Citation Nr: 1339636 Decision Date: 12/03/13 Archive Date: 12/18/13 DOCKET NO. 09-21 904 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to a compensable evaluation prior to March 16, 2011, and in excess of 10 percent from March 16, 2011, for morphea. 2. Entitlement to service connection for hemorrhoids. REPRESENTATION Appellant represented by: Georgia Department of Veterans Services WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Joseph R. Keselyak, Counsel INTRODUCTION The Veteran served on active duty from May 2000 to November 2007. This matter comes to the Board of Veterans' Appeals (Board) from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. In a January 2009 rating decision, the RO granted entitlement to service connection for morphea with a noncompensable (zero percent) evaluation and denied entitlement to service connection for hemorrhoids. In a May 2011 rating decision, the RO increased the evaluation of morphea to 10 percent disabling, effective March 16, 2011. Because the maximum benefit was not granted, the issue of entitlement to a higher evaluation remains on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). In June 2013, the Veteran was afforded a hearing before the Board. A transcript of the testimony offered at this hearing has been associated with the record. At the Board hearing, the Veteran requested that the record be held open for 30 days to allow for the submission of additional evidence. See 38C.F.R. § 20.709 (2013). Such evidence was received, but it has not yet been considered by the RO. In this regard, the Board may consider this evidence in the first instance because the Veteran has waived initial RO consideration thereof. See 38 C.F.R. § 20.1304(c) (2013). The issue of entitlement to service connection for hemorrhoids is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Prior to March 16, 2011, the Veteran's morphea affected at least 5 percent of his entire body. 2. During the entire length of the appeal period, the Veteran's morphea did not affect 20 percent or more of the entire body or exposed areas, and it did not require systemic therapy. CONCLUSIONS OF LAW 1. Prior to March 16, 2011, a 10 percent evaluation is warranted for morphea. 38 U.S.C.A. §§ 1155, 5107(a) (West 2002 & Supp. 2013); 38 C.F.R. § 3.102, 3.159, 3.321(b)(1), 4.7, 4.118, Diagnostic Code 7821 (2013). 2. An evaluation in excess of 10 percent is not warranted for morphea. 38 U.S.C.A. §§ 1155, 5107(a) (West 2002 & Supp. 2013); 38 C.F.R. § 3.102, 3.159, 3.321(b)(1), 4.7, 4.118, Diagnostic Code 7821 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Notice and Assistance Upon receipt of a complete or substantially complete application for benefits and prior to an initial unfavorable decision on a claim by an agency of original jurisdiction, VA is required to notify the appellant of the information and evidence not of record that is necessary to substantiate the claim. In the notice, VA will inform the claimant which information and evidence, if any, that the claimant is to provide to VA and which information and evidence, if any, that VA will attempt to obtain on behalf of the claimant. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159 (2011); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Notice should also address the rating criteria and effective date provisions that are pertinent to the appellant's claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). In a case such as this, where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service connection claim has been more than substantiated, it has been proven, thereby rendering 38 U.S.C.A. § 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Dingess v. Nicholson, 19 Vet. App. 473 (2006); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). The appellant bears the burden of demonstrating any prejudice from defective notice with respect to the downstream elements. Goodwin v. Peake, 22 Vet. App. 128 (2008). The Veteran has not alleged any prejudice; thus, that burden has not been met in this case. Nevertheless, the Board notes that VA has fully complied with the notice provisions of 38 U.S.C.A. § 5103(a). In a letter dated in August 2008, the Veteran was advised of how to substantiate his claim for service connection, his and VA's respective duties in developing the claim, and as to the disability rating and effective date elements of his claims. VA has obtained the Veteran's service treatment records, assisted the Veteran in obtaining evidence, afforded the Veteran physical examinations, obtained medical opinions as to the severity of his service-connected morphea, and afforded the Veteran the opportunity to give testimony before the Board. All known and available records relevant to the issue on appeal have been obtained and associated with the Veteran's claims file; and the Veteran has not contended otherwise. The United States Court of Appeals for Veterans Claims (hereinafter 'the Court'') has held that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that VA examinations obtained in this case are adequate. They are predicated on a substantial review of the record and medical findings and consider the Veteran's complaints, symptoms and history. As the examination reports ultimately provide sufficient information such that the Board can render an informed determination, they are adequate. Accordingly, VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issue addressed in this decision has been met. 38 C.F.R. § 3.159(c)(4). VA has substantially complied with the notice and assistance requirements and the Veteran is not prejudiced by a decision on the claim at this time. Laws and Regulations Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2013). Separate rating codes identify the various disabilities. 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability is resolved in favor of the veteran. 38 C.F.R. § 4.3. The VA schedule of ratings will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). 38 C.F.R. Section 3.321(b)(1) provides that, in exceptional circumstances, where the schedular evaluations are found to be inadequate, the veteran may be awarded a rating higher than that encompassed by the schedular criteria. According to the regulation, an extraschedular disability rating is warranted upon a finding that "the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards." Id. Both the use of manifestations not resulting from service-connected disease or injury in establishing the service-connected evaluation, and the evaluation of the same manifestation under different diagnoses are to be avoided. 38 C.F.R. § 4.14. Notwithstanding the above, VA is required to provide separate evaluations for separate manifestations of the same disability which are not duplicative or overlapping. See Esteban v. Brown, 6 Vet. App. 259, 261 (1994). Where entitlement to compensation 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. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). In addition, an appeal from the initial assignment of a disability rating requires consideration of the entire time period involved, and contemplates "staged ratings" where warranted. See Fenderson v. West, 12 Vet. App. 119 (1999). In claims for VA benefits, VA shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board notes that during the course of the appeal, VA amended the Schedule for Rating Disabilities by revising that portion of the schedule that addresses the skin, so that it more clearly reflects VA's policies concerning the evaluation of scars, and specifically, 38 C.F.R. § 4.118, Diagnostic Codes 7800-7805; however, the amendment is effective for claims filed on and after October 23, 2008. See 73 Fed. Reg. 54708-54712 (September 23, 2008). The Veteran's claim was received in July 2008, and he has not requested review under the revised regulations. See 77 Fed. Reg. 2910-10 (January 20, 2012). Under the applicable criteria, the Veteran's morphea is currently evaluated as noncompensably disabling prior to March 2011, and 10 percent thereafter, pursuant to 38 C.F.R. § 4.118, Diagnostic Code 7821. That code provides for evaluation of cutaneous manifestations of collagen-vascular diseases not listed elsewhere (including scleroderma, calcinosis cutis, and dermatomyositis). Under Diagnostic Code 7821, a 10 percent rating is warranted where at least 5 percent, but less than 20 percent of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas are affected; or, intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs are required for a total duration of less than 6 weeks during the past 12-month period. A 30 percent rating is warranted when 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas are affected, or if systemic therapy such as corticosteroids or other immunosuppressive drugs were required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A maximum 60 percent rating is warranted if more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or if constant or near constant systemic therapy such as corticosteroids or other immunosuppressive drugs were required during the past 12-month period. Notably, morphea has been indicated as affecting the neck. Diagnostic Code 7800 provides ratings for disfigurement of the head, face, or neck. Note (1) to Diagnostic Code 7800 provides that the 8 characteristics of disfigurement, for purposes of rating under 38 C.F.R. § 4.118, are: Scar is 5 or more inches (13 or more cm.) in length. Scar is at least one-quarter inch (0.6 cm.) wide at the widest part. Surface contour of scar is elevated or depressed on palpation. Scar is adherent to underlying tissue. Skin is hypo-or hyper-pigmented in an area exceeding six square inches (39 sq. cm.). Skin texture is abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 sq. cm.). Underlying soft tissue is missing in an area exceeding six square inches (39 sq. cm.). Skin is indurated and inflexible in an area exceeding six square inches (39 sq. cm.). Diagnostic Code 7800 provides that a skin disorder with one characteristic of disfigurement of the head, face or neck is rated 10 percent disabling. A skin disorder of the head, face or neck with visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips; or, with two or three characteristics of disfigurement, is rated 30 percent disabling. A skin disorder of the head, face or neck with visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips); or, with four or five characteristics of disfigurement, is rated 50 percent disabling. A skin disorder of the head, face or neck with visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips); or, with six or more characteristics of disfigurement, is rated 80 percent disabling. Note (2) to Diagnostic Code 7800 provides that tissue loss of the auricle is to be rated under Diagnostic Code 6207 (loss of auricle), and anatomical loss of the eye under Diagnostic Code 6061 (anatomical loss of both eyes) or Diagnostic Code 6063 (anatomical loss of one eye), as appropriate. Note (3) provides that un-retouched color photographs are to be taken into consideration when rating under these criteria. 38 C.F.R. § 4.118. Facts The Veteran filed his claim for service connection for morphea in July 2008. In September 2008 he was afforded a VA examination. At the time of the examination, he complained of a "patch of spots on [his] side," that never went away and sometimes itched. He denied any past or present treatment, as well as any functional limitations or episodes of incapacitation related to the condition. Examination of the skin showed multiple lentigos on the upper torso and lower extremities with evidence of seborrheic keratosis on the back. There were several small brown macules on the right ribcage area. Both feet had intact skin. Morphea affecting zero percent of exposed body and .5% of the entire body was assessed. In March 2009, the Veteran submitted a Notice of Disagreement (NOD) with respect to the RO's assignment of a noncompensable evaluation of morphea. In the NOD, he explained that he felt that morphea covered at last 5 percent of his entire body. He related that he had morphea on his right forearm, the back of his neck, his back and most of his torso. He stated that the area covered was at least 5 percent of his entire body and that the condition should be rated at least 10 percent. In a June 2009 Substantive Appeal (VA Form 9) the Veteran reiterated his contentions and asserted that the condition covered a large portion of his body, i.e. more than 5 percent. On March 16, 2011, he was afforded another VA examination of the skin. In terms of medical history, the examination report notes that the condition was diagnosed in 2007 and was constant, stable and not progressive. The Veteran also reported intermittent itching of the spots, and denied any functional limitations or episodes of incapacitation due to the condition. Examination showed a 4 cm. x 5 cm. patch of light brown oval shaped spots on the right forearm, and a 2.5 cm. x 3 cm. patch on the left upper chest. There was a large palpable fibrotic ring with a clear center that extended from the upper chest to the abdomen. There was a linear fibrotic lesion on the right and left anterior neck, with the right measuring 4 cm. x 0.2 cm. and the left measuring 6 cm. x 0.3 cm. There were also multiple scattered freckles on the chest, back and arms. The examiner assessed morphea affecting 3.125 percent of exposed body and 8 percent of entire body. Notably, the examiner that conducted this examination is the same that conducted the September 2008 VA examination. In June 2013, the Veteran testified before the Board. At this time, he discussed whether the claim had been assigned the correct effective date, noting that the claim should be granted effective the date following his discharge. He also testified as to the manifestations and history of morphea. In this regard, he testified that the condition appeared on his right forearm, back, neck and torso. He described that it affected more than 5 percent of his body. He described about a 9 in. x 9 in. spot on his left side, as well as a 9 in. x 4 in. area on his right torso. He described that the condition was almost black in spots and raised in others. He related that the condition had remained stable since its manifestation in the military and had remained the same size. He testified that he had been advised by treating doctors there was no treatment, including medication, for the condition and that it was something he had "to live with." He related that he had pictures of the affected areas and agreed to submit them following the hearing. He waived initial RO consideration of the pictures, as well. In regard to the pictures, the Board has reviewed them. They show that the condition affects the Veteran's left torso, in an area measuring about 9 in. x 9 in, his right torso, in an area measuring 7 in. x 5 in. from top to bottom, his lower right torso in an area measuring about 2 in. x 4 in., his right underarm/back in an area measuring about 3 in. x 3 in., and his right forearm in an area measuring about 6 in. x 3 in. In terms of measurements, the Board is utilizing the tape measure reflected in the pictures, although in each picture the Veteran has provided only one dimension of measurement. Analysis Initially, the Board will address the Veteran's assertions regarding the effective date of his claim for clarification purposes only, as this issue is not on appeal. In July 2008, the Veteran brought his claim for service connection. In a January 2009 rating decision, the RO granted the Veteran's claim for service connection of morphea, and assigned a noncompensable evaluation, effective November 17, 2007, the date of the day following the Veteran's discharge from active duty. See DD Form 214. Thus, despite a noncompensable rating being assigned, service connection was, in fact, granted as of the date after his discharge. In the case of an original service connection claim either the date of the day following discharge or the date of claim may be awarded. 38 C.F.R. § 3.400. Thus, the Board notes that the earliest effective date possible has been granted. Turning to the issue on appeal, that of the rating for the service-connected disability, the Board concludes that a 10 percent evaluation is warranted prior to March 16, 2011. In this regard, the Board acknowledges that the September 2008 VA examination report notes that zero percent of the exposed body and 0.5 percent of the entire body was affected by the condition. However, the Veteran has competently related that the condition has affected about 5 percent of his total body and has remained constant since the initial manifestations of the condition in service. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (explaining in footnote 4 that a Veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). Notably, the March 16, 2011, VA examination report documents an assessment of morphea affecting 3.125 percent of exposed body and 8 percent of entire body, and the examiner did measure the areas. Thus, the Veteran's lay description and provided pictures appear consistent with the documented observations of the March 2011 VA examiner. As noted above, with at least 5 percent, but less than 20 percent of the entire body or of exposed areas affected, a 10 percent, but no greater evaluation is warranted. Thus, as the evidence shows that 8 percent of the entire body is affected, and the Veteran's competent lay testimony indicates that this has been constant throughout the relevant period, a 10 percent evaluation is warranted prior to March 16, 2011. Because the Board has granted entitlement to a 10 percent evaluation prior to March 16, 2011, the issue of entitlement to an evaluation in excess of 10 percent for the entire relevant period remains. The next available schedular evaluation of 30 percent is warranted when 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas are affected, or if systemic therapy such as corticosteroids or other immunosuppressive drugs were required for a total duration of six weeks or more, but not constantly, during the past 12-month period. The maximum schedular evaluation of 60 percent is warranted when more than 40 percent of the entire body or more than 40 percent of exposed areas are affected, or if constant or near constant systemic therapy such as corticosteroids or other immunosuppressive drugs were required during the past 12-month period. Here, the Veteran's condition has never required systemic therapy, and examination has never shown that approximately 20 percent or more of the entire body or exposed areas are affected. The Veteran has not described that such an area is affected and has largely asserted that a 10 percent evaluation is warranted. Absent such findings during the relevant period, the Board does not find that the evidence is at least balanced such that an evaluation in excess of 10 percent is warranted. The Board notes the potential applicability of Diagnostic Code 7800. However, to the extent that application of this diagnostic code would not be viewed as pyramiding, it cannot provide for an evaluation in excess of 10 percent, or even a compensable evaluation. In this regard, the Board notes that the condition has manifested on the Veteran's neck by pigmentation changes. The area affecting the neck measures 2.6 sq. cm. in total, as shown by VA examination in March 2011. Thus, it does not approximate 39 sq. cm. Accordingly, this diagnostic code would not yield an increased evaluation. 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). According to the regulation, an extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1) (2013). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must first determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the service-connected morphea is inadequate. A comparison between the level of severity and symptomatology of the Veteran's condition with the established criteria shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. The rating criteria specifically contemplate the Veteran's symptomatology as well as economic impairment. In short, there is nothing in the record to indicate that the service-connected disability on appeal causes impairment over and above that which is contemplated in the assigned evaluation. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (noting that the disability rating itself is recognition that industrial capabilities are impaired). The Board, therefore, has determined that referral of this case for extraschedular consideration pursuant to 38 C.F.R. 3.321(b)(1) is not warranted. ORDER Entitlement to a 10 percent evaluation, but no greater, morphea is granted for morphea prior to March 16, 2011, subject to regulations applicable to the payment of monetary benefits. Entitlement to an evaluation in excess of 10 percent for morphea is denied. REMAND The Veteran claims that he incurred hemorrhoids in service, but did not receive any treatment for the condition in service. His service treatment records document no hemorrhoids at entrance. See May 2000 Report of Medical Examination. Likewise, his service treatment records document no complaints, diagnosis or treatment of hemorrhoids. In November 2008, the Veteran was afforded a VA examination. At the time of the examination, he complained of intermittent rectal bleeding, anal itching and painful bowel movements, with flare-ups occurring about 1 to 2 times per month, lasting a few days to 1 week. He explained that he had had such symptoms in service, but denied seeking medical treatment for these. Examination resulted in an assessment of personal history of hemorrhoids and rectal examination was negative for palpable hemorrhoids. Of record is a May 2009 private report of a colonoscopy. The report contains an assessment of hematochezia from minor hemorrhoidal disease. In furtherance of attempting to substantiate the claim for service connection of hemorrhoids, the Veteran submitted a July 2013 letter from W.S.W., M.D. In the letter, Dr. W. relates that the Veteran "has had hemorrhoids, with occasional episodes of bleeding since 2009. Dr. W. stated also that the Veteran still showed "evidence of previous hemorrhoidal disease" and that it is "possible that this could be service[-]connected due to excessive abdominal straining during his active duty time." At his September 2013 Board hearing, the Veteran related that he had been diagnosed as having hemorrhoids in 2009. He explained that he did have hemorrhoid symptoms in service, but that he only used over the counter medications. He testified that due to embarrassment, he never sought any treatment for his symptoms in service. In Barr v. Nicholson, 21 Vet. App. 303, 311 (2007), the United States Court of Appeals for Veterans Claims (Court) found that once VA undertakes the effort to provide an examination when developing a service-connection claim, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided. In Stefl v. Nicholson, 21 Vet. App. 120 (2007), the Court found that, "[w]ithout a medical opinion that clearly addresses the relevant facts and medical science, the Board is left to rely on its own lay opinion, which it is forbidden from doing." Pursuant to 38 C.F.R. § 4.2 (2013), it is incumbent upon the rating board to return an examination report as inadequate if it does not contain sufficient detail. The Veteran should be afforded a new VA examination to address the etiology of his claimed hemorrhoids. The November 2008 VA examination report of record is now inadequate, in light of the subsequent evidence received, i.e., the Veteran's credible testimony regarding in-service symptoms, and the May 2009 colonoscopy noting minor hemorrhoidal disease. Furthermore, although couched in speculative terms, the July 2013 medical opinion tends to associate the hemorrhoids with service. Thus, a thorough examination and opinion are required to address this evidence. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA examination by an appropriate medical professional for the purpose of ascertaining the presence, nature and likely etiology of the Veteran's claimed hemorrhoids. The claims folder should be made available to the medical professional providing the opinion for review in conjunction with rendering the opinion and the examination report should note that the claims file was reviewed. The examiner should obtain a complete, pertinent history from the Veteran, to include relevant symptoms in service. Based upon the examination and a review of the record, the examiner should provide an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that hemorrhoids, if present at any time following the Veteran's discharge, are attributable to service. Review of the entire file is required; however, attention is invited to Veteran's credible reports of in-service symptoms, the May 2009 colonoscopy, and the July 2013 attempted nexus opinion. In rendering any requested opinion, the examiner must specifically acknowledge and discuss the competent and credible lay evidence reported by the Veteran. The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. Any and all opinions must be accompanied by a discussion of the underlying reasons. If the examiner is unable to reach an opinion without resort to speculation, he or she should explain the reasons for this inability and comment on whether any further tests, evidence or information would be useful in rendering an opinion. 2. After the development requested above has been completed to the extent possible, review the record and readjudicate the Veteran's claim. If the benefits sought on appeal remain denied, the Veteran and his representative should be furnished a Supplemental Statement of the Case (SSOC) and given the opportunity to respond thereto before this case is returned to the Board. (CONTINUED ON NEXT PAGE) The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board 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). ______________________________________________ BETHANY L. BUCK Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs