Citation Nr: 1600559 Decision Date: 01/07/16 Archive Date: 01/21/16 DOCKET NO. 14-19 258 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Phoenix, Arizona THE ISSUES 1. Entitlement to an initial rating in excess of 50 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for traumatic brain injury (TBI). 3. Entitlement to service connection for low back strain. 4. Entitlement to service connection for a right knee condition. 5. Entitlement to service connection for a left knee condition. 6. Entitlement to service connection for a neck condition. 7. Entitlement to service connection for a respiratory condition due to Gulf War hazards as due to an undiagnosed illness. REPRESENTATION Appellant represented by: John S. Berry, Attorney at Law ATTORNEY FOR THE BOARD C.S. De Leo INTRODUCTION The Veteran served on active duty from July 2007 to November 2007, February 2008 to May 2008, and October 2009 to November 2010. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Phoenix, Arizona, which granted service connection for PTSD with an evaluation of 50 percent and denied service connection for TBI, low back strain, bilateral knee condition, neck condition, and a respiratory condition. This appeal was processed using the Virtual VA and the Veterans Benefits Management System (VBMS) paperless claims processing systems. Accordingly, any future consideration of this appellant's case should take into consideration the existence of this electronic record. The appeals for a higher initial rating for PTSD, service connection for a TBI, low back strain, bilateral knee condition and a neck condition are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDING OF FACT The Veteran does not have any objective manifestations of a chronic respiratory disorder nor is it shown that he has a respiratory disability that is related to his active service. CONCLUSION OF LAW The criteria for service connection for chronic respiratory disorder have not been met. 38 U.S.C.A. §§ 1110, 1117, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.303 , 3.317 (2015). REASONS AND BASES FOR FINDING AND CONCLUSION I. Duty to Notify and Assist When VA receives a complete or substantially complete application for benefits, it must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). See also Quartuccio v. Principi, 16 Vet. App. 183 (2002); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Dingess v. Nicholson, 19 Vet. App. 473 (2006). Here, VA's duty to notify was satisfied through a notice letter dated in June 2011, that informed the Veteran of his duty and VA's duty for obtaining evidence and the process by which disability ratings and effective dates are assigned. VA must also make reasonable efforts to assist the appellant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Here, service treatment records (STRs), VA treatment records, and the Veteran's lay statements have been obtained and associated with the claims file. The Veteran has not identified any additional records that should be obtained prior to a Board decision. The Board notes that there are issues being Remanded based on the Veteran request to obtain treatments from private care providers. Both the Veteran and his attorney specifically noted that those records related to the treatment of his claimed orthopedic disorders. Indeed, as the Veteran clearly indicated on examination that is not experiencing active respiratory symptoms, no useful purpose would be served in Remanding this matter for those records. The Veteran was also provided a VA examination in April 2013. See 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159; Wells v. Principi, 326 F.3d 1381 (Fed. Cir. 2003). The Board finds the examination is adequate for the purpose of evaluating the claim as the examiner reviewed the Veteran's pertinent medical history, considered his self-reported history, and provided medical opinion evidence sufficient to rate the disability on appeal. See generally Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). II. Analysis Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C.A. §§ 1110 , 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires evidence of: (1) a current disability (for which service connection is sought); (2) incurrence or aggravation of a disease or injury in service; and (3) a nexus between the claimed disability and the disease or injury in service. See Shedden v, Principi, 381 F.3d 1153, 1166-1167 (Fed. Cir. 2004). The Veteran's service records show that he meets the criteria for consideration as a Persian Gulf veteran for purposes of 38 C.F.R. § 3.317. Under this regulation, service connection may be established for a disability due to undiagnosed illness of a Veteran who served in the Southwest Asia Theater of operations during the Persian Gulf War. In order establish service connection on that basis, there must be objective indications of a chronic disability resulting from an illness or combination of illnesses manifested by one or more signs or symptoms such as fatigue, signs or symptoms involving the skin, headache, muscle pain, joint pain, neurological signs or symptoms, neuropsychological signs or symptoms, signs or symptoms involving the respiratory system (upper and lower), sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, and menstrual disorders. Such illness must become manifest during either active service in the Southwest Asia theater of operations during the Persian Gulf War or to a degree of 10 percent or more, under the appropriate diagnostic code of 38 C.F.R. Part 4, during the presumptive period prescribed by the Secretary. The period within which such disabilities must become manifest to a compensable degree in order for entitlement to compensation to be established is currently December 31, 2016. See 38 C.F.R. § 3.317(a)(1)(i). In order to qualify, the chronic disability must not be attributed to any known clinical disease by history, physical examination, or laboratory tests. 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317(a), (b). There must be objective signs that are perceptible to an examining physician and other non-medical indicators that are capable of independent verification. There must be a minimum of a six-month period of chronicity. There must be no affirmative evidence that relates the undiagnosed illness to a cause other than being in the Southwest Asia Theater of operations during the Persian Gulf War. 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317. If signs or symptoms have been medically attributed to a diagnosed (rather than undiagnosed) illness, the Persian Gulf War presumption of service connection does not apply. VAOPGCPREC 8-98 (Aug. 3, 1998). A qualifying chronic disability means a chronic disability resulting from any of the following (or any combination of the following): (A) an undiagnosed illness; (B) the following medically unexplained chronic multisymptom illnesses that are defined by a cluster of signs or symptoms: (1) chronic fatigue syndrome; (2) fibromyalgia; (3) irritable bowel syndrome; or (4) any other illness that the Secretary determines meets the criteria for a medically unexplained chronic multisymptom illness; or (C) any diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C.A. § 1117(d) warrants a presumption of service-connection. 38 C.F.R. § 3.317(a)(2)(i). For purposes of this section, the term medically unexplained chronic multisymptom illness means a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multisymptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii). For purposes of this section, "objective indications of chronic disability" include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all of the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (finding that the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis herein focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (holding that the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). The standard of proof to be applied in decisions on claims for veterans' benefits is set forth in 38 U.S.C.A. § 5107 (West 2014). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). Service Connection for a Respiratory Condition due to Gulf War Hazards The Veteran seeks service connection for a respiratory condition. In his May 2011 claim for compensation, he specifically noted that his respiratory disorder was due to his active service in the Persian Gulf. A December 2006 STR shows the Veteran was treated for sinusitis. Post-service medical evidence concerning this issue consists solely of the April 2013 VA Gulf War general medical examination and respiratory condition examination. In the report of the Gulf War examination, the examiner noted that the Veteran was "not claiming a respiratory condition", that he was "surprised when it was addressed", and that "he does not have a respiratory condition." Similarly, at his respiratory examination, the examiner noted the Veteran reported having had no respiratory condition. After interviewing the Veteran and conducting an examination of him, the VA examiner concluded that the Veteran's claim for a respiratory condition appeared to have been due to a misinterpretation of his reporting a past history of hay fever. Specifically, he checked "yes" to specify a history of hay fever, which instead indicated "yes" to the "asthma" portion of a combined question. According to the Veteran, he does not have asthma or symptoms thereof and was unaware of the pending claim for service connection for a respiratory condition. Having reviewed the evidence pertaining to the Veteran's claim, the Board concludes that service connection for a respiratory disorder under the provisions of 38 C.F.R. § 3.317 is not warranted. The Veteran has simply not identified any objective manifestations of a respiratory disorder. There are likewise no non-medical indicators that would be capable of independent verification. Indeed, as discussed, the Veteran explained to the VA examiner that he did not have a respiratory disorder, and that he had not intended to file such a claim. Service connection is limited to those cases where disease or injury has resulted in a disability. There is no evidence of diagnosed disability of the respiratory system at any time during the appeal period. The Veteran does not argue the contrary. In the absence of proof of a present disability for which service connection is sought, there is no valid claim of service connection on a direct basis. See Brammer v. Derwinski, 3 Vet. App. 223 (1992). ORDER Entitlement to service connection for a respiratory condition due to Gulf War hazards as due to an undiagnosed illness is denied. REMAND After a thorough review of the Veteran's claims file, the Board has determined that additional evidentiary development is necessary prior to the adjudication of the Veteran's claim for a higher initial rating for PTSD, service connection TBI, low back strain, bilateral knee condition, and a neck condition. Although the Board sincerely regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide the Veteran's claims so that he is afforded every possible consideration. Service Connection for a Low Back and Neck Disability With respect to the Veteran's service connection claim for a low back and neck disability, he asserts that he injured his neck and back during active service and he has suffered from chronic back and neck symptomatology since this time. See February 2014 Statement. His service treatment records confirm that he experienced low back symptomatology during service. The Veteran was afforded a VA examination in connection to his back and neck conditions in May 2013, at which time he provided his military history and reported to have injured his neck and back during service. In the resulting reports, the examiner noted a diagnosis of low back strain in service but concluded that the Veteran had no specific back diagnosis during the examination. Further, the examiner noted that x-rays taken in November 2011 revealed mild multilevel spondylosis of the lumbar spine. Additionally, the examiner concluded that the Veteran had no specific neck diagnosis during the examination. Since that time, evidence pertinent to the Veteran's service connection claim for low back strain and a neck condition has been associated with the claims folder. The evidence includes a private treatment report titled The Core Institute Clinical Summary, date stamped as received by the RO in March 2014. The report indicates the Veteran was diagnosed with degeneration of the lumbar or lumbosacral intervertebral disc, lumbar facet arthropathy, lumbar radiculopathy, and spondylolisthesis. The report also notes that the Veteran started treatment on October 16, 2013. Additionally, x-rays of the Veteran's lumbar spine and neck, date stamped as received by the RO in November 2013 has also been associated with the claims folder. The record does not reflect the AOJ's consideration of the additional evidence received or issuance of a supplemental statement of the case (SSOC) for such consideration. The record also reflects that there may be outstanding private treatment records. Of record are five medical release forms dated stamped as received by the VA in March 2014. See March 2014 VA Forms 21-4142. The Veteran provided the names and addresses of private clinicians and noted that he had received treatment for pain management from Dr. J.O. from October 2013 through January 2014, and also from Dr. R.L. from November 2013 to February 2014. Additionally, the Veteran provided the names and addresses of Dr. J. P.D. who treated him for his back and also for Dr. H.B. who performed surgery on his back. The record does not show that the AOJ attempted to obtain these records. Increased Rating for PTSD With respect to the Veteran's higher rating for PTSD claim, the AOJ awarded service connection for PTSD with an evaluation of 50 percent in a June 2013 decision. Since that time, the Veteran has been evaluated by a private clinician for his PTSD disability. Those records suggest a worsening of his PTSD. In view of the treatment for his PTSD disability since the most recent May 2013 VA examination and the time that has lapsed, an updated examination would be helpful in evaluating the PTSD disability. Another examination is required to evaluate his current PTSD disability. See VAOPGCPREC 11-95 (April 7, 1995); Snuffer, supra; Green v. Derwinski, 1 Vet. App. 121, 124 (1991) (VA has a duty to provide the veteran with a thorough and contemporaneous medical examination). Service Connection for a Bilateral Knee Disability The Veteran contends that he is entitled to service connection for a bilateral knee condition. He states he injured his knees during active service and he has suffered from knee symptomatology since this time. VA treatment records dated from May 2011 through September 2012 reflect the Veteran was treated for bilateral knee pain. Specifically, a May 2011 VA treatment record reflects the Veteran presented with complaints of bilateral knee pain. He reported that he was told he had arthritis. Examination revealed mild limitation and pain. The examiner also recommended orthopedic consultation. See Farmington Community Based Outpatient Clinic Treatment Records located in Virtual VA. A January 2012 orthopedic consult shows x-ray of the knees revealed suprapatellar bursa effusion. Examination revealed medial joint line tenderness and also that the Veteran ambulated with a mild limp. The Veteran reported that during active military service in Iraq, he fell and twisted his right knee. He also reported that since that time he experienced swelling, giving away and medial joint line pain. A provisional diagnosis of suprapatellar bursa effusion was noted. See Phoenix VA Medical Center Treatment Records located in Virtual VA. An August 2012 VA treatment record shows the Veteran was diagnosed with right knee pain. See Sun City Arizona Community Based Outpatient Clinic Treatment Records located in Virtual VA. A September 2012 MRI report of the right knee revealed patellar bone contusion, an oblique tear posterior medial meniscus and joint effusion. An orthopedic consult was submitted. See Phoenix V Medical Center Treatment Records located in Virtual VA. The Veteran was afforded a VA examination in connection with his bilateral knee condition in May 2013, at which time he provided his military history and reported that "lots of work hurt the knees." In the resulting report, the examiner noted a diagnosis of knee strain per the Veteran's history concluding that a knee condition was not identified upon examination. The Veteran reported that an MRI was conducted at Banner VA Medical Center and that he was told he had arthritis. The May 2013 examination report indicates that neither MRI of the knees nor a consult were associated with the claims folder. However, the examination report addressed a November 2011 x-ray of the right knee, which revealed "possible knee effusion" and also that x-ray of the knees were performed, which the examiner noted as "suspicion of fluid on x-ray . . . speculation only." The Board finds the May 2013 VA examination inadequate. Inadequate medical examinations include examinations that contain only data and conclusions, do not provide an etiological opinion, are not based upon a review of medical records, or provide unsupported conclusions. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The VA examination report does not make apparent the extent to which the examiner may have considered the August 2012 MRI diagnosing a medial meniscus tear of the right knee, the January 2012 VA treatment record diagnosing suprapatellar bursa effusion, or the VA treatment records documenting the Veteran's treatment for bilateral knee pain. Accordingly, a remand is required to obtain a supplemental medical opinion and an etiology opinion with respect to the conditions. Service Connection for TBI After a review of all evidence, both lay and medical, the Board finds that further evidentiary development is necessary before a decision can be reached on the merits of the underlying claim for a TBI. According to the Veteran, on more than one occasion during active military service he experienced head trauma. Specifically, he first injured his head during pre-mobilization prior to deployment to Iraq. He did not report a specific incident. Thereafter, in July 2010, while servicing a helicopter, he fell off a maintenance stand with another person causing him to hit the concrete. According to the Veteran, the other person, weighing 300 pounds, landed on top of him. He reported immediate symptoms to include severe pain in the head and back. See May 2013 VA Examination. Treatment records on file include a May 2011 positive TBI, PTSD, and depression screening. See Farmington CBOC Treatment Records located in Virtual VA. A June 27, 2011 TBI screening reflects the Veteran was diagnosed as having TBI during deployment. See Sun City Arizona Community Based Outpatient Center Treatment Records. A subsequent June 30, 2011 TBI evaluation note reflects the Veteran had prior treatment for TBI to include medication. See Phoenix VA Medical Center Treatment Records. Another June 30, 2011 treatment note reflects that based on the Veteran's reported history he did not suffer a deployment related TBI. At this time, the Veteran reported he sustained a head injury in service after a 360 pound man fell on top of him. He reported that he did not lose consciousness, but he did "see stars." The examiner concluded that there was insufficient evidence of residuals from a TBI, therefore only limited psychological testing was completed. Additionally, noting that depression and anxiety would likely negatively impact his cognitive abilities. Id. A November 2012 neurology note reflects the Veteran provided a CD to the VA clinician that showed evidence of prominent ventricular system and low lying cerebellar tonsils, noted as Chiari I malformation. Id. The Veteran was afforded a VA TBI examination in May 2013. In the resulting examination report, the examiner noted that the Veteran was initially diagnosed as having had a TBI in 2009. The VA examiner noted the Veteran's reported history of head trauma in service and the Veteran's reported symptomatology since that time to include memory loss, constant tinnitus, dizziness, and a numbing, tingling sensation at the base of the skull that radiates into his neck when he lands on his heels too hard. According to the VA examiner, his symptoms of impact related to sudden numbness and tingling in the back of the head and neck is "concerning for a structural problem for which a sudden impact could produce symptoms, such as this, one would think in this setting about a possible symptomatic Chiari." The examiner concluded that the Veteran's symptoms of transient numbness upon impact may imply intermittent aggravation of the Chiari and requested the CD images for review. The examiner did not address whether or not the Veteran's TBI diagnosis was etiologically related to service. Accordingly, another VA examination or opinion is necessary. Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007) (once VA provides an examination to a Veteran, VA has a duty to ensure that the examination is adequate for evaluation purposes). Accordingly, the case is REMANDED for the following action: 1. Undertake appropriate development to obtain any outstanding medical records (VA or private) relevant to the appeal, to include private treatment records from Dr. R.L., Dr. H.B, Dr. J.O., and Dr. J.P.D. related to the Veteran's treatment for a back condition and pain management. If records are unavailable from any sources, a negative reply must be requested. All responses received should be associated with the claims file. If any records sought are determined to be unavailable, or a negative response is received, the AOJ should make a formal finding of unavailability, the Veteran must be notified. 2. All reasonable attempts should be made to obtain any identified records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran and his representative must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C.A. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 3. After completing the action requested in paragraphs 1 and 2, schedule the Veteran for an examination to determine the current severity of his PTSD. The claims file, to include a copy of this remand, must be made available to the examiner for review in connection with the examination. The reviewer must also consider the lay statements of record, including the statements regarding the Veteran's symptoms. All pertinent symptomatology and findings must be reported in detail. Any indicated diagnostic tests and studies must be accomplished. The examiner should identify the nature, frequency, and severity of all current manifestations of the Veteran's PTSD. Findings necessary to apply the rating criteria should be elicited from the examiner, and a GAF score in accordance with DSM-IV should be sought. (The Board recognizes that the Veterans Benefits Administration is now required to apply concepts and principles set forth in DSM-5; however, the Secretary of VA has specifically indicated that DSM-IV is still to be applied by the Board for claims pending before it. 79 Fed. Reg. 45094 (Aug. 4, 2014)). The examiner must also determine whether PTSD has caused the Veteran to be unable to obtain or maintain substantially gainful employment, including what types of employment activities are limited because of this disability and what types of employment, if any, are feasible given his functional impairment. The examiner must provide a rationale for each opinion expressed. If an opinion cannot be made without resort to speculation, the examiner must provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. 4. Schedule the Veteran for another VA orthopedic examination with a VA orthopedic physician to determine the nature and etiology of any knee disability. The claims file and all electronic records must be made available to the examiner, and the examiner must specify in the examination report that these records have been reviewed. All pertinent symptomatology and findings must be reported in detail. All indicated diagnostic tests and studies should be accomplished. The examiner should identify the ranges of right and left knee flexion and extension shall be reported in degrees. The examiner shall also specify whether and to what extent there is any additional loss of knee flexion and/or extension (stated in degrees) due to any weakened movement, excess fatigability, incoordination, flare ups, and/or pain. In this regard, some speculation/conjecture on the examiner's part may be necessary. The examiner shall report if there is ankylosis of the right or left knee and, if so, the angle at which the knee is held. The examiner shall also report whether there is subluxation or instability of the right or left knee, and if present, provide an opinion as to its severity (i.e. slight, moderate, or severe). For each knee disability identified the examiner should provide the following opinions: Whether it as likely as not (50 percent probability or greater) it had its clinical onset in service or is otherwise related to active service. Whether it is at least as likely as not (50 percent or greater probability) that suprapatellar bursa effusion and meniscus tear of the right knee identified, or any residuals thereof are etiologically related to active service. The examiner must provide a comprehensive report including complete explanation for all opinions and conclusions reached, taking into account, and citing where appropriate, the evidence in the record, including the Veteran's reports of his history, his current symptomatology, and all associated functional and occupational limitations found. A complete rationale for all opinions must be given. If the examiner cannot provide the requested opinion without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. The examiner must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the examiner must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. 5. Schedule the Veteran for an appropriate examination to evaluate a traumatic brain injury. The claims folder must be made available to and reviewed by the examiner in conjunction with the examination report. Any indicated studies should be performed. The examiner should determine whether the Veteran has a TBI. In so opining, the examiner should discuss the diagnosis of a TBI in the VA treatment records to include the May 2013 VA examination report. The examiner should also discuss the June 2011 VA treatment record indicating that the Veteran did not have a deployment related TBI and reconcile any conflicting medical diagnosis. The examiner should then provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that a TBI is related to his military service. In so opining, the VA examiner should discuss his lay assertions of in-service head injuries. The examiner must provide a comprehensive report including complete rationales for all conclusions reached. 6. After undertaking any other development deemed appropriate, the AOJ should re-adjudicate the issues on appeal. If any benefit sought is not granted, the Veteran and his attorney should be furnished with a supplemental statement of the case (SSOC) and he and his attorney should be afforded an opportunity to respond before the case is returned to the Board. The appellant 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 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 2014). ______________________________________________ MICHAEL A. HERMAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs