Citation Nr: 1610562 Decision Date: 03/16/16 Archive Date: 03/23/16 DOCKET NO. 11-06 933 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for sleep apnea. 2. Entitlement to service connection for a right shoulder disability. 3. Entitlement to a compensable rating for bilateral hearing loss. 4. Entitlement to a rating in excess of 10 percent for chronic bronchitis. REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD N. Nelson, Associate Counsel INTRODUCTION The Veteran served on active duty from December 1964 to October 1980, including service in Vietnam. These matters come before the Board of Veterans' Appeals (Board) on appeal from a November 2010 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas, which denied service connection for sleep apnea and a right shoulder disability, continued a noncompensable (zero percent) ratings for bilateral hearing loss, and increased the rating for chronic bronchitis to 10 percent effective March 23, 2010. In March 2011, the Veteran notified the Board that he did not want a Board hearing. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2015). 38 U.S.C.A. § 7107(a)(2) (West 2014). The issues of entitlement to service connection for sleep apnea and a right shoulder disability are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. For the entire period of appeal, the Veteran's bilateral hearing loss disability has been manifested by no more than Level II hearing acuity in the right ear and Level II hearing acuity in the left ear. 2. For the period of appeal prior to June 18, 2014, the Veteran's chronic bronchitis manifested by a FEV1 of 74 percent predicted, FEV1/FVC of 74 percent predicted, and DLCO of 97 percent predicted. 3. For the period of appeal from June 18, 2014, the Veteran's chronic bronchitis manifested by a FEV1 of 42 percent predicted and FEV1/FVC of 57 percent predicted. CONCLUSIONS OF LAW 1. The criteria for the assignment of a compensable rating for bilateral hearing loss have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.7, 4.85, 4.86, Diagnostic Code 6100 (2015). 2. For the period of appeal prior to June 18, 2014, the criteria for the assignment of a rating in excess of 10 percent for chronic bronchitis have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.7, 4.96, 4.97, Diagnostic Code 6600 (2015). 3. For the period of appeal from June 18, 2014, the criteria for the assignment of a rating of 60 percent, but no more, for chronic bronchitis have been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.7, 4.96, 4.97, Diagnostic Code 6600 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, 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); Quartuccio v. Principi, 16 Vet. App. 183 (2002). VA notice letters must also include notice of a disability rating and an effective date for award of benefits if service connection is granted. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Here, the RO provided a notice letter to the Veteran in June 2010, prior to the adjudication of the claims for increased ratings for hearing loss and chronic bronchitis. The letter notified the Veteran of what information and evidence must be submitted to substantiate the claims for increased ratings, what information and evidence must be provided by the Veteran, and what information and evidence would be obtained by VA. The Veteran was told to inform VA of any additional information or evidence that VA should have, and was told to submit evidence to the RO in support of his claims. The content of the letter complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b). The record establishes that the Veteran has been afforded a meaningful opportunity to participate in the adjudication of his claims for increased ratings for hearing loss and bronchitis. The Board notes that there has been no allegation from the Veteran or his representative that he has been prejudiced by any of notice defects. See Shinseki v. Sanders, 556 U.S. 396 (2009). Thus, there is no prejudice to the Veteran in the Board's considering these issue on its merits. The Board finds that the duty to notify provisions have been fulfilled with regard to the increased ratings claims, and any defective notice is nonprejudicial to the Veteran and is harmless. The Board further finds that all relevant evidence has been obtained with regard to the Veteran's increased ratings claims, and the duty to assist requirements have been satisfied with regard to these claims. All available service treatment records (STRs) were obtained, and VA medical records and private medical records are associated with the claims file. The Board has reviewed the Veteran's statements and medical evidence of record and concludes that there is no outstanding evidence with respect to this claim. The Veteran underwent VA examinations in October 2010, October 2012, and February 2014 to obtain medical evidence regarding the severity of the hearing loss and bronchitis disabilities. The Board finds the VA examinations adequate for adjudication purposes. The examination was performed by medical professionals based on review of the claims file, solicitation of history and symptomatology from the Veteran, and examination of the Veteran. The examination reports are accurate and fully descriptive. Opinion is provided as the severity of any diagnosed conditions. As such, the Board finds that the Veteran has been afforded adequate examinations. The Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion for the bilateral hearing loss and chronic bronchitis disabilities has been met. See 38 C.F.R. § 3.159(c)(4); Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the duties to notify and assist the Veteran have been met with regard to the increased ratings claims, so no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of these claims. Increased Rating Claims I. Law and Regulations Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) found in 38 C.F.R. Part 4. 38 U.S.C.A. § 1155. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. §§ 3.321(a), 4.1, 4.21. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, where the evidence contains factual findings that show a change in the severity of symptoms during the course of the rating period on appeal, assignment of staged ratings would be permissible. See Fenderson v. West, 12 Vet. App. 119 (1999). Once the evidence has been assembled, it is the Board's responsibility to evaluate the evidence. 38 U.S.C.A. § 7104(a). The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. It is VA's defined and consistently applied policy to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 3.102, 4.3. II. Bilateral Hearing Loss Where the evaluation of hearing loss is at issue, an examination for VA purposes must be conducted by a state-licensed audiologist and must include a controlled speech discrimination test (Maryland CNC) and a pure tone audiometry test. Examinations will be conducted without the use of hearing aids. 38 C.F.R. § 4.85(a). A rating for hearing loss is determined by a mechanical application of the rating schedule to the numeric designations assigned based on audiometric test results. See Lendenmann v. Principi, 3 Vet. App. 345 (1992). Evaluations of bilateral hearing loss range from noncompensable to 100 percent based on organic impairment of hearing acuity, as measured by a controlled speech discrimination test and the average hearing threshold, as measured by puretone audiometric tests at the frequencies of 1,000, 2,000, 3,000 and 4,000 Hertz. The rating schedule establishes 11 auditory acuity levels designated from Level I, for essentially normal hearing acuity, through level XI for profound deafness. Under 38 C.F.R. § 4.85, Table VI (Numeric Designation of Hearing Impairment Based on Puretone Threshold Average and Speech Discrimination) is used to determine a Roman numeral designation (I through XI) for hearing impairment based on a combination of the percent of speech discrimination (horizontal rows) and the puretone threshold average (vertical columns). The Roman numeral designation is located at the point where the percentage of speech discrimination and puretone average intersect. 38 C.F.R. § 4.85(b). The puretone threshold average is the sum of the puretone thresholds at 1,000, 2,000, 3,000 and 4,000 Hertz, divided by 4. This average is used in all cases to determine the Roman numeral designation for hearing impairment. 38 C.F.R. § 4.85(d). Table VI Numeric designation of hearing impairment based on puretone threshold average and speech discrimination. % of discrim- ination Puretone Threshold Average 0-41 42-49 50-57 58-65 66-73 74-81 82-89 90-97 98+ 92-100 I I I II II II III III IV 84-90 II II II III III III IV IV IV 76-82 III III IV IV IV V V V V 68-74 IV IV V V VI VI VII VII VII 60-66 V V VI VI VII VII VIII VIII VIII 52-58 VI VI VII VII VIII VIII VIII VIII IX 44-50 VII VII VIII VIII VIII IX IX IX X 36-42 VIII VIII VIII IX IX IX X X X 0-34 IX X XI XI XI XI XI XI XI Alternatively, VA regulations provide that in cases of exceptional hearing loss, when the puretone thresholds at each of the four specified frequencies (1,000, 2,000, 3,000 and 4,000 Hertz) is 55 decibels or more, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral. Each ear will be evaluated separately. 38 C.F.R. § 4.86(a). The provisions of 38 C.F.R. § 4.86(b) further provide that, when the puretone threshold is 30 decibels or less at 1,000 Hertz, and 70 decibels or more at 2,000 Hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral. That numeral will then be elevated to the next higher Roman numeral. Each ear will be evaluated separately. Table VIA Numeric designation of hearing impairment based only on puretone threshold average: 0-41 42-48 49-55 56-62 63-69 70-76 77-83 84-90 91-97 98-104 105+ I II III IV V VI VII VIII IX X XI The findings for each ear from either Table VI or Table VIA, are then applied to Table VII (Percentage Evaluations for Hearing Impairment) to determine the percentage evaluation by combining the Roman numeral designations for hearing impairment of each ear. The horizontal rows represent the ear having the better hearing and the vertical columns the ear having the poor hearing. The percentage evaluation is located at the point where the rows and column intersect. 38 C.F.R. § 4.85(e). Table VII Percentage evaluation for hearing impairment (diagnostic code 6100) Poorer Ear XI 100* X 90 80 IX 80 70 60 VIII 70 60 50 50 VII 60 60 50 40 40 VI 50 50 40 40 30 30 V 40 40 40 30 30 20 20 IV 30 30 30 20 20 20 10 10 III 20 20 20 20 20 10 10 10 0 II 10 10 10 10 10 10 10 0 0 0 I 10 10 0 0 0 0 0 0 0 0 0 XI X IX VIII VII VI V IV III II I In this case, the Veteran was afforded a VA audiological examination in October 2010. He reported that he had difficulty understanding conversation with women and children, especially with background noise, and listening to the TV at a comfortable level for others. His pure tone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 average RIGHT EAR 25 40 65 90 55 LEFT EAR 30 40 75 95 60 Speech recognition ability was 94 percent in both ears. In October 2011, the Veteran's VA hearing aids were adjusted. Treatment records indicate that he was wearing them approximately 2-3 hours per day, and that the Veteran reported wearing them "when needed." The Veteran had another VA audiological examination in October 2012. His pure tone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 average RIGHT EAR 30 30 65 95 55 LEFT EAR 40 45 80 100 66.25 Speech recognition ability was 94 percent in the right ear and 92 percent in the left ear. VA treatment reports indicate that in June 2015, the Veteran's pure tone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 average RIGHT EAR 30 40 65 95 57.5 LEFT EAR 40 45 85 100 67.5 Speech recognition ability was not tested. The VA audiologist indicated that compared to previous audiometric results, the Veteran's hearing loss remained essentially unchanged. Although the October 2010 and October 2012 examinations indicate that the Veteran's hearing declined somewhat, the findings nonetheless still translate to, at worst, Level II hearing loss in the right ear and Level II hearing loss in the left ear when applied to Table VI of the rating schedule. This level of hearing loss warrants a zero percent rating and no higher under Table VII of the rating schedule. Therefore, a compensable disability evaluation is not warranted under Diagnostic Code 6100 for any period of the appeal. See 38 C.F.R. § 4.85, Diagnostic Code 6100. In sum, a compensable disability evaluation is not warranted for the bilateral hearing loss under Diagnostic Code 6100 at any time during the appeal period. The Board considered the provisions for paired organs under 38 C.F.R. § 3.383; however as neither ear's hearing loss is compensable to a degree of 10 percent or more, this regulation does not apply. 38 C.F.R. § 3.383 (a)(3). Because the preponderance of the evidence weighs against the claim, the benefit of the doubt doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49, 53-54 (1990). Accordingly, the claim for an increased rating for bilateral hearing loss is denied. III. Chronic Bronchitis For the Period of Appeal Prior to June 18, 2014 As an initial matter, the Board notes that the Veteran is current service-connected for allergic rhinitis (rated as 30 percent disabling) and chronic sinusitis with associated headaches (rated as noncompensable). He was also denied entitlement to service connection for chronic heart failure in an August 2013 rating decision. As such, these symptoms attributable to these three disabilities will not be discussed in relation to the claim for an increased rating for chronic bronchitis. Diagnostic Code 6600, for chronic bronchitis, provides for a 10 percent rating for bronchitis when the FEV1 (Forced Expiratory Volume in one second) is 71 to 80 percent predicted, or; FEV1/FVC (Forced Expiratory Volume in one second to Forced Vital Capacity) is 71 to 80 percent predicted, or; DLCO (SB) (Diffusion Capacity of the Lung for Carbon Monoxide by the Single Breath Method) of 66 to 80 percent predicted. 38 C.F.R. § 4.97, Diagnostic Code 6600. A 30 percent rating is assigned when the FEV1 is 56 to 70 percent predicted, or; FEV1/FVC is 56 to 70 percent predicted, or; DLCO (SB) of 56 to 65 percent predicted. Id. A 60 percent rating is assigned when the FEV1 is 40 to 55 percent predicted, or; FEV1/FVC is 40 to 55 percent predicted, or; DLCO (SB) of 40 to 55 percent predicted, or with maximum oxygen consumption of 15 to 20 ml/kg/min (with cardiorespiratory limit). Id. A maximum 100 percent rating is awarded for FEV-1 less than 40 percent of predicted value; or the ratio of FEV-1/FVC is less than 40 percent; or DLCO (SB) less than 40 percent predicted; or maximum exercise capacity less than 15 ml/kg/min oxygen consumption (with cardiac or respiratory limitation); or cor pulmonale (right heart failure); or right ventricular hypertrophy; or pulmonary hypertension (shown by Echo or cardiac catheterization); or episode(s) of acute respiratory failure; or requires outpatient oxygen therapy. Id. PFTs are required to rate respiratory conditions except in certain situations. See 38 C.F.R. § 4.96(d). If a DLCO (SB) test is not of record, rating should be based on alternative criteria as long as the examiner states why the DLCO (SB) test would not be useful or valid in a particular case. When the PFTs are not consistent with clinical findings, rating should generally be based on the PFTs. Post-bronchodilator studies are required when PFTs are done for rating purposes with some exceptions. When rating based on PFTs, post- bronchodilator results are to be used unless they are poorer than the pre-bronchodilator results, then the pre-bronchodilator values should be used for rating purposes. When the results of different PFTs (FEV-1, FVC, etc.) are disparate, the test result that the examiner states most accurately indicates the level of disability should be used for rating, and if the FEV-1 and the FVC are both greater than 100 percent, a compensable rating based on a decreased FEV-1/FVC ratio should not be assigned. Here, the Veteran had a VA examination for bronchitis in October 2010. He reported that he quit smoking in 2006 after intermittent smoking for 4-5 years of smoking 1-2 cigarettes per day. He indicated that his treatment included an inhaled bronchodilator (intermittently) and inhaled inflammatory (intermittently). Physical examination revealed no evidence of congestive heart failure, pulmonary hypertension, or abnormal breath sounds. His FEV1 was 74 percent of the predicted value, FEV1/FVC ratio was 74 percent, and the DLCO was 104 percent predicted. In November 2010, the examiner indicated that the diagnosis was bronchitis, acute, remote with residuals. The Veteran was afforded another VA examination in February 2014. He reported that he had been to the hospital twice for shortness of breath and was told that he had congestive heart failure. He stated that his symptoms included spitting up excessive amounts of phlegm continuously. He stated that he used daily inhalational bronchodilator therapy and inhalational anti-inflammatory medication; he did not use the oral bronchodilators, antibiotics, or oxygen therapy. Pulmonary function testing revealed that the DLCO was 21.2 ml/mmHg/min, or 97 percent predicted, and that spirometry and flow volume could not be interpreted due to poor quality from poor effort. As stated above, a 30 percent rating is warranted where the FEV1 is 56 to 70 percent predicted, or; FEV1/FVC is 56 to 70 percent predicted, or; DLCO (SB) of 56 to 65 percent predicted. 38 C.F.R. § 4.97, Diagnostic Code 6600. In this case, for the period of appeal prior to June 18, 2014, the Veteran's FEV1 was 74 percent predicted, his FEV1/FVC was 74 percent predicted, and his DLCO was, at worst, 97 percent predicted. As such, a rating in excess of 10 percent is not warranted for this period of the appeal. For the Period of Appeal from June 18, 2014 Private treatment records from Dr. F.M. dated in June 2014 indicate that the Veteran's FEV1 was 42 percent of the predicted value. VA treatment records indicate that Dr. F.M. measured the FEV1/FVC ratio to be 57 percent. In August 2015, the Veteran was afforded a third VA examination of his bronchitis. The examiner indicated that his condition required chronic low dose (maintenance) corticosteroids and intermittent inhalational bronchodilator therapy. The examiner indicated that the Veteran declined to have pulmonary function tests or x-ray tests, stating that he would obtain these reports and forward them to his regional VA office. Subsequent VA treatment reports indicate that the Veteran submitted a PFT study from Dr. F.M in August 2015, which showed FEV1 1.97, FEV1/FVC 51, and DLCO 32.3, with no further values or percentages were noted. A chest x-ray showed underlying chronic obstructive disease, with no lung infiltrates and a normal size heart. The diagnosis was a moderate obstructive lung defect. A 60 percent rating is assigned when the FEV1 is 40 to 55 percent predicted, or; FEV1/FVC is 40 to 55 percent predicted, or; DLCO (SB) of 40 to 55 percent predicted, or with maximum oxygen consumption of 15 to 20 ml/kg/min (with cardiorespiratory limit). 38 C.F.R. § 4.97, Diagnostic Code 6600. Here, for the period of appeal from June 18, 2014, resolving all reasonable doubt in favor of the Veteran, the Veteran's FEV1 was 42 percent predicted and his FEV1/FVC was 57 percent predicted. It is unclear what his DLCO is for this period of the appeal. As such, a 60 percent rating, but no more, is warranted for this period of the appeal. There is no evidence that the Veteran's FEV-1 has been measured at less than 40 percent of predicted value, the ratio of FEV-1/FVC less than 40 percent, or DLCO (SB) less than 40 percent predicted. There is also no evidence of maximum exercise capacity less than 15 ml/kg/min oxygen consumption, cor pulmonale (right heart failure), right ventricular hypertrophy, pulmonary hypertension (shown by Echo or cardiac catheterization), episode(s) of acute respiratory failure, or requirement of outpatient oxygen therapy to warrant a higher 100 percent rating. IV. Extraschedular Consideration The Board has considered whether referral for an "extraschedular" evaluation is warranted. In exceptional cases, an extraschedular rating may be provided. 38 C.F.R. § 3.321. The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for the service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). If the criteria reasonably describe the Veteran's disability level and symptomatology, then the Veteran's disability picture is contemplated by the rating schedule and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate a Veteran's level of disability and symptomatology and is found inadequate, it must determine whether the Veteran's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. § 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step, a determination of whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. In this case, the evidence fails to show unique or unusual symptomatology regarding the Veteran's service-connected disabilities that would render the schedular criteria inadequate. The Veteran's symptoms, including having a hard time understanding what people are saying and impaired lung capacity, are contemplated in the ratings assigned; thus, the application of the Rating Schedule is not rendered impractical. Moreover, the Veteran has not argued that his symptoms are not contemplated by the rating criteria; rather, he merely disagreed with the assigned disability ratings for his levels of impairment. In other words, he does not have any symptoms from his service-connected disabilities that are unusual or different from those contemplated by the schedular criteria. Moreover, the Veteran has not alleged or indicated that the collective impact or combined effect of more than one service-connected disability presents an exceptional or unusual disability picture to render inadequate the schedular rating criteria. See Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014). Accordingly, the Board finds that referral for consideration of an extraschedular rating is not warranted, as the manifestations of the Veteran's disabilities are considered by the schedular rating assigned. 38 C.F.R. § 3.321; Thun, 22 Vet. App. 111. ORDER A compensable rating for bilateral hearing loss is denied. For the period of appeal prior to June 18, 2014, a rating in excess of 10 percent for the chronic bronchitis is denied. For the period of appeal from June 18, 2014, an increased rating of 60 percent for chronic bronchitis is granted. REMAND With regard to the claim for service connection for sleep apnea, the Veteran contends that he reported having trouble sleeping on more than one occasion while on active duty, particularly after his second tour in Vietnam. He stated that he did not want to have the issue documented too strongly because he thought it could interfere with his chances for Army promotions. See the November 2011 notice of disagreement; March 2011 statement. STRs indicate that in a June 1980 report of medical history, the Veteran indicated that he had frequent trouble sleeping. Private treatment reports show that the Veteran was diagnosed with obstructive sleep apnea in July 2004. In September 2004, Dr. R.S. indicated that the Veteran had "severe and poorly responsive central sleep apnea." The Board finds that the Veteran's statements and evidence of record meet the standard of McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006), and a VA examination and medical opinion should be obtained. With regard to the claim for service connection for a right shoulder disability, the Veteran indicated in a March 2011 VA Form 9 for other issues that he disagreed with a November 2010 rating decision that denied service connection for a right shoulder disability. Such as statement constitutes a timely notice of disagreement. A Statements of the Case (SOC) has not been issued. As such, the Board is required to remand the issue for issuance of an SOC. Manlincon v. West, 12 Vet. App. 238 (1999). Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Schedule the Veteran for a VA examination to determine the existence and etiology of any current sleep disorder. The examiner should review the claims file, and should note that review in the report. For each identified disability, the examiner should opine on whether it is at least as likely as not (50 percent or greater probability) that the condition is related to incident, injury, or event in active service, including the June 1980 report of frequent trouble sleeping. The examiner should clearly outline the rationale for any opinion expressed. If any requested medical opinion cannot be given, the examiner should state the reason(s) why. 2. After completing the above development, and any additional development deemed necessary, readjudicate the claim for service connection for sleep apnea. If any benefit sought on appeal remains denied, then a fully responsive supplemental statement of the case should be furnished to the Veteran and his representative, and they should be afforded a reasonable opportunity for response. 3. Issue an SOC to the Veteran addressing the issue of service connection for a right shoulder disability. The Veteran should be advised of the time limit in which to file a Substantive Appeal. Then, if the appeal is timely perfected, the issue should be returned to the Board for further appellate consideration, if otherwise in order. The appellant has the right to submit additional evidence and argument on the matter or 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 2014). ______________________________________________ K. PARAKKAL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs