Citation Nr: 1417220 Decision Date: 04/17/14 Archive Date: 05/02/14 DOCKET NO. 10-46 967 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Whether new and material evidence has been received to reopen a previously denied claim for service connection for posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for PTSD. 3. Entitlement to service connection for an acquired psychiatric disorder, to include delusional disorder and anxiety disorder. 4. Entitlement to service connection for urinary incontinence. REPRESENTATION Veteran represented by: Missouri Veterans Commission ATTORNEY FOR THE BOARD Sara Kravitz, Associate Counsel INTRODUCTION The Veteran served on active duty from May 1967 to January 1969. This case comes before the Board of Veterans' Appeals (the Board) on appeal from a March 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri, which in part denied the Veteran's claims for service-connection for PTSD and urinary incontinence. The Board notes that the Veteran's specific claim related to service connection for PTSD. The United States Court of Appeals for Veterans Claims (Court) has held that a veteran, who is a lay person, is not competent to diagnose his specific psychiatric disability. Therefore, VA must consider whether the Veteran's psychiatric symptoms, regardless of the label attached to them, warrant service connection. Clemons v. Shinseki, 23 Vet. App. 1 (2009). During the Veteran's September 2010 VA mental health examination, he was diagnosed with delusional disorder and anxiety disorder. Accordingly, the issues have been recharacterized to include service connection for an acquired psychiatric disability, to include delusional disorder and anxiety disorder. The issue of entitlement to non-service connected pension has been raised by the record in an informal claim submitted in February 2014, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. 38 C.F.R. § 19.9(b) (2013). The Board notes that, in addition to the paper claims file, there are electronic claims files associated with the Veteran's claim. The Board has reviewed the documents in both the paper claims file and the electronic claims files. The issues of service connection for an acquired psychiatric disorder and service connection for urinary incontinence are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDINGS OF FACT 1. In an unappealed decision, dated in April 2008, the RO denied the Veteran's claim for service-connection for PTSD. 2. Assuming its credibility, the evidence associated with the claims file subsequent to the April 2008 decision is neither cumulative nor redundant, and by itself or in connection with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim and raises a reasonable possibility of substantiating the claim of entitlement to service-connection for PTSD. 3. The Veteran does not have a current PTSD diagnosis that conforms to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). CONCLUSIONS OF LAW 1. The April 2008 decision that denied the Veteran's claim for service connection for PTSD is final. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2008). 2. New and material evidence having been presented, the claim for service connection for PTSD, is reopened. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156 (2013). 3. PTSD was not incurred in or aggravated by military service. 38 U.S.C.A. §§ 1110, 1154, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 4.125 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist With respect to the claim for new and material evidence, the Board is reopening the service-connection claim. Therefore, any defect in the notice letter concerning the evidence needed to reopen the claim-or, indeed, any deficiency in VA's compliance with its duty to assist the Veteran-cannot be prejudicial to him. The Board is granting the new and material aspect of the Veteran's appeal in full. Thus, the Board concludes that the notice requirements as they pertain to new and material evidence have been complied with, and that a defect, if any, in providing notice and assistance to the Veteran was at worst harmless error in that it did not affect the essential fairness of the adjudication. Mayfield v. Nicholson, 19 Vet. App. 103, 115 (2005); Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004); Pelegrini v. Principi, 18 Vet. App. 112, 119-120 (2004); Bernard v. Brown, 4 Vet. App. 384 (1993); VAOPGCPREC 16-92. Regarding the merits of the claim for service connection for PTSD, in correspondence dated in September 2009, prior to the March 2010 rating decision, the RO satisfied its duty to notify the Veteran under 38 U.S.C.A. § 5103(a) (West 2002) and 38 C.F.R. § 3.159(b) (2013). Specifically, the RO notified the Veteran of: information and evidence necessary to substantiate the claim; information and evidence that VA would seek to provide; and information and evidence that the Veteran was expected to provide. The September 2009 letter also notified the Veteran of the process by which initial disability ratings and effective dates are established. Dingess v. Nicholson, 19 Vet. App. 473 (2006). VA has done everything reasonably possible to assist the Veteran with respect to his claim for PTSD in accordance with 38 U.S.C.A. § 5103(A) (West 2002) and 38 C.F.R. § 3.159(c) (2013). All identified and available treatment records have been secured. The Veteran's service treatment records and post-service medical records are in the claims folder. The VA examination report reflects that the examiner reviewed the Veteran's past medical history and conducted a psychological examination. The examiner also recorded the Veteran's current complaints, conducted appropriate evaluations of the Veteran, and rendered appropriate diagnoses and opinions consistent with the remainder of the evidence of record. The Board concludes that the examination reports of record are adequate for purposes of rendering a decision in the instant appeal. See 38 C.F.R. § 4.2 (2013); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion for PTSD has been met. 38 C.F.R. § 3.159(c)(4) (2013); Barr, 21 Vet. App. at 312. The Board additionally observes that all appropriate due process concerns have been satisfied. See 38 C.F.R. § 3.103 (2013). The Veteran has declined the opportunity to present testimony in support of his claim. Therefore, the duties to notify and assist have been met. New and Material Evidence Claim-PTSD Although the RO has reopened the previously denied claim for service connection for PTSD in the March 2010 Rating Decision, the Board is required to address this particular issue (e.g., the new and material claim) in the first instance. The Board has the jurisdiction to address a new and material issue and to reach the underlying de novo claim. If the Board determines that new and material evidence has not been received, the adjudication of the particular claim ends, and further analysis is neither required nor permitted. Any decision that the RO may have made with regard to a new and material claim is irrelevant. Jackson v. Principi, 265 F. 3d 1366 (Fed. Cir. 2001). Thus, the Board must determine whether new and material evidence was presented to reopen the claim in the first instance. New evidence is defined as existing evidence not previously submitted to VA, and material evidence is defined as existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a) (2013). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). Furthermore, consideration is not limited to whether the newly submitted evidence relates specifically to the reason the claim was last denied, but instead should include whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering the Secretary's duty to assist or through consideration of an alternative theory of entitlement. Id. at 118. Only evidence presented since the last final denial on any basis (either upon the merits of the case, or upon a previous adjudication that no new and material evidence has been presented) will be evaluated in the context of the entire record. Evans v. Brown, 9 Vet. App. 273, 284 (1996). For the purpose of establishing whether new and material evidence has been received, the credibility of the evidence, but not its weight, is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). However, VA is not bound to consider credible the patently incredible. Duran v. Brown, 7 Vet. App. 216 (1994). In April 2008, the RO denied service connection for PTSD, based on the finding that the Veteran did not have any PTSD diagnosis of record. The Veteran did not appeal the decision and it became final. At the time of the April 2008 denial there was no indication that the Veteran actually had a PTSD diagnosis, and he had not submitted any stressor verification. The evidence of record included VA medical center (VAMC) treatment records with a provisional diagnosis of depression in 2004, as we well as notations of a "paranoid state" in February 2007. Since the April 2008 final decision, in September 2008, there was a notation of PTSD in the Veteran's VA medical records. In October 2009, the Veteran also tested positive during a PTSD screen. In December 2009 he was noted to have diagnosis of "PTSD subclinical" by a VA psychiatrist during an initial mental health consultation. In March 2010, the Veteran was seen at Jefferson Barracks Psychiatry and was again found the have subclinical PTSD. The above evidence is new, as it came into existence after the issuance of the April 2008 RO decision and could not have been considered by prior decision makers. Moreover, it is material as it addresses the possibility of a current diagnosis of PTSD, which was one of the elements of service connection that was previously unsubstantiated. New and material evidence having been received, reopening of the previously denied claim of service-connection for PTSD is warranted. Service Connection for PTSD-Analysis The Veteran essentially contends that he developed PTSD as a result of service in Vietnam. In order to establish service connection there must be (1) evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). Service connection for PTSD requires: (1) medical evidence diagnosing PTSD (the provisions of 38 C.F.R. § 4.125(a) require that a diagnosis of a mental disorder conform to the Diagnostic and Statistical Manual, Fourth Edition (DSM-IV)); (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a link between current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304(f) (2013); see Cohen v. Brown, 10 Vet. App. 128 (1997). Section 4.125(a) of 38 C.F.R. requires that diagnoses of mental disorders conform to the DSM-IV and that if a diagnosis is not supported by the findings on the examination report, the rating agency shall return the report to the examiner to substantiate the diagnosis. Effective July 13, 2010, VA has amended its rules for adjudicating PTSD claims under 38 CFR § 3.304(f) to relax the evidentiary standard for establishing the required in-service stressor in certain cases. 38 C.F.R. § 3.304(f) previously only authorized VA to accept statements from Veterans who served in combat, as denoted by combat-related awards or decorations or other evidence sufficient to establish participation in combat, and former Prisoners-of-War, as sufficient to establish the occurrence of the claimed in-service stressor. The amendment of 38 CFR § 3.304(f), however, eliminates the requirement for corroborating evidence of the claimed in-service stressor if it is related to the Veteran's "fear of hostile military or terrorist activity." In September 2008, there was a notation of PTSD in the Veteran's VA medical records. The Veteran also stated at a May 2009 VAMC visit that he had a diagnosis of PTSD since Vietnam. He also submitted private treatment records from September 2006 to March 2007 from the Psychology Trauma and Wellness Center showing that he had been treated for PTSD symptoms related to work stressors. He sought help because he stated that after he took a construction job, his coworkers and supervisors would verbally and physically attack him. He also stated that his coworkers were breaking into his house and persecuting him and that he had dreams about being assaulted by them. None of his treatment there addressed his service period. The Veteran also submitted private treatment records from Catholic Family Services from August 2009 to December 2009, where he was treated by a social worker. The social worker stated that the Veteran "discussed trauma suffered during years of military service" in December 2009. The Veteran also discussed his belief that airplanes were following him. His treatment goal was to experience relief from the symptoms of acute anxiety related to PTSD. In December 2009, the Veteran was noted to have diagnosis of "PTSD subclinical" by a VA psychiatrist during an initial mental health consultation in which the Veteran stated that he had been diagnosed as having PTSD by two people five years ago and was filing for a claim. In March 2010, the Veteran was seen at Jefferson Barracks Psychiatry and was again found the have subclinical PTSD and referred for further care and medication. In February 2011, he stated his PTSD was "under good control." In October 2011, the Veteran was seen for treatment for PTSD at the VAMC, during which he stated that airplane noise triggers his memories of Vietnam and that his faith helps him to forget about Vietnam. In September 2010, the Veteran was afforded a VA examination to determine whether service connection for PTSD was warranted, based on fear of hostile military or terrorist activity, which does not require a corroborated stressor if the claimed stressor is consistent with the places, types and circumstances of a veteran's service. During the examination, the Veteran relayed an incident with a phosphorus bomb that he witnessed injure people. He also stated that he saw a Vietnamese laborer get killed while trying to get onto a truck, which then caused a soldier to fire shots into a crowd, which the Veteran noted "scared me real bad." The Veteran also stated that he believes the military is against him because he sees and hears airplanes circle over his house that emit a white mist, and that they also follow him around. He stated he would ask "Am I alright? Is somebody coming after me?" The Veteran estimated that he had dreams three times per week of planes dropping things on him. The examiner noted that the Veteran did not actually claim to have any dreams about incidents from Vietnam, and that it was not evident that he was avoiding memories of Vietnam. The Veteran also stated during his examination that he worked near a hospital in Vietnam and saw casualties being transported to and from the hospital which is still upsetting for him, however, the examiner noted these memories did not occupy any of the Veteran's current dreams or ruminative ideation. The examiner noted that the Veteran's disturbing experiences appeared to be more perceptual, and that the Veteran's contentions regarding the airplanes were more suggestive of hallucinations with psychotic features than flashbacks. Overall, these symptoms were not indicative that the Veteran experienced a traumatic event that is persistently experienced through recurrent and intrusive distressing recollections; recurrent distressing dreams; acting or feeling as if the traumatic event were reoccurring; intense psychological distress at exposure to cues that resemble the event; or psychological reactivity to cues that resemble the traumatic event; any of which is required for a DSM-IV PTSD diagnosis. Furthermore, the examiner found no persistent avoidance of stimuli or persistent symptoms of increased arousal. There was no evidence of amnesia or emotional numbing. The examiner opined that the Veteran's social estrangement was not congruent with avoidance of Vietnam memories. The Veteran also denied irritability, difficulty concentrating, or easily startling. The Veteran's memory was not grossly disorganized although attention and concentration were weak. The examiner opined that while the Veteran's symptoms superficially resembled PTSD because he felt socially isolated and complained of dreams, there was no actual connection to Vietnam. The examiner noted that the Veteran was not reporting fear of terrorism or hostile enemy action related to service but was actually reporting a current fear of hostile action by the U.S. government making it less likely than not that his fear was related to service. The examiner ultimately diagnosed him with delusional disorder and anxiety disorder not otherwise specified. The VA examiner did not render a PTSD diagnosis; nor have any of the records provided a DSM IV diagnosis for VA compensation purposes. Treatment records from September 2006 to March 2007 from the Psychology Trauma and Wellness Center show the Veteran was being treated for PTSD symptoms related to work stressors, and that he sought help because stated that his co-workers were breaking into his house and persecuting him. However, there was no DSM-IV diagnosis that would be valid for compensation purposes. Furthermore, while the social worker at Catholic Services stated that the Veteran "discussed trauma suffered during years of military service" in December 2009, there is no notation that the Veteran ever described what this trauma was, and how it related to his present day symptoms. The only other PTSD treatment that related to service was in October 2011, when the Veteran was seen for treatment for PTSD, during which he stated that airplane noise triggers his memories of Vietnam and that his faith helps him to forget about Vietnam. The clinician during this meeting never specifically opined as to the etiology of the Veteran's PTSD, or whether the Veteran met the diagnostic criteria for PTSD for compensation purposes. It should be noted that a bare transcription of lay history, unenhanced by additional comment by the transcriber does not become competent medical evidence merely because the transcriber is a health care professional. LaShore v. Brown, 8 Vet. App. 406, 409 (1995). These statements, recorded for treatment purposes, are not adequate for compensation purposes. In short, there is no evidence of record of a diagnosis of PTSD that conforms to the regulatory requirements set out in 38 C.F.R. §§ 3.304 and 4.125. The Board does not in any way intend to diminish the Veteran's psychiatric care. However, it is bound by the applicable laws and regulations, which for PTSD, require a diagnosis consistent with the DSM-IV, which has been specifically ruled out in this case. In this case, even if the VA were to accept the other diagnoses of PTSD as evidence of a current disability conforming to the DSM-IV, the Veteran's claim falls short due to elements (2) and (3): credible supporting evidence that the claimed in-service stressor actually occurred; and medical evidence of a link between current symptomatology and the claimed in-service stressor. The Veteran was given numerous opportunities to verify his PTSD stressor, but has failed to do so. In October 2007, VA provided notification of how the Veteran could substantiate a PTSD claim and also enclosed a PTSD questionnaire. VA also requested the Veteran's personnel file to show his unit of assignment, dates of assignment, participation in any combat operations, any wounds in action, any awards and decorations, and travel outside of the United States. In January 2008, VA sent another letter with a VA form 21-0781 requesting that the Veteran describe his stressors. In February 2010, there was a formal finding of lack of information required to corroborate the stressors associated with the Veteran's claim for service connecting for PTSD. The Veteran's record was negative for any combat-related medals; and he was not a prisoner of war. Nor has the Veteran shown, either through corroboration or by making lay statements consistent with the places, types, and circumstances of his service, that he was exposed to an in-service stressor involving the fear of hostile military or terrorist activity. Any fear the Veteran has regularly presented, such as the U.S. government flying planes over his house, was unable to be linked to his experiences in service. The Board has considered the other reports but find them to be of less probative value than the VA opinion in September 2010 as to whether there is medical evidence of a link between current symptomatology and the claimed in-service stressor. The treatment notes from the Psychology Trauma and Wellness Center, while giving the Veteran a diagnosis of PTSD, do not relate this PTSD in any way to service. The social worker's notes from the therapy session, while mentioning trauma from service, did not relay a specific event that the Veteran experienced, witnessed, or was confronted with that would have led to a "fear of hostile military of terrorist activity." By contrast, the 2010 VA examiner thoroughly explained why the Veteran did not have PTSD and set forth exactly why the Veteran's symptoms were more consistent with other psychiatric disorders, as well as describing why the Veteran's current symptoms do not demonstrate that the Veteran's experiences in service relate to his current delusions that he is being followed by airplanes and watched by the U.S. government. As to the Veteran's contentions that he has had PTSD since service, the Board acknowledges that the Veteran is competent to testify as to any symptoms he has experienced during and since service. However, there is nothing in the record to suggest that the Veteran has the appropriate training, experience, or expertise to render a diagnosis of PTSD. See 38 C.F.R. § 3.159 (a)(1) (2013) (setting forth that competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions). As outlined above, none of the diagnoses of PTSD were rendered in accordance with the DSM-IV, and the September 2010 VA examiner specifically opined that the Veteran did not have an Axis I diagnosis of PTSD. Thus, the Board concludes that the Veteran does not have a diagnosis of PTSD that meets the regulatory requirements for that disability for VA compensation purposes. The Board finds that the preponderance of the evidence is against the Veteran's claim; therefore, the benefit of the doubt provision does not apply. As the threshold requirement of a current diagnosis of the disability claimed is not met, service connection must be denied. ORDER New and material evidence having been received, the claim of entitlement to service connection for PTSD is reopened. Service connection for PTSD is denied. REMAND Under McLendon v. Nicholson, 20 Vet. App. 79 (2006), in disability compensation (service-connection) claims, VA must provide a VA medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran's service or with another service connected disability, but (4) insufficient competent medical evidence on file for the VA to make a decision on the claim. First, while the examiner in the September 2010 VA examination did not render a diagnosis of PTSD, he did give the Veteran diagnoses of delusional disorder and anxiety, which have been noted in other treatment records as well. The examiner however, did not opine as to the etiology of these psychiatric disorders, and whether they could be related to service; therefore, the possibility of a nexus to service cannot be ruled out. Therefore, the Veteran must be afforded a new psychiatric examination to determine the nature and etiology of his psychiatric disorders. Also, there is a March 1995 St. Louis VA admission report for the Veteran for "fixed para[noid] delusional," however it appears further records regarding this treatment may be outstanding. Upon remand, further records should be obtained if they exist. Second, the Veteran contended in his November 2010 VA Form 9 Substantive Appeal that his urinary incontinence is a result of a problem in service that required him to have shots and be hospitalized, and that it has been worse since he was diagnosed with his service-connected diabetes. There are also September 1967 and March 1968 service treatment record notes indicating that the Veteran was treated by a urologist. The Veteran has established that he has a current diagnosis and there is evidence that there was in-service event or injury. As there is no medical record that specifically opines on the etiology of the Veteran's incontinence, again the possibility cannot yet be ruled out that it is connected to service. Accordingly, the case is REMANDED for the following actions: 1. Obtain any outstanding VA treatment records, including any from March 1995 regarding the Veteran's treatment for any acquired psychiatric disorder. If, after continued efforts to obtain the records it is concluded that it is reasonably certain they do not exist or further efforts to obtain them would be futile, notify the Veteran and (a) identify the specific records that are unable to be obtained; (b) briefly explain the efforts made to obtain those records; (c) describe any further action to be taken by VA with respect to the claim; and (d) inform the Veteran that he is ultimately responsible for providing the evidence. The Veteran must then be given an opportunity to respond. 2. Schedule the Veteran for an examination to determine the nature and etiology of any acquired psychiatric disorder (other than PTSD). The claims file and a copy of this remand must be made available to and be reviewed by the examiner in conjunction with the examination. The examination report must reflect that the claims file was reviewed in conjunction with the examination. Identify any current psychiatric diagnosis of record and provide an opinion, with supporting rationale, as to the nature and etiology of the disorder. Specifically, the examiner must determine whether it is at least as likely as not (a 50 percent or greater probability) that any diagnosed psychiatric disorder began in or is etiologically related to any incident of the Veteran's military service. Review of the whole file is required; however, attention is invited to: The September 2010 VA examination where the Veteran was given diagnoses of delusional disorder and anxiety disorder, not otherwise specified. All findings must be reported in detail and all indicated testing must be accomplished. The examiner should provide a complete rationale for any opinion rendered. 3. Send the Veteran VCAA notice on how to substantiate a claim for secondary service-connection pursuant to 38 C.F.R. § 3.310. 4. Schedule the Veteran for an examination to determine the nature and etiology of his claimed urinary incontinence. The claims file and a copy of this remand must be made available to and be reviewed by the examiner in conjunction with the examination. The examination report must reflect that the claims file was reviewed in conjunction with the examination. All findings must be reported in detail and all indicated testing must be accomplished. Specifically, the examiner must determine the following: a. whether it is at least as likely as not (a 50 percent or greater probability) that that the Veteran's urinary incontinence began in or is etiologically related to any incident of the Veteran's military service. Review of the whole file is required; however, attention is invited to notations of urology treatment in the Veteran's service treatment records, including in September 1967 and March 1968. b. whether it is at least as likely as not (a 50 percent probability or greater) that urinary incontinence was either (1) caused by or (2) is aggravated (permanently worsened beyond its normal progression) by the Veteran's service-connected diabetes. If the examiner determines that urinary incontinence is aggravated by the Veteran's service-connected diabetes, the examiner should report the baseline level of severity of the urinary incontinence prior to the onset of aggravation. If some of the increase in severity of the urinary incontinence is due to the natural progress of the disability, the examiner should indicate the degree of such increase in severity due to the natural progression of the disability. See 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995). The examiner is asked to explain the reasons behind any opinions expressed and conclusions reached. 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. If the examiner is unable to offer any of the requested opinions, it is essential that the examiner offer a rationale for the conclusion that an opinion could not be provided without resorting to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. See Jones v. Shinseki, 23 Vet. App. 382 (2011). 5. Then, after ensuring any other necessary development has been completed, readjudicate the Veteran's claims. If action remains adverse to the Veteran, provide the Veteran and his representative with a supplemental statement of the case and allow an appropriate opportunity to respond. Thereafter, the case should be returned to the Board. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2013). ______________________________________________ BETHANY L. BUCK Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs