann should be requested, and the Veteran indicated that these would be included in records from Advanced Medical Specialists. The RO requested records from each of the identified providers in October 2010. In November 2010, requested records from MDHS Surgery & Skin Laser Center, Dr. Michael Margulies, Advanced Medical Specialists, Gastroenterology Care Center, Cohen Madorsky, and Miami Cardiology Group were received. The RO also arranged for a VA opinion describing all residuals that are related to non-Hodgkin's lymphoma. The reviewing clinician identified the periods during which non-Hodgkin's lymphoma was an active disease or undergoing a treatment phase, and addressed whether the Veteran's non-Hodgkin's lymphoma resulted in weakened immunity or a distinct immunity disorder which caused additional disability. These actions are in substantial compliance with the Board's instructions and no additional development is necessary. ORDER Restoration of a 100 percent disability rating for the service connected non-Hodgkin's lymphoma from October 1, 2007 to December 15, 2008, and from February 1, 2010 to present is denied. ____________________________________________ MICHELLE L. KANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs