Citation Nr: 1500409 Decision Date: 01/06/15 Archive Date: 01/13/15 DOCKET NO. 10-07 766 ) DATE ) ) Received from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUES 1. Entitlement to service connection for arteriosclerotic heart disease secondary to service-connected hypertension. 2. Entitlement to service connection for diabetes mellitus secondary to service-connected hypertension. 3. Entitlement to service connection for spastic colon secondary to service-connected hypertension. 4. Entitlement to service connection for a left knee disability. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD K. Neilson, Counsel INTRODUCTION The Veteran served on active duty from September 1961 to September 1963. He had additional service with a National Guard unit from April 1982 to May 2000. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. In September 2010, the Veteran testified at a Board hearing by video conference before the undersigned Veterans Law Judge. A transcript of that hearing is associated with the claims file. The issues of entitlement to service connection for arteriosclerotic heart disease, spastic colon, diabetes mellitus, and a left knee disability were twice previously before the Board. Most recently, in September 2013, the matters were remanded to the agency of original jurisdiction (AOJ) for additional development. After the AOJ undertook the requested development, the Appeals Management Center (AMC) issued an August 2014 supplemental statement of the case (SSOC) wherein it denied entitlement to service connection for the Veteran's claimed disabilities. The case was thereafter returned to the Board. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). 38 U.S.C.A. § 7107(a)(2) (West 2014). (The decision below addresses all claims save the claim of service connection for arteriosclerotic heart disease, which claim is addressed in the remand that follows the Board's decision.) FINDINGS OF FACT 1. The Veteran does not have a left knee disability that is attributable to his military service. 2. The evidence does not show that diagnosed diabetes mellitus was caused by or has been chronically worsened due to service-connected hypertension. 3. The evidence does not show that diagnosed spastic colon was caused by or has been chronically worsened due to service-connected hypertension. CONCLUSIONS OF LAW 1. The Veteran does not have a left knee disability that is the result of disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2014). 2. The Veteran does not have diabetes mellitus that has been caused or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1101, 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.310 (2014). 3. The Veteran does not have spastic colon that has been caused or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1101, 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.310 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Notice and Assistance The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2014), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2014), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim. They also require VA to notify the claimant and the claimant's representative of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a) (West 2014); Quartuccio v. Principi, 16 Vet. App. 183 (2002); 38 C.F.R. § 3.159(b). As part of the notice, VA is to specifically inform the claimant and the claimant's representative of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. The VCAA notice requirements apply to all five elements of a service connection claim. These are: (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. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The Veteran has not disputed the contents of the VCAA notice in this case. Further, the Board finds that the Veteran was adequately informed of the information and evidence necessary to substantiate the claims decided herein, as well as of VA's duty to assist and of his responsibilities in the adjudication of his claims, via a letter dated in May 2009. The Board finds that this letter complies with the requirements of 38 U.S.C.A. § 5103(a) and Dingess, supra, and afforded the Veteran a meaningful opportunity to participate in the development of his claims. Thus, the Board is satisfied that the duty-to-notify requirements under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) were satisfied. Regarding the duty to assist, the Board also finds that VA has adequately fulfilled its obligation to assist the Veteran in obtaining the evidence necessary to substantiate the claims decided herein. The relevant evidence obtained includes the Veteran's service treatment records (STRs), VA treatment records, private medical evidence, VA examination reports, National Guard records, and statements from the Veteran. He also has not alleged that there is any additional outstanding evidence pertinent to his claims and the Board is also unaware of any such outstanding evidence. In this regard, the Board notes that in a prior remand action, the Board instructed the AOJ to contact the Veteran with a request that he provide further information regarding treatment for various private physicians so as to enable the AOJ to attempt to secure copies of any relevant treatment records. The Veteran did not respond to the AOJ's request in this regard. The Veteran also failed to sign the necessary authorizations for release of private medical records to VA. Given that "the duty to assist is not always a one-way street," Wood v. Derwinski, 1 Vet. App. 190, 193 (1991), and it is the Veteran who is ultimately responsible for providing private medical evidence to VA, the Board finds that no further assistance in this regard is warranted and that the terms of its prior remand have been met. See Stegall v. West, 11 Vet. App. 268 (1998). Further, in November 2013, the Veteran was afforded a VA examination in connection with his claim of service connection for a left knee disability and in July 2014 the AOJ obtained, in compliance with the terms of the Board's prior action, an opinion regarding the likelihood that the Veteran's claimed disabilities are secondary to his service-connected hypertension. Although the Veteran's claim of service connection for heart disease is being remanded due to the submission of evidence that seemingly undermines the clinician's opinion regarding that disability, the Board finds that the medical evidence developed in connection with the Veteran's remaining claims contains sufficient evidence by which to evaluate the Veteran's claim of service connection for a left knee disability, diabetes mellitus, and spastic colon based on the theories advanced by the Veteran. The Board thus concludes the Veteran was provided with an adequate medical examination and that the opinion obtained is sufficient. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007) (describing adequacy of medical examinations). II. Analysis Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131 (West 2014); 38 C.F.R. §§ 3.303, 3.304 (2014). Service connection may be granted for any disease diagnosed after discharge when all evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Generally, establishing service connection requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999). Alternatively, for chronic diseases, as defined by regulation, shown in service, the second and third elements of service connection may be established through demonstrating chronicity or continuity of symptomatology in accordance with 38 C.F.R. § 3.303(b). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (38 C.F.R. § 3.303(b) only applies to the listed chronic disabilities in 38 C.F.R. § 3.309(a)); Savage v. Gober, 10 Vet. App. 488, 495-96 (1997). The law also provides a disability may be service connected on a secondary basis by demonstrating that the disability is either (1) proximately due to or the result of an already service-connected disease or injury or (2) aggravated by an already service-connected disease or injury. See Allen v. Brown, 7 Vet. App. 439, 448 (1995); 38 C.F.R. § 3.310 (2014). A. Left Knee Disability The Veteran seeks service connection for a left knee disability that he believes is attributable to an injury sustained in service. It is the Veteran's contention that he had sustained an injury to his left knee during basic training, received treatment thereafter, and reinjured his knee during his National Guard service. During his Board hearing, the Veteran reported that during basic training, he fell over a 12-foot wall and hit his left knee on the corner of a rock. The Veteran's STRs are, however, silent for complaints related to his left knee. At the time of his separation examination, the Veteran's lower extremities and musculoskeletal system were clinically evaluated as normal, and the accompanying report of medical history contains no indication of any knee problems. The Veteran's National Guard records also contain no specific mention of his left knee, but do show treatment for back pain and high blood pressure and note that the Veteran had been variously placed on profiles related to his physical capacity and upper and lower extremities. At the time of his April 2000 National Guard retirement examination, the Veteran's lower extremities and musculoskeletal system were clinically evaluated as normal, but he was noted to have arthritis in his back. Private medical records associated with the claims folder contain the report of a May 2009 magnetic resonance imaging (MRI) scan showing diagnoses of a subtle subchondral fracture of the posteromedial tibial plateau with depression; a sprain of the medial collateral ligament (MCL); and a near full-thickness cartilage defect along the lateral trochlear facet. Also of record is a December 2001 letter from the Veteran's private physician, T.L., M.D., noting ongoing treatment for hypertension, lumbar disc disease and lumbar strain, and a left rotator cuff tear. In a January 2012 letter, however, Dr. L. stated that he had been treating the Veteran for 15 years and noted that the Veteran was "still having problems" with his left knee, in addition to problems with his back, left shoulder, and ankle. Dr. L. then concluded that the mentioned disabilities were associated with the Veteran's military service and/or were exacerbated by such. Notably, Dr. L. did not indicate that the Veteran sustained any left knee injury in service. The Veteran was afforded a VA examination in November 2013. The examiner reviewed the claims folder and noted the Veteran's belief that his left knee disability was related to a contusion sustained in service. The examiner also stated that his review of the Veteran's medical records failed to indicate any complaints of knee pain until 2009 and that the MRI report indicated a new sprain at that time. The examiner then opined against an association between the Veteran's left knee disability and service, to include the Veteran's National Guard service. As rationale for his negative nexus opinion, the examiner stated that the Veteran's described injury was not the type that would lead to internal derangement of the knee. The examiner also indicated that it was not logical to believe that the Veteran would have lived for 49 years with his disability before undergoing surgical repair in 2009. Upon review of the evidence, the Board finds that service connection for a left knee disability is not warranted. At the outset, as discussed in its prior action, the Board finds that Dr. L.'s opinion itself cannot serve as the basis of an award of service connection for a left knee disability as it is not supported by any rationale, does not specifically discuss whether the Veteran sustained a left knee injury in service, and does not expound upon the nature of the Veteran's current left knee disability. See Stefl, 21 Vet. App. at 123-24 (discussing adequacy of medical opinions and noting that it is required of a VA examiner to consider all of the relevant evidence before forming an opinion). Regarding the VA examiner's negative nexus opinion, the Board finds that it is adequately supported by the reasons stated therein. It is clear that the examiner considered a variety of factors, to include the Veteran's lay statements, the alleged injury sustained in service, the nature of the Veteran's current left knee disability, and the length of time between the alleged injury and treatment for the current disability, in concluding that the Veteran's left knee disability is not related to service. The Board finds that, in light of the VA examiner's opinion, there is no basis to establish service connection for a left knee disability, as a crucial element of service connection has not been shown. See Davidson, supra (service connection requires evidence of a nexus between the claimed in-service disease or injury and the present disability); see also Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (a prolonged period without medical complaint can be considered, along with other factors, as evidence of whether a disability was incurred in service or whether an injury, if any, resulted in any chronic or persistent disability that still exists currently). In finding that service connection for a left knee disability is not warranted based on the lack of nexus evidence, the Board is cognizant of the fact that "[l]ay testimony is competent ... to establish the presence of observable symptomatology and 'may provide sufficient support for a claim of service connection.'" Barr v. Nicholson, 21 Vet. App. 303, 307 (2007) (quoting Layno v. Brown, 6 Vet. App. 465, 469 (1994)). Here, although the Veteran has asserted that he hurt his left knee in September 1961 and has had pain since that time, examination reports subsequent to the alleged injury are silent for any complaints related to the knee and there is no evidence suggestive of a left knee disability at the time that the Veteran's was separated from service. Further, post-service treatment records do not disclose any complaints of left knee pain until 2009. Although a November 1995 private medical record shows a diagnosis of right knee patellar tendonitis, there was no mention of left knee pain at that time. Moreover, in 2001, Dr. L made no mention of the Veteran having a specific left knee disability or left knee symptomatology since service. This evidence certainly suggests that the Veteran did not experience continuous pain after his 1961 contusion. Further, it appears that the VA examiner considered the Veteran's complaints of ongoing pain since service, but found that the injury alleged to have occurred in service was not of the type that would lead to his current left knee disability, diagnosed many years later. Thus, even if the Veteran did have pain since service, in the absence of medical evidence establishing a relationship between the present disability and such symptomatology, a finding of service connection cannot be made. See Savage v. Gober, 10 Vet. App. 488, 497 (1997) ("[B]ecause it would not necessarily follow that there is a relationship between any present disability and the continuity of symptoms demonstrated, medical evidence . . . is required to demonstrate such a relationship unless such a relationship is one as to which a lay person's observation is competent."). As to any contention by the Veteran that because he injured his left knee in service, his current disability must therefore be etiologically related to that in-service injury, the Board notes that etiology of dysfunctions and disorders is generally a medical determination. See Jandreau v. Nicholson, 492 F.3d 1372, 1374-75 (Fed. Cir 2007); see also Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed.Cir.2010) (recognizing that in some cases lay testimony "falls short" in proving an issue that requires expert medical knowledge). Here, the Veteran, as a lay person without the appropriate medical training and expertise, is not competent to make such an etiological conclusion with regard to his left knee disability, especially in light of the VA examiner's conclusion to the contrary and the fact that the evidence fails to demonstrate the onset of that disability in service. See Jandreau, supra; B. Diabetes Mellitus The Veteran is seeking service connection for diabetes mellitus, which he believes is secondary to his hypertension. A review of the record shows that the Veteran was diagnosed as having diabetes mellitus in 2000. He was awarded service connection for hypertension by way of a June 2013 rating action, effective from March 2009. As to the Veteran's specific theory of service connection, the evidence of record fails to support a finding that the Veteran's diagnosed diabetes mellitus was caused or aggravated by his service-connected hypertension. During his September 2010 hearing, the Veteran stated that his private cardiologist, Dr. J.H. informed him that his diabetes mellitus was related to his hypertension. No further rationale for Dr. J.H.'s opinion was discussed. As noted above, in February 2012, the Veteran was requested to provide an authorization for release of private records from Dr. J.H. to VA. The Veteran did not respond to the request and has not himself provided any records or supporting statements from Dr. J.H. that would substantiate his 2010 testimony. Given the absence of supporting evidence or any further detail from the Veteran regarding the basis of Dr. J.H.'s opinion, the Board concludes that although the Veteran is certainly competent to report on what a physician may have told him, the Veteran's statement, and Dr. J.H.'s reported opinion, in this regard carries little probative weight. This is so because although there is no requirement imposed on a medical examiner to provide detailed reasons for an opinion, Ardison v. Brown, 6 Vet. App. 405, 407 (1994), to be adequate, an opinion must be supported with an analysis that the Board can consider and weigh against contrary opinions, Stefl, 21 Vet. App. at 124. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (holding, in the context of weighing one medical opinion with another, that "[i]t is the factually accurate, fully articulated, sound reasoning for the conclusion . . . that contributes probative value to a medical opinion"). Thus, even if Dr. J.H. did indicate an association between the Veteran's hypertension and his diabetes mellitus, because there is no evidence to support that opinion and the basis of the opinion is not clear from the Veteran's statement, the Board cannot conclude that Dr. J.H.'s opinion is adequate to support an award of service connection. See id. at 301 (stating that "[a] medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two"). Likewise, as discussed in the Board's prior action, although a VA examiner opined in December 2012 that the Veteran's diabetes mellitus was not caused or aggravated by his hypertension, that opinion is also not adequate because it was not supported by any rationale. Thus, the matter was remanded to obtain another opinion the included an extended rationale. Another opinion was obtained in July 2014, which opinion was based on a review of the record as opposed to an in-person examination of the Veteran. That VA clinician opined that it was less likely than not that the Veteran's service-connected hypertension caused or aggravated the Veteran's diabetes. The clinician stated that there was no such mechanism by which causation or aggravation would occur, as those disabilities are independent of each other. The clinician also stated that there was no medical literature that would support the Veteran's theory. In an August 2014 statement in support of his claim, the Veteran pointed to provisions of VBA's Adjudication Procedure Manual M21-1 Manual Rewrite (M21-1MR), which he alleged supported his claim of service connection on a secondary basis. Specifically, the Veteran cited to M21-1MR, Part III, Subpart iv, Ch.4 Section F, Topic 22, which pertains to rating diabetes mellitus. Although this section of the M21-1MR indicates that hypertension may be a complication of diabetes, the cited provision does not support the Veteran's theory that diabetes may result from hypertension. Nor does it provide support for a finding of aggravation. The Board has also reviewed M21-1MR, Part III, Subpart iv, Ch.4 Section E, Topic 20, which pertains to heart conditions. Although, as will be discussed in the remand that follows below, this M21-1MR section suggests that hypertension may cause arteriosclerosis, nothing in this section supports a conclusion that diabetes mellitus may be in any way attributed to pre-existing or co-existing hypertension. In consideration of the evidence of record, the Board finds no basis upon which to award service connection for diabetes mellitus under the Veteran's theory of entitlement. This is so because the evidence fails to establish that the Veteran's diabetes mellitus was caused or chronically worsened by the service-connected hypertension. In the instant case, there is no indication that the VA clinician who reviewed the Veteran's claims file in July 2014 failed to consider any piece of relevant evidence before providing the requested opinion. The Board also finds no reason to discount the medical opinion based on the clinician's expertise and qualification as a medical professional. Moreover, no other medical professional has provided evidence to support the Veteran's theory that his diabetes mellitus was caused or aggravated by his hypertension. As discussed above, Dr. J.H.'s indicated opinion is not sufficient. The Veteran has also not provided any medical literature or other evidence that would tend to contradict the VA clinician's July 2014 negative opinion in this regard. Accordingly, while not overly detailed in its reasoning, the fact remains that the negative opinion procured in July 2014 was rendered by medical professional, was based on a review of the claims folder, and was supported by some stated reasoning, namely, that there is in fact no basis in medical literature or knowledge to support the Veteran's proffered theory of entitlement to service connection. The Board thus concludes the opinion is not only probative as to the issue at hand, but may be relied upon in this case. In short, there is no basis upon which to conclude that the Veteran's diabetes mellitus was caused or aggravated by his service-connected hypertension. Although the Veteran may believe that this is the case, the Board notes that etiology of dysfunctions and disorders is generally a medical determination. See Colantonio and Jandreau, both supra. Here, the Veteran, as a lay person without the appropriate medical training and expertise, is not competent to make such an etiological conclusion, especially in light of the fact that the medical evidence fails to establish a relationship between the two disabilities. See Jandreau, supra. C. Spastic Colon The Veteran is seeking service connection for spastic colon, which he also believes is secondary to his hypertension. A review of the record shows that the Veteran has a diagnosis of spastic colon and service connection is currently in effect for hypertension. As to the Veteran's specific theory of service connection, the evidence of record fails to support a finding that the Veteran's diagnosed spastic colon disease was caused or aggravated by service-connected hypertension. During his September 2010 hearing, the Veteran stated that his private cardiologist, Dr. J.H. informed him that his spastic colon was related to his hypertension. No further rationale for Dr. J.H.'s opinion was discussed. As noted above, without any additional information from Dr. J.H., the reported opinion is inadequate to support a finding of service connection. See Nieves-Rodriguez, Stefl, and Ardison, all supra. Likewise, a December 2012 VA examiner's opinion that the Veteran's spastic colon was not caused or aggravated by his hypertension is not adequate as it also lacked any supporting rationale. See id. Another opinion was obtained in July 2014, which opinion was based on a review of the Veteran's claims folder. That VA clinician opined that it was less likely than not that he Veteran's service-connected hypertension caused or aggravated the Veteran's spastic colon. The clinician stated that there was no such mechanism by which causation or aggravation would occur, as hypertension and spastic colon as independent of each other. The clinician also stated that there was no medical literature that would support the Veteran's theory. As stated above, there is no indication that the VA clinician who provided the July 2014 opinion failed to consider any piece of relevant evidence before providing the requested opinion. There is also no reason to discount the medical opinion based on the clinician's expertise and qualifications as a medical professional. Moreover, no other medical professional has provided probative evidence that may be relied upon to support the Veteran's theory that his spastic colon was caused or aggravated by his hypertension, and the Veteran has not provided any medical literature or other evidence that would tend to contradict the VA clinician's negative opinions in this regard. As with the diabetes claim, there is no basis upon which to conclude that the Veteran's spastic colon was caused or aggravated by service-connected hypertension. Although the Veteran may believe that this is the case, as stated above, the etiology of dysfunctions and disorders is generally a medical determination. See Jandreau, supra. Here, the Veteran, as a lay person without the appropriate medical training and expertise, is not competent to make such an etiological conclusion, especially in light of the fact that the medical evidence fails to establish a relationship between the two. See id. ORDER Entitlement to service connection for a left knee disability is denied. Entitlement to service connection for diabetes mellitus secondary to service-connected hypertension is denied. Entitlement to service connection for spastic colon secondary to service-connected hypertension is denied. REMAND Regarding the claims of service connection for arteriosclerotic heart disease, a December 2012 VA examination report contains a diagnosis of coronary artery disease, an often cause of which is atherosclerosis. Although the July 2014 VA clinician opined that it was less likely than not that the Veteran's service-connected hypertension had caused or aggravated the Veteran's heart disease, stating that there was no such mechanism by which causation or aggravation would occur, and that there was no medical literature that would support the Veteran's theory, the Veteran has argued that M21-1MR, Part III, Subpart iv, Ch.4 Section E, Topic 20, supports his position that his heart disease is attributable to his hypertension. That manual section provides that hypertension may "cause arteriosclerosis of uneven distribution that often involves the vessels of one organ to a greater degree than those of the rest of the body, in cases where hypertension is long-standing." It also provides circumstance in which service connection for arteriosclerotic manifestations due to hypertension may be granted. The July 2014 VA clinician's opinion therefore appears to be somewhat undermined by information contained in VBA's Adjudication Procedure Manual, so another opinion that takes into account the M21-1MR provisions must be obtained. Accordingly, the case is REMANDED to the AOJ for the following action: 1. The AOJ should arrange for the Veteran's claims folder to be reviewed by a cardiologist and obtain from him/her an opinion whether it is at least as likely as not the Veteran's hypertension has caused or made chronically worse the Veteran's diagnosed heart disease. (If the clinician does not have access to VBMS, any relevant treatment records contained therein and not otherwise available must be printed and made available for the clinician's review.) The clinician must address both causation and aggravation and is reminded that merely stating a conclusory opinion is not sufficient. An explanation is required that takes into account the evidence of record and pertinent medical principles, and the clinician's rationale should include citation to pertinent evidence and/or medical principles relied upon to form that opinion. The clinician's opinion must also address the information contained in M21-1MR, Part III, Subpart iv, Ch.4 Section E, Topic 20, that states that hypertension may "cause arteriosclerosis," and state why or why this M21-1MR provisions supports a finding of service connection in this case. If the clinician determines that an opinion cannot be provided without resorting to speculation, the clinician should explain the inability to provide an opinion, identifying precisely what facts could not be determined. In particular, he/she should comment on whether an opinion could not be rendered because the limits of medical knowledge have been exhausted regarding the etiology of a diagnosed disorder or whether additional testing or information could be obtained that would lead to a conclusive opinion. See Jones v. Shinseki, 23 Vet. App. 382, 389 (2010). (The AOJ should ensure that any additional evidentiary development suggested by the clinician should be undertaken so that a definite opinion can be obtained. If another examination is required to formulate an opinion, then another examination should be scheduled in order for the questions to be answered.) 2. After completing the above, and any other development deemed necessary, readjudicate the issue remaining on appeal. If the benefit sought is not granted, the appellant should be furnished with a supplemental statement of the case and afforded an opportunity to respond before the record is returned to the Board. Thereafter, the case should be returned to the Board for further appellate review. By this remand, the Board intimates no opinion as to any final outcome warranted. No action is required of the appellant until he is notified. 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 case must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the United States Court of Appeals for Veterans Claims (Court) for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). _________________________________ MARK F. HALSEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs