Citation Nr: 1510925 Decision Date: 03/16/15 Archive Date: 03/27/15 DOCKET NO. 13-11 204 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUES 1. Entitlement to service connection for hepatitis infections. 2. Entitlement to service connection for cirrhosis of the liver, to include as due to hepatitis infections. 3. Entitlement to increased rating in excess of 40 percent for thoracolumbar osteoarthritis with lumbar disc protrusion (low back disability). 4. Entitlement to increased rating in excess of 10 percent for radiculopathy of the right lower extremity. 5. Entitlement to increased rating in excess of 10 percent for radiculopathy of the left lower extremity. REPRESENTATION Appellant represented by: Virginia A. Girard-Brady, Attorney ATTORNEY FOR THE BOARD A. Dixon, Associate Counsel INTRODUCTION The Veteran, who is the appellant, had active service from April 1972 to November 1972. These matters come before the Board of Veterans' Appeals (Board) on appeal from a March 2012 rating decision denying service connection for hepatitis infections and cirrhosis of the liver, and a March 2013 rating decision granting service connection and assigning initial disability ratings for lumbar back disability and radiculopathy of each lower extremity. In adjudicating this appeal, the Board has not only reviewed the physical claims file, but has also reviewed the electronic file on the Virtual VA and VBMS systems to ensure a total review of the evidence. The issues of increased ratings for low back disability and peripheral neuropathy of the lower extremities are addressed below in the REMAND section, and are remanded to the AOJ. The issue of service connection for cancer of the liver has been raised by the record in an October 2014 statement submitted by the Veteran's representative, 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) (2014). FINDINGS OF FACT 1. The Veteran does not have an active hepatitis infection. 2. The in-service hepatitis risk factors were needle tattoos and immunizations received using a pneumatic air gun. 3. Pre-service and post-service hepatitis risk factors were tattoos, intravenous drug use, incarceration, and family history of hepatitis C. 4. Symptoms of cirrhosis of the liver were not chronic in service. 5. Symptoms of cirrhosis of the liver have not been continuous since service. 6. Cirrhosis of the liver did not manifest to a compensable degree within one year of service. 7. Cirrhosis of the liver is not related to service. CONCLUSIONS OF LAW 1. The criteria for service connection for hepatitis have not been met. 38 U.S.C.A. § 1110 (2014); 38 C.F.R. § 3.303 (2014). 2. The criteria for service connection for cirrhosis of the liver have not been met. 38 U.S.C.A. §§ 1110, 1112, 1137 (2014); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duty to notify and assist claimants in substantiating their claims for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2014). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and the representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). The United States Court of Appeals for Veterans Claims (Court) issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service-connection claim, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status, (2) existence of a disability, (3) a connection between a veteran's service and the disability, (4) degree of disability, and (5) effective date of the disability. In a January 2012 letter sent prior to the initial denial of the claims for service connection in March 2012, the RO notified the Veteran about the evidence not of record that was necessary to substantiate the claims that specifically identified hepatitis risk factors and asked the Veteran which risk factors applied to him, VA and the Veteran's respective duties for obtaining evidence, and how disability ratings and effective dates are assigned. For these reasons, the Board concludes that VA satisfied its duties to notify the Veteran. The Board also concludes that VA has satisfied its duties to assist the Veteran. VA has made reasonable efforts to obtain relevant records and evidence. Specifically, the information and evidence that has been associated with the claims file includes pertinent medical records including the Veteran's STRs and VA outpatient treatment reports. The Veteran was also provided with VA examinations in March 2012 and March 2013 regarding hepatitis infection and liver cirrhosis. The examination report reflects that the Veteran became hostile toward the March 2012 VA examiner and terminated the examination. This refusal by the Veteran to fully participate and complete the examination resulted in incomplete examination findings just as if he had failed to report for the VA examination. 38 C.F.R. § 3.655(a) (2014). Due to the Veteran's failure to provide a full and accurate history and submit to clinical testing, the VA examiner could not obtain enough information to formulate a nexus opinion. It is the Veteran's actions that prevented the creation of a medical nexus opinion. Because this is an original claim, the case must be adjudicated on the basis of the evidence of record, which does not include a favorable current diagnosis or nexus opinion, which is evidence that is needed to substantiate the claims for service connection. 38 C.F.R. § 3.655(b). As to the March 2013 VA examination, the Veteran has made no allegations as to the inadequacy of that examination. As such, the Board is entitled to presume the competence of the VA examiner and the adequacy of the examination. Sickels v. Shinseki, 642 F.3d 1362 (Fed. Cir. 2011). Accordingly, the Board finds that no further development is required in this case. Service Connection for Hepatitis and Cirrhosis Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110. Establishing service connection generally requires: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498, 505 (1995). That a condition or injury occurred in service alone is not enough; there must be a current disability resulting from that condition or injury. Chelte v. Brown, 10 Vet. App. 268, 271 (1997). In the absence of proof of a current disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Additionally, to be present as a current disability, there must be evidence of the condition at some time during the appeals period. McClain v. Nicholson, 21 Vet. App. 319 (2007); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013). For chronic diseases listed in 38 C.F.R. § 3.309(a), which include cirrhosis of the liver, service connection will be presumed under 38 C.F.R. § 3.303(b) where there are either chronic symptoms shown in service or continuous symptoms since service. See Walker v. Shinseki, 708 F.3d 1331, 1338-40 (Fed. Cir. 2013) (holding that continuity of symptomatology is an evidentiary tool to aid in the evaluation of whether a chronic disease existed in service or an applicable presumptive period). With a chronic disease shown as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). Service connection also may be granted on a presumptive basis for certain chronic diseases, including cirrhosis of the liver, if the disability was manifested to a compensable degree within one year of separation from service. 38 U.S.C.A. § 1112; 38 C.F.R. § 3.307(a)(3), 3.309(a). Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a) (2014). Additional disability resulting from the aggravation of a non-service-connected condition by a service-connected condition is also compensable under 38 C.F.R. § 3.310(b). See Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. In this case, the Veteran contends that he acquired hepatitis B and C from air gun inoculations received in service, and that those infections caused him to develop cirrhosis of the liver. The Veteran has provided several statements in support of the claims. In a letter dated February 7, 2011, the Veteran wrote that the American Red Cross informed him in 1973 that blood he had donated earlier that year contained the hepatitis virus; however, that letter did not specify which strain of hepatitis virus the Veteran had contracted. The Veteran wrote that he did not seek treatment after being informed by the Red Cross that his blood contained hepatitis because he did not have insurance or a job to pay for it. He reported that he underwent a hernia repair in either 1986 or 1987, at which time a physician informed him that he had cirrhosis of the liver. The Veteran wrote that the physician had asked if he was an alcoholic, to which the Veteran responded that he was not, and that the physician then informed the Veteran that if he was he needed to stop drinking. The Veteran also wrote that, at the time he enlisted in the military, he had two tattoos which had been cut into his arm using a razor blade, and that he had received three tattoos at Doc's tattoo shop in San Diego, California, while on active duty, and that he did not obtain any additional tattoos until 1977. Following receipt of notification from VA as to what evidence was needed to decide the claim, and the risk factors associated with hepatitis C, the Veteran submitted an additional statement dated February 21, 2012, in which he reiterated that he was given immunizations in service with an air gun, and the American Red Cross had informed him in 1973 that his blood contained hepatitis. However, he added that he did not have "a blood transfusion or anything else" that was considered a risk factor for hepatitis. The Veteran was provided with VA examinations in March 2012 and March 2013. As discussed above, the March 2012 VA examiner was unable to complete the examination due to termination by the Veteran. The March 2013 VA examiner, however, obtained a detailed medical history from the Veteran, who reported that he did not get any tattoos in service, and was able to administer a complete examination. The Veteran also reported to the VA examiner that he did not seek medical attention of follow-up after being informed by the American Red Cross that his blood contained hepatitis, and had no specific instances of illness, known infections, or liver conditions. The March 2013 VA examiner also reviewed the Veteran's VA treatment records and noted histories of hepatitis B diagnosed in April 2009, hepatitis C diagnosed in October 2008, and cirrhosis of the liver diagnosed in August 2010. The VA examiner in March 2013 also noted that a gastroenterology specialist had attributed the cirrhosis to the hepatitis C infection and 25+ years of moderate-heavy alcohol use. As to the Veteran's specific risk factors for hepatitis, the VA examiner in March 2013 determined that the risk factors included: tattoos received prior to, during, and after service, IV drug use, incarceration from 1977 to 1980, and family history of hepatitis C. Upon examination, the March 2013 VA examiner documented that the Veteran did not require continuous medication for control of his liver conditions. Additionally, the VA examiner assessed that the Veteran did not currently have the signs or symptoms attributable to chronic or infectious liver diseases, but did have splenomegaly attributable to cirrhosis of the liver. Laboratory studies showed that the Veteran's blood contained positive surface and IgG core antibodies with negative core IgM antibody for hepatitis B, and negative Be antigen, antibody, and negative DNA viral load for hepatitis C. Based on the above, the VA examiner concluded that the Veteran's prior hepatitis B and hepatitis C infections had resolved, and that the cirrhosis of the liver was caused by prior hepatitis C infections and alcohol use. The Board finds that the Veteran's in-service risk factors for hepatitis infections were the immunizations he received by air gun injector and two tattoos. Service treatment records show that the Veteran received immunizations in June 1972 and August 1972. The Veteran is competent to report that those immunizations involved air gun injectors, and his statements in that regard are credible. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Veteran has provided conflicting statements as to whether he received tattoos while on active duty, in addition to the pre-service and post-service tattoos that he has reported; however, the Board credits the February 2011 statement by the Veteran that he got tattoos while on active duty, because it was provided closer in time to service and gave significant details regarding the circumstances of both pre-service and active duty tattoos. The evidence also reflects that the Veteran had pre-service or post-service hepatitis risk factors of tattoos, intravenous drug use, incarceration, and family history of hepatitis C. See March 2013 VA examination; VA treatment records dated December 12, 2008, December 29, 2008, July 16, 2010, and August 23, 2011. The Board finds the Veteran's contention that he has no risk factors for hepatitis other than air gun inoculation not to be not credible, as such contention is outweighed by the other lay and medical evidence, including the Veteran's own medical histories, of exposure to both pre-service and significant, multiple post-service risk factors of tattoos, intravenous drug use, incarceration, and family history of hepatitis C, in addition to the reported risk factor of inoculations via air gun injectors during service. As to the Veteran's claims for service connection for hepatitis B and hepatitis C, the Board finds that the weight of the shows that the Veteran does not have an active hepatitis infection that may be considered a current disability; therefore, the evidence demonstrates no current disability for VA disability compensation purposes. With respect to an active hepatitis B infection, the March 2013 VA examiner determined that the Veteran had a prior infection that had resolved, as evidenced by positive surface and IgG core antibodies with negative core IgM antibody, negative B antigen and antibody, and a negative DNA viral load from 2008 to 2010. The VA examiner in March 2013 similarly determined that the Veteran had a prior hepatitis C infection that had resolved, as evidenced by reactive hepatitis C antibody with negative RNA viral load from 2008 to 2010. The VA examiner also noted that the Veteran did not currently have signs or symptoms attributable to chronic or infectious liver diseases. The Veteran's VA treatment records reflect reports of symptoms and findings that are consistent with the March 2013 VA examiner's findings. See VA treatment records dated July 16, 2010, and August 23, 2011. As there is no evidence to the contrary, the Board finds that the weight of the evidence shows that the Veteran did not have an active hepatitis B or C infection at the time he filed his claim or at any time during the appeal; therefore, the Veteran does not have a current disability as defined for VA purposes. McClain, 21 Vet. App. at 321; Romanowsky, 26 Vet. App. at 293. As to residuals of hepatitis infections, namely cirrhosis of the liver, the Board finds that the weight of the evidence demonstrates that the cirrhosis is not related to service. First, as to the question of whether the Veteran's prior hepatitis C infection (and therefore, any current residuals) was incurred in service, the March 2013 VA examiner opined that the prior hepatitis C infection was not as likely as not related to service. In support of this opinion, the VA examiner acknowledged the Veteran's and his uncle's statements that the Red Cross rejected his blood due to hepatitis infection in 1973, but commented that, because the Red Cross did not test for hepatitis C prior to 1990, a report from the Red Cross would not be of hepatitis C but would more likely be a detection of hepatitis B. The VA examiner further reasoned that, due to the durability of the hepatitis C virus, it is less likely able to be transmitted via pneumatic air gun. The VA examiner further stated that she knew of no medical cases in which hepatitis C infection resulted from pneumatic air gun inoculation; rather, hepatitis C infection is most notably related to direct contact via intravenous (IV) drug use or blood transfusion. After considering the Veteran's risk factors, the VA examiner specifically noted that the Veteran's IV drug use and incarceration carried an increased risk of hepatitis C infection. Finally, the VA examiner assessed that "the greater risk factors, including the most common cause of infection being IV drug use, occurred after service and is more likely than not the source of hepatitis C infection." With respect to the liver cirrhosis, the March 2013 examiner opined that it was caused by prior hepatitis C infection and concomitant moderate-heavy alcohol use. In reaching that conclusion, the VA examiner reasoned that hepatitis C is a prevalent cause of cirrhosis, with much greater likelihood of cirrhosis development than hepatitis B. The VA examiner also opined that the Veteran's 25 years of moderate-heavy alcohol use compounded the cirrhosis caused by hepatitis C infection. With respect to the Veteran's alcohol use, it is unclear from the record whether the alcohol abuse began in service or shortly thereafter. See VA treatment record dated December 29, 2008 (Veteran reported that he was a heavy drinking until 1998), July 16, 2010 (Veteran reported that he stopped drinking in 1987 when he underwent a hernia repair and was told his liver looked cirrhotic), and August 23, 2011 (noting history of drinking in the military). However, that distinction is irrelevant because primary service connection for alcohol-related disorders cannot be established. 38 U.S.C.A. § 1110 (prohibiting compensation for disabilities resulting from the veteran's abuse of alcohol or drugs); see also 38 C.F.R. § 3.301(a), (d) (2014) (defining alcohol abuse as the use of alcoholic beverages over time, or such excessive use at one time, sufficient to cause disability to or death of the user). In addition to providing a negative nexus opinion, the March 2013 VA examiner supported the opinion by identifying the most likely source of hepatitis B, namely, tattoos received either before or during service. While the Veteran also had tattoos during service, such does not tend to relate the cirrhosis to the in-service tattoos, as the VA examiner ultimately determined that the Veteran's cirrhosis of the liver was caused by hepatitis C and alcohol abuse, which is not related to service, rather than to hepatitis B. The Board has considered the Veteran's allegations that he contracted hepatitis in service, to include lay statements in the record that the Red Cross rejected his blood due to hepatitis infection, and that his doctor informed him that he had cirrhosis of the liver after a hernia repair in the late 1980s. The Veteran is certainly competent to relay information conveyed to him by the Red Cross and any physicians. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (2007). However, that evidence only tends to show that the Veteran had hepatitis B and cirrhosis of the liver at some point prior to the appeal period. As indicated above, the Veteran's and his uncle's statements that the Red Cross rejected his blood due to hepatitis infection in 1973 have no tendency to demonstrate the presence of hepatitis C because the Red Cross did not test for hepatitis C prior to 1990. Aside from the Veteran's assertions, the other evidence of record shows two tattoos and air gun injections during service, but does not relate later hepatitis infections or cirrhosis to service. In that regard, the Board finds that the reasoned opinion of the March 2013 VA examiner outweigh the general assertions of the Veteran and his uncle that purport to relate hepatitis or cirrhosis to air gun injections or tattoos in service. The VA examiner's opinion is based on a more thorough and accurate factual history that included pre-service and post-service risk factors, as well as relevant clinical testing, and is supported by specific rationale that addresses all reported or established risk factors, dates of onset of symptoms, and availability of specific hepatitis clinical testing. Furthermore, the VA examiner has education, training, and experience on these matters that the Veteran is not shown to have. Therefore, the Board finds that the Veteran's opinion that his prior hepatitis C infection and cirrhosis of the liver are related to service is less probative than the opinion of the March 2013 VA examiner. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (a medical opinion based on an inaccurate factual premise is not probative); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (holding that a medical opinion that contains only data and conclusions without any supporting analysis is accorded no weight). Finally, the Board has considered the articles indicating that hepatitis could be transmitted via pneumatic air gun; however, the Board finds that evidence is of lesser probative value than the more case-specific VA examiner's opinion that accounts for the full history and risk factors in this Veteran's case, which include multiple other pre-service and post-service risk factors, and specific rationale that identify and address that history and all risk factors. In sum, the Board finds that the weight of the evidence shows that the Veteran's cirrhosis of the liver was caused by hepatitis C infections and alcohol abuse that are not related to service. Accordingly, service connection for cirrhosis of the liver, as due to hepatitis B and C infections, must be denied. With regard to presumptive service connection for cirrhosis of the liver, the weight of the evidence shows no chronic symptoms of cirrhosis of the liver during service, no continuous symptoms of cirrhosis of the liver since service, and that cirrhosis of the liver did not manifest to a compensable degree within one year of service. The service treatment records (STRs) are absent for any showing of chronic symptoms or testing or diagnosis for liver cirrhosis. The November 1972 service separation examination showed that the digestive system (which includes the liver) was clinically normal. The first mention of liver cirrhosis in the record is not until December 2008, at which time the Veteran claimed to have been diagnosed in the late 1980s (at least a decade after he left the military). See VA treatment record dated December 12, 2008; see also Veteran statement dated February 7, 2011. On the question of direct service connection, the service examination reports, VA medical records, and VA examination reports do not include any competent opinion linking liver cirrhosis directly to service. A review of the record does not indicate, nor does the Veteran allege, that his liver cirrhosis is directly related to service. In conclusion, the Board finds that the Veteran does not have a current hepatitis B or C infection on which he may base his claim for service connection. The Veteran's cirrhosis of the liver, caused by hepatitis C infection and alcohol abuse, is not related to service. For these reasons, service connection on both direct and presumptive bases for cirrhosis of the liver must be denied. 38 C.F.R. §§ 3.303(b), 3.307, 3.309. ORDER Service connection for hepatitis infections is denied. Service connection for cirrhosis of the liver is denied. REMAND Increased Ratings for Low Back and Lower Extremity Neuropathy Disabilities In a March 2013 rating decision that was issued on April 29, 2013, the RO granted service connection for thoracolumbar osteoarthritis with lumbar disc protrusion (low back disability), radiculopathy of the right lower extremity, and radiculopathy of the left lower extremity, effective from April 25, 2003. The RO assigned initial ratings of 40 percent for the low back disability and 10 percent for each of the lower extremity peripheral neuropathy disabilities. The April 29, 2013 letter advised the Veteran and attorney of appellate rights. A notice of disagreement with the initial ratings assigned was not received within one year of issuance of the March 2013 rating decision on April 29, 2013. None of the correspondence or submissions during the one year period expressed disagreement with the March 2013 rating decision or expressed a desire to appeal the decision. While the Veteran filed a claim for increase in March 2014, he did not enter a notice of disagreement with the initial ratings assigned. In addition, no additional relevant evidence was submitted or received by VA within one year of notice of the rating decision assigning the initial ratings to require a readjudication or to preclude the decision from becoming final. Because no VA examination was conducted in April 2014, for whatever reason, no additional relevant evidence was created to require a readjudication of the initial ratings assigned. See 38 C.F.R. § 3.156(b) (2014). For these reasons, the March 2013 rating decision assignment of initial rating became final. 38 U.S.C.A. § 7105(c) (West 2014); 38 C.F.R. §§ 20.302, 20.1103 (2014). The Veteran filed a new claim for increased rating in March 2014 (VA Form 21-526EZ). On the claim form, the Veteran wrote that he was filing for an "Increase for" the back and sciatic nerve/paralysis disabilities. While this new claim for increase was received within one year of the April 29, 2013 rating decision, it does not express disagreement with that decision. The new claim for increased rating was adjudicated in a rating decision dated April 25, 2014 (mailed on May 1, 2014), which denied an increased rating on the basis of no VA or private evidence of worsened disability and failure to appear for a VA examination. In July 2014 the Veteran's representative entered a notice of disagreement with the May 1, 2014 rating decision, asserting that the Veteran did not receive notice of an April 2014 VA examination. The RO has yet to issue a Statement of the Case as to this matter; therefore, remand is required. Manlincon v. West, 12 Vet. App. 238, 240-41 (1999); 38 C.F.R. §§ 20.201 , 20.300 (2013). Accordingly, the issues of increased ratings for low back and lower extremity peripheral neuropathy disabilities are REMANDED for the following action: Provide the Veteran with a statement of the case as to the issues of increased ratings for low back and lower extremity peripheral neuropathy disabilities. The Veteran must file a timely and adequate substantive appeal in order to perfect an appeal of these issues to the Board. See 38 C.F.R. §§ 20.200 , 20.202, and 20.302(b) (2014). If a timely substantive appeal is not filed, the claims should not be certified 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). ______________________________________________ J. Parker Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs