Citation Nr: 1339173 Decision Date: 11/27/13 Archive Date: 12/13/13 DOCKET NO. 07-09 983 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUES 1. Entitlement to service connection for glaucoma, to include as secondary to service-connected diabetes mellitus, chronic renal insufficiency, and/or coronary artery disease. 2. Entitlement to service connection for hypertensive vascular disease, to include as secondary to service-connected diabetes mellitus, chronic renal insufficiency, and/or coronary artery disease. 3. Entitlement to a disability rating in excess of 20 percent for diabetes mellitus, type II, for the period beginning December 30, 2009. REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL Appellant and his spouse ATTORNEY FOR THE BOARD David Gratz, Counsel INTRODUCTION The Veteran had active service from April 1965 to March 1967. He served in the Republic of Vietnam from September 1965 to September 1966. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2006 rating decision of the Department of Veterans Affairs (VA), Regional Office (RO), in Detroit, Michigan, that granted service connection for diabetes mellitus and denied service connection for hypertension. This matter also comes before the Board on appeal from a December 2007 rating decision of the RO that denied service connection for glaucoma. In March 2008, the Veteran and his spouse testified at a hearing at the RO before a Decision Review Officer (DRO). In June 2009, the Veteran and his spouse testified at a personal hearing over which the undersigned presided while at the RO. A transcript of each hearings has been associated with the claims file. This matter was previously before the Board in August 2009 and September 2011 at which time it was remanded for additional development. It is now returned to the Board. In August 2012, the Veteran submitted additional evidence with a waiver of Agency of Original Jurisdiction (AOJ) consideration. Therefore, the Board may properly consider such newly received evidence. 38 C.F.R. § 20.1304(c) (2013). In addition to the paper claims file, there is a Virtual VA paperless claims file associated with the Veteran's claim. A review of the documents in such file reveals that they are either duplicative of the evidence in the paper claims file or are irrelevant to the issues on appeal. The Board also notes that entitlement to a total disability rating based on individual unemployability (TDIU) was denied by the RO in September 2013. The United States Court of Appeals for Veterans Claims (Court) has held that, generally, a claim for a TDIU exists as part of a claim for an increased disability rating. See Rice v. Shinseki, 22 Vet. App. 447 (2009). In Locklear v. Shinseki, 24 Vet. App. 311, 315 (2011), however, the Court distinguished the circumstances of certain cases from Rice where VA has specifically separated adjudication of the schedular disability rating from the adjudication of entitlement to a TDIU. The Court in Locklear held that "[b]ifurcation of a claim generally is within the Secretary's discretion." Id. Here, because entitlement to TDIU was denied in the September 2013 rating decision, and the Veteran has not appealed that issue, entitlement to a TDIU based in part on other service-connected disabilities is not currently before the Board. The issues of service connection for glaucoma and for hypertensive vascular disease, each to include as secondary to service-connected diabetes mellitus, chronic renal insufficiency, and/or coronary artery disease, are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDING OF FACT For the period beginning December 30, 2009, the Veteran's diabetes mellitus has been manifested by the need for oral medication and a restricted diet, but does not require regulation of activities. CONCLUSION OF LAW The criteria for a disability rating in excess of 20 percent for diabetes mellitus, type II, for the period beginning December 30, 2009, have not been met. 38 U.S.C.A. §§ 1155, 5103, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.7, 4.119, Diagnostic Code 7913 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION VA's Duties to Notify and Assist VA has a duty to provide notification to the Veteran with respect to establishing entitlement to benefits, and a duty to assist with development of evidence under 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159(b). With respect to the issue of entitlement to a disability rating in excess of 20 percent for diabetes mellitus, type II, as of December 30, 2009, this claim arises from a disagreement with the initial disability rating that was assigned following the grant of service connection. Courts have held that once service connection is granted the claim is substantiated, additional notice 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). Additionally, VA provided the Veteran with notice of the type of evidence necessary to establish a disability rating or effective date for the disability under consideration, pursuant to the holding in Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd, Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007), in June 2010. Accordingly, the Board finds that VA satisfied its duty to notify under the VCAA in accordance with 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)(1). VA also has a duty to assist the Veteran in the development of the claims. This duty includes assisting the Veteran in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all relevant facts have been properly developed, and that all available evidence necessary for equitable resolution of the issue has been obtained. The Veteran's service treatment records, VA and private treatment records, Social Security Administration records, and lay statements have been obtained. A VA medical opinion will be considered adequate if it (1) is based upon consideration of the Veteran's prior medical history, (2) describes the disability in sufficient detail so that the Board's "'evaluation of the claimed disability will be a fully informed one,'" Ardison v. Brown, 6 Vet.App. 405, 407 (1994) (quoting Green v. Derwinski, 1 Vet.App. 121, 124 (1991)), and (3) "supports its conclusion with an analysis that the Board can consider and weigh against contrary opinions." Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The Board finds that the December 2009, January 2010, and November 2011 examination reports as to the Veteran's diabetes mellitus, type II, are adequate because the examiners discussed the Veteran's medical history, described the service-connected disability and its effect on employability in sufficient detail, and supported all conclusions with analysis and, where possible, objective test results. This claim was remanded by the Board for additional development in August 2009 and September 2011. There has been substantial, if not full, compliance with the Board's remand directives, insofar as VA has requested additional treatment records and lay statements. Additionally, VA provided the Veteran with new examinations in January 2010 and November 2011. D'Aries v. Peake, 22 Vet. App. 97 (2008); Stegall v. West, 11 Vet. App. 268 (1998). The Veteran has testified at personal hearings before a DRO (March 2008) and a Veterans Law Judge of the Board (June 2009) in which he presented oral argument in support of his claim. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that the Veterans Law Judge and DRO that chairs the hearings fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the hearings, the Veterans Law Judge and DRO did not note the bases of the prior determinations or the elements that were lacking to substantiate the claims. However, they each asked specific questions directed at identifying whether the Veteran had symptoms meeting the schedular criteria for a higher disability rating. The VLJ and DRO did not specifically seek to identify any pertinent evidence not currently associated with the claim. This was not necessary, however, because the Veteran volunteered his treatment history and symptoms since service. Accordingly, the Veteran is not shown to have been prejudiced on this basis. Finally, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has he identified any prejudice in the conduct of the Board or DRO hearing. By contrast, the hearings focused on the elements necessary to substantiate the claim, and the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claim. As such, the Board finds that, consistent with Bryant, the Veterans Law Judge and DRO complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). The Veteran has not indicated there are any additional records that VA should seek to obtain on his behalf. Thus, the Board finds that VA made reasonable efforts to satisfy its duty assist and to obtain evidence necessary to substantiate the Veteran's claim. No further assistance to develop evidence is required. Increased Disability Rating for Diabetes Mellitus from December 30, 2009 As an initial matter, the Board notes that the issue of entitlement to an initial disability rating in excess of 10 percent for diabetes mellitus for the period from February 14, 2004, to December 30, 2009, was adjudicated in the Board's September 2011 decision. As such, this appeal is limited to the issue of entitlement to a disability rating in excess of 20 percent for diabetes mellitus, type II, for the period beginning December 30, 2009. Disability ratings are intended to compensate impairment in earning capacity due to a service-connected disorder. 38 U.S.C.A. § 1155. Separate diagnostic codes identify the various disabilities. Id. It is necessary to rate the disability from the point of view of the Veteran working or seeking work, 38 C.F.R. § 4.2, and to resolve any reasonable doubt regarding the extent of the disability in the Veteran's favor. 38 C.F.R. § 4.3. If there is a question as to which disability rating to apply to the Veteran's disability, the higher rating will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2013). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2 (2013); Peyton v. Derwinski, 1 Vet. App. 282 (1991). While the Veteran's entire history is reviewed when assigning a disability rating, 38 C.F.R. § 4.1, where service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). However, when appealing the initial assignment of a disability rating, the severity of the disability is to be considered during the entire period from the initial assignment of the disability rating to the present time. Fenderson v. West, 12 Vet. App. 119 (1999). Additionally, in determining the present level of a disability for any increased rating claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. 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 an individual's relevant medical history, the current diagnosis and demonstrated symptomatology. Any change in a diagnostic code by VA must be specifically explained. Pernorio v. Derwinski, 2 Vet. App. 625 (1992). Words such as "moderate," "moderately severe," and "severe" are not defined in the Rating Schedule. 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). Use of terminology such as "severe" by VA examiners and others, although evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6 (2013). It is possible for a Veteran to have separate and distinct manifestations from the same injury that would permit rating under several diagnostic codes; however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); 38 C.F.R. § 4.14 (2013) (precluding the assignment of separate ratings for the same manifestations of a disability under different diagnoses). The Veteran contends in his October 2006 notice of disagreement that a higher initial disability rating is warranted for his service-connected diabetes mellitus, type II. At his June 2009 Board hearing, he reported that he would take insulin when in the hospital, but not otherwise. See June 2009 transcript, pp. 22-23. The Veteran's spouse further described his symptoms and reported that his private doctor intended to talk with him about taking oral medication for his diabetes. Id. The Veteran also reported that he was on a restricted diet, and had been instructed to regulate his activities insofar as he was not supposed to lift anything heavier than 20 pounds. Id., pp. 24-25. The Veteran's service-connected diabetes mellitus, type II, has been rated as 20 percent disabling under 38 C.F.R. § 4.119, Diagnostic Code 7913, which provides the rating criteria for diabetes mellitus. Under 38 C.F.R. § 4.119, Diagnostic Code 7913, a 20 percent disability rating applies where diabetes requires insulin and restricted diet, or; oral hypoglycemic agent and restricted diet. A 40 percent disability rating is warranted where the diabetes requires insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities). A 60 percent disability rating is warranted where the diabetes requires insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately rated. A 100 percent rating applies where the diabetes requires more than one daily injection of insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately rated. After review of the record, the Board finds that the most probative evidence of record demonstrates that the Veteran's diabetes mellitus, type II, does not require the regulation of activities. In a December 2009 VA genitourinary examination, the examiner documented that the Veteran's VA medical records verify that his diabetes mellitus requires diet only for control, and that he takes no medications for his diabetes mellitus. However, subsequent VA treatment reports show that VA clinicians prescribed Metformin for the Veteran's diabetes mellitus in December 2009 and January 2010. A January 2010 VA examination report shows that the Veteran reported that he was following a diabetic diet and taking oral antidiabetic medications. He denied taking insulin injections. He denied experiencing ketoacidosis or hypoglycemic episodes, or frequent hospitalizations for the management of his diabetes. The diagnosis was adult-onset diabetes mellitus in good glycemic control with a restricted diet and oral antidiabetic medications. The examiner opined that the Veteran's medical conditions were not likely preventing him from doing his daily routine activities and light-duty sedentary jobs. In August 2010, the Veteran's private clinician, G. Boyer, M.S., P.A.-C, documented that the Veteran required a strict diet as well as oral medications for his diabetes mellitus. A VA examination report dated in October 2011 shows that the examiner documented that the Veteran was prescribed insulin of more than one injection per day. The examiner further documented that the Veteran did not require regulation of activities as part of medical management of his diabetes mellitus. The diagnosis was diabetes mellitus, type II. The examiner opined that the diabetes mellitus did not impact his ability to work. After reviewing all of the clinical and lay evidence of record throughout the appellate period, the Board finds that the preponderance of the evidence shows that a disability rating in excess of 20 percent for the Veteran's diabetes mellitus, type II, for the period beginning December 30, 2009, is not warranted under 38 C.F.R. § 4.104, Diagnostic Code 7913 because the Veteran's diabetes mellitus does not require regulation of activities. While acknowledging the Veteran's lay statements to the contrary, the Board finds that the October 2011 VA examiner's determination that the Veteran does not require regulation of activities as part of the medical management of his diabetes mellitus warrants greater probative weight because of the examiner's greater medical expertise. Furthermore, there is no finding by any clinician, VA or private, in any of the Veteran's treatment records that his diabetes mellitus requires regulation of activities. Buczynski v. Shinseki, 24 Vet.App. 221, 224 (2011) (noting that where there is a lack of notation of medical condition or symptoms where such notation would normally be expected, the Board may consider this as evidence that the condition or symptoms did not exist). The Veteran has not provided any competent medical evidence to rebut the opinions against the claim or otherwise diminish their probative weight. See Wray v. Brown, 7 Vet. App. 488, 492-93 (1995). Moreover, in light of both the numerous VA and private treatment records in the claims file and the October 2011 VA examiner's determination, the Board finds that the Veteran's report of clinician-instructed regulation of activities is of limited probative value. The Board finds that assigning a disability rating in excess of 20 percent for diabetes mellitus, type II, absent fulfillment of the criteria that the diabetes requires the regulation of activities is contrary to applicable regulations. Middleton v. Shinseki, 727 Vet.App. 1172 (Fed. Cir. 2013); Camacho v. Nicholson, 21 Vet.App. 360, 363-64 (2007). Compensable complications of diabetes are rated separately unless they are part of the criteria used to support a 100 percent disability rating. Noncompensable complications are considered part of the diabetic process under Diagnostic Code 7913. In this case, the Veteran is already rated separately for associated chronic renal insufficiency, coronary artery disease, peripheral neuropathy of the extremities, and erectile dysfunction. Based upon the above evidence of record, the Veteran's diabetes is appropriately rated as 20 percent disabling, for the period beginning December 30, 2009. The Board has considered whether additional staging of the disability is warranted, however, the Veteran's symptoms remained constant throughout the course of the period on appeal, as such, an additional staged ratings is not warranted. In conclusion, the Board finds that the preponderance of the evidence is against a disability rating higher than 20 percent for diabetes mellitus, type II, for the period beginning December 30, 2009. Hence, the doctrine of reasonable doubt is not for application, see 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990), and the appeal is denied. Extra-schedular Consideration 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 extra-schedular 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 extra-schedular 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). Here, the applicable rating criteria adequately contemplate the manifestations of the Veteran's diabetes mellitus, type II-namely, oral medication and a restricted diet. The rating criteria are therefore adequate to rate the diabetes mellitus, type II, and referral for consideration of an extraschedular rating is not warranted. ORDER A disability rating in excess of 20 percent for diabetes mellitus, type II, for the period beginning December 30, 2009, is denied. REMAND After carefully considering this matter, and for reasons expressed immediately below, the Board believes that the issues of service connection for glaucoma and for hypertensive vascular disease, both to include as secondary to service-connected diabetes mellitus, chronic renal insufficiency, and/or coronary artery disease, must be remanded for further development of the record. The Board regrets the delay associated with this remand, especially considering that this matter was the subject of two previous remands. However, another remand is necessary to ensure that the Veteran is accorded full compliance with the statutory duty to assist, specifically, in order to obtain a medical opinion which fully addresses the questions set forth in the Board's September 2011 remand. D'Aries v. Peake, 22 Vet. App. 97 (2008); Stegall v. West, 11 Vet. App. 268 (1998). In the September 2011, the Board requested that a VA medical opinion be obtained as to "whether glaucoma or hypertension [is] related to [diabetic] renal insufficiency," and as to "whether the Veteran's [glaucoma or] hypertension is due to his service connected cardiovascular disease." September 2011 remand, pp. 13-14. With respect to glaucoma, the October 2011 VA examiner checked a box indicating that the Veteran's glaucoma was not secondary to diabetes. He neither specifically addressed diabetic renal insufficiency or cardiovascular disease, nor provided any rationale. With respect to hypertension, the November 2011 VA examiner opined that the Veteran did not have renal insufficiency, and that "coronary artery disease is not the cause or aggravation of hypertension." [Full capitalization removed.] The examiner did not provide a rationale. Additionally, even if the Veteran was asymptomatic as to renal insufficiency at the time of the November 2011 VA examination, the Board notes that the Veteran is currently in receipt of service connection for chronic renal insufficiency, with a disability rating of 60 percent. As such, an opinion is required as to whether chronic renal insufficiency, during its active period(s), caused or aggravates the Veteran's glaucoma or hypertension. It is inadequate to base a negative nexus opinion solely on the absence of the service-connected renal insufficiency unless a medical explanation is provided explaining why the Veteran's diagnosis of renal insufficiency has been in error throughout the pendency of the claims-i.e., for glaucoma, since March 2007, and for hypertension, since February 2005. On remand, separate VA medical opinions as to causation and aggravation by both renal insufficiency and cardiovascular disease for both glaucoma and hypertension must be obtained. Allen v. Brown, 7 Vet. App. 439 (1995). Moreover, all of the requested opinions must be accompanied by medical rationales. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Horn v. Shinseki, 25 Vet. App. 251 (2012). Finally, as this matter is being remanded for the reasons set forth above, any additional VA treatment records of the Veteran for his asserted disabilities should also be obtained. See 38 U.S.C.A. § 5103A(b), (c); 38 C.F.R. § 3.159(b); see also Bell v. Derwinski, 2 Vet. App. 611 (1992) (VA medical records are in constructive possession of the agency, and must be obtained if the material could be determinative of the claim). Accordingly, the case is REMANDED for the following action: 1. The RO/AMC shall ask the Veteran to identify all locations of VA treatment or evaluation for his asserted disabilities and contact each VA medical facility identified by the Veteran to obtain ongoing medical treatment records pertaining thereto. All records obtained must be associated with the Veteran's claims file. 2. The RO/AMC shall obtain an addendum to the October 2011 VA examination report, preferably from the original examiner. The claims file and a copy of this Remand must be made available to the reviewing examiner, and the examiner shall indicate in the addendum report that the claims file was reviewed. If the original examiner is no longer available to provide requested opinion, another equally qualified VA examiner shall provide the necessary additional opinion. The need for an additional examination of the Veteran is left to the discretion of the VA examiner. The examiner is directed to answer all of the following questions as definitively as possible: (a) Is it at least as likely as not that the Veteran's glaucoma and hypertensive vascular disease diagnosed over the course of this appeal are etiologically related to the Veteran's period of active service? (b) Is it at least as likely as not that any of the Veteran's diagnosed glaucoma and hypertensive vascular disease were caused (in whole or in part) by a service-connected disability, to include specifically include diabetes mellitus, chronic renal insufficiency, and/or coronary artery disease? (c) Is it at least as likely as not that any of the Veteran's diagnosed glaucoma and hypertensive vascular disease are aggravated (permanently worsened) by a service-connected disability, to include specifically include diabetes mellitus, chronic renal insufficiency, and/or coronary artery disease? In drafting this opinion, the examiner is directed to consider the June 2009 statement of the Veteran's private clinician, D. Tyynisman, FNP-BC, linking the Veteran's glaucoma to his service-connected diabetes; and the April 2006 statement of J. Johnson, D.O., F.A.C.O.S., linking the Veteran's hypertension to his service-connected diabetes. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. If the examiner rejects the Veteran's reports of symptomatology, he or she must provide a reason for doing so. The absence of evidence of treatment for a glaucoma or hypertensive vascular disease in the Veteran's service treatment records cannot, standing alone, serve as the basis for a negative opinion. If the examiner is unable to provide an opinion without resort to speculation, he or she should explain why this is so and what if any additional evidence would be necessary before an opinion could be rendered. The examiner must identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching a conclusion. 3. The RO/AMC will then review the Veteran's claims file and ensure that the foregoing development actions have been conducted and completed in full, and that no other notification or development action, in addition to those directed above, is required. If further action is required, it should be undertaken prior to further claims adjudication. 4. The RO/AMC will then readjudicate the Veteran's claims. If the benefits sought on appeal remain denied, the Veteran and his representative should be provided with a Supplemental Statement of the Case. An appropriate period of time should be allowed for response. Thereafter, if appropriate, the case is to be returned to the Board, following applicable appellate procedure. The Veteran need take no action until he is so informed. He 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). The purposes of this remand are to obtain additional information and comply with all due process considerations. No inference should be drawn regarding the final disposition of this claim as a result of this action. 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). ______________________________________________ DEMETRIOS G. ORFANOUDIS Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs