Citation Nr: 1619905 Decision Date: 05/17/16 Archive Date: 05/27/16 DOCKET NO. 10-20 404 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for bilateral hearing loss. 2. Entitlement to service connection for tinnitus. 3. Entitlement to service connection for psychiatric disability, to include posttraumatic stress disorder (PTSD) and anxiety disorder. 4. Entitlement to service connection for migraines. 5. Entitlement to service connection for bilateral eye disability. 6. Entitlement to service connection for disability of the bilateral upper extremities, claimed as peripheral neuropathy, to include as secondary to service-connected lumbar spine disability. 7. Entitlement to service connection for a skin disability of the bilateral ankles, claimed as rash and scarring (ankle rash). 8. Entitlement to service connection for gastrointestinal or esophageal disability, claimed as ischemic bowel syndrome, esophageal stricture, gastritis, and erosive duodenopathy, to include as residuals of food poisoning (GI disability). 9. Entitlement to increases in the "staged" ratings assigned for service-connected degenerative disc and joint disease, lumbar spine with stenosis (lumbar spine disability), currently evaluated at 20 percent, prior to February 15, 2010, and 10 percent thereafter. REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD L. Zobrist, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from January 1952 to October 1954. The matters of service connection for a GI disability and ankle rash are before the Board of Veterans' Appeals (Board) on appeal from an October 2008 rating decision by the Waco, Texas, Department of Veterans Affairs (VA) Regional Office (RO). The matters of service connection for hearing loss, tinnitus, psychiatric disability, migraines, eye disability, and upper extremity disability are on appeal from an October 2012 rating decision. The matter of the rating assigned for lumbar spine disability is on appeal from a June 2010 rating decision that granted service connection and assigned a 10 percent rating. An interim May 2013 rating decision granted an increased 20 percent rating for the period prior to February 15, 2010, and continued a 10 percent rating from that point. (The Veteran's initial claim for service connection for PTSD has been recharacterized, in accordance with the holding in Clemons v. Shinseki, 23 Vet. App. 1 (2009), to be inclusive of other psychiatric diagnoses of record, which include anxiety disorder.) 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 the rating assigned for lumbar spine disability and entitlement to service connection for GI disability, ankle rash, hearing loss, tinnitus, psychiatric disability, migraines, and upper extremity disability are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDING OF FACT A (compensable) disability of either eye was not manifested in service and there is no competent and credible evidence that the Veteran's current eye disabilities are related to an event, injury, or disease in service. CONCLUSION OF LAW Service connection for bilateral eye disability is not warranted. 38 U.S.C.A. §§ 1110, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2015). REASONS AND BASES FOR FINDING AND CONCLUSION Notice and Assistance The requirements of 38 U.S.C.A. §§ 5103 and 5103A (West 2014) have been met. By correspondence dated in May 2012, VA notified the Veteran of the information needed to substantiate and complete his claim, to include a request that he complete a VA Form 21-4176 report of accidental injury for his eye disability, claimed as the result of an in-service accident. The Board notes that the Veteran returned the "VCAA Notice Response" form included in the May 2012 correspondence, but declined to complete and return the VA Form 21-4176. He has had ample opportunity to respond/supplement the record, and has not alleged that notice was less than adequate. The Veteran's service treatment records (STRs) and identified pertinent postservice treatment records have been secured. The AOJ arranged for VA examination in September 2012. The Board finds that the examination report contains sufficient clinical findings and information regarding the history and features of the disability to constitute probative medical evidence adequate for rating purposes. See Barr v. Nicholson, 21 Vet. App. 303 (2007). The Veteran has not identified any other potentially pertinent evidence that remains outstanding. (As noted above, the Veteran declined to provide VA Form 21-4176, which requested details of the in-service accident he described, see Wood v. Derwinski, 1 Vet. App. 190, 193 (1991) (noting that VA's duty to assist the Veteran in developing the facts and evidence pertinent to a claim is not a one-way street); however, the Board has considered the Veteran's lay testimony as to the relevant events as provided elsewhere, see Facts and Analysis, below.) VA's duty to assist is met. Accordingly, the Board will address the merits of the claim. Legal Criteria The Board notes that it has reviewed all the evidence in the record. Although the Board has an obligation to provide adequate reasons and bases supporting its decision, there is no requirement that the Board discuss every piece of evidence in the record. The Board will summarize the relevant evidence, as deemed appropriate, and the Board's analysis will focus on what the evidence shows, or fails to show, as to the claim. See Gonzalez v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Service connection may be established for disability due to disease or injury that was incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). To establish service connection for a disability, there must be evidence of: a present disability; incurrence or aggravation of a disease or injury in service; and a causal relationship between the present disability and the disease or injury incurred or aggravated in service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). A disease diagnosed after discharge may still be service connected if the evidence, establishes that such disease was incurred in service. 38 C.F.R. § 3.303(d); Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). The determination as to whether the above requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Facts The Veteran's STRs note refractive error at entry to service. A July 1953 "Special Duty Abstract" notes refractive error; no other eye conditions were noted. His "E" rating on the PULHES assessment was 2. A November 1953 STR notes a burned arm, treated with ointment. A June 1954 STR notes a complaint of dull pain in the eyes, diagnosed as palpebral conjunctivitis and treated with a sulfacetamide ointment (antibiotic). In August 1954, when the Veteran sought treatment for a cold, an ophthalmological consultation was requested because the Veteran had lost his glasses. On September 1954 separation examination, refractive error was noted; the examination report notes that there was no other current disability of the eyes. In May 2011, the Veteran claimed entitlement to service connection for bilateral eye disability based on "in service accident"; no additional details were provided. Private ophthalmological treatment records from June 2009 through June 2012 note diagnoses of refractive error, bilateral open angle glaucoma, allergic conjunctivitis, blepharitis, and dry eye syndrome, with subjective complaints of itching, eye discharge, occasional pain, tearing, and sensation of foreign bodies in the eyes. (The Board notes that the blepharitis apparently resolved prior to the period on appeal, as it is not noted after July 2009, which it was assessed as much improved, and was not seen on VA examination, below.) A June 2011 VA ophthalmologic treatment record notes refractive error and a four-year history of glaucoma. On September 2012 VA examination, the examiner noted the Veteran's lay testimony that an explosion in service affected one or both eyes, he was not sure. He reported that he sought medical treatment and was given a salve for face and hands, but did not remember any specific treatment for the eyes. He stated that he may have been given eye drops and cold towels. He reported current treatment with drops for glaucoma, as well as artificial tears. He reported current symptoms of occasional itchiness or gritty feelings, but good vision with glasses. On examination, refractive error was noted, corrected to 20/40 or better bilaterally. Pupils were round and reactive to light. Intraocular pressure was 16, bilaterally. Nuclear sclerotic cataracts, corneal arcus, optic disc abnormalities, and loss of visual field were noted; the eye was otherwise normal on examination. Based on examination, and review of the record, the examiner provided current diagnoses of bilateral open angle glaucoma, cataracts, and dry eyes, noting that visual field loss was due to glaucoma (as opposed to cataract). No eye scarring was noted. The examiner opined that the Veteran's current eye disabilities were less likely than not due to service. In her rationale, the examiner noted the single treatment during service for palpebral conjunctivitis, as well as the lack of any follow-up treatment. She noted that there was "no clear evidence of defective vision while in the service" and no current defect of visual acuity. Therefore, she concluded that the Veteran's current eye disabilities were neither incurred during nor caused by his active service. A September 2012 VA ophthalmologic treatment record notes diagnoses of glaucoma, cataracts, and refractive error. The cornea was otherwise clear. Medication was prescribed for glaucoma and itching. A December 2013 VA ophthalmologic treatment record notes current diagnoses of glaucoma, cataracts, and refractive error. There was no surface irregularity of either eye. The examination was otherwise normal. A February 2015 VA ophthalmologic treatment record notes the Veteran's report that he injured his eyes during service when a can blew up, sending scalding water into his eyes and scarring his right eye. He reported that the eye was very uncomfortable for several years after, but gradually improved. He reported occasional itching that is relieved by his glaucoma medication. A slight irregular surface was noted on the right eye, but the examination was otherwise within normal limits or consistent with prior diagnoses of current eye disability (i.e., glaucoma, cataract, refractive error.) Analysis The Board has considered the Veteran's general contentions that he injured his eyes on active duty and that his current eye disabilities are related to the in-service injury. (See, e.g., July 2015 substantive appeal.) With respect to the claimed incident in service, the Board recognizes that the Veteran is competent to report experiences capable of lay observation. In this specific case, however, the Board finds that the Veteran's testimony of eye injury following explosion or being splashed by scalding water is contradicted by the contemporaneous medical evidence of record. The Board notes that the Veteran's STRs are silent for any mention of the claimed eye injury and subsequent treatment. The Board also notes that the Veteran's treatment for conjunctivitis and a burned arm were clearly documented, to include receiving prescribed ointment for each (separate) incident, and that the Veteran received ophthalmological examinations prior to, during, and at separation from active service, all of which were negative for any finding of eye disability other than refractive error (which existed prior to service and is not considered a disease or injury under 38 C.F.R. § 3.303(c)). The Board also notes that the Veteran's STRs document treatment for numerous other routine medical concerns, such as upset stomach, rashes, back pain, headache, respiratory ailment, and urinary complaints. Thus, the Board finds it reasonable that if the Veteran received an injury to his eyes from an explosion or scalding water during service that resulted in scarring it would have been reported. See AZ v. Shinseki, 731 F.3d 1303, 1315-17 (2013) (recognizing the widely held view that the absence of an entry in a record may be considered evidence that the fact did not occur if it appears that the fact would have been recorded if present); Buczynski v. Shinseki, 24 Vet. App. 221, 224 (2011). To the extent that the indication of a burned arm suggests corroboration of the Veteran's report of injury due to scalding water, the Board notes that the STR does not indicate injury to the eye, and finds it reasonable that any such injury would be noted when documenting/treating the arm injury. Similarly, to the extent that the February 2015 VA treatment record notes a slight irregularity of the right eye surface, the Board notes that no such irregularly was noted in the Veteran's STRs, on prior VA or private treatment, or on VA examination. Therefore, the Board finds that the February 2015 VA treatment record does not corroborate the Veteran's report of injury during service that resulted in scarring. Consequently, the Board finds that the Veteran's testimony regarding an in-service accident and subsequent treatment for an eye injury is not credible. (The Board is not making a finding that this lack of credibility is due to any negative motive on the Veteran's part; it may simply constitute misrecollection due to the passage of time). Furthermore, and on an independent basis, the Board finds that the medical evidence of record weighs against the Veteran's claim. The Board acknowledges the Veteran's belief that his current eye disabilities are related to his active service. However, even if the Veteran's eyes were injured during service, the etiology of his current diagnosed eye disabilities (to include glaucoma, cataracts, and dry eyes) is a complex medical question that requires medical expertise, and the Veteran, a lay person, has not indicated that he possesses the training or expertise to competently opine as to etiology. 38 C.F.R. § 3.159(a); Jandreau v. Nicholson, 492 F. 3d 1372, 1377 (Fed. Cir. 2007). There is no indication in the record that medical evidence has linked the Veteran's bilateral eye disabilities to his active service. His private and VA treatment records are silent as to etiology (other than that provided by the Veteran, who (as a lay person without specialized training/expertise) is not competent to provide such opinion). The VA examiner reviewed the Veteran's claims file, to include his STRs (noting no evidence of defective vision in service), considered his lay testimony, and conducted an examination. Her negative nexus opinion is consistent with the evidence of record, which is silent for indication that cataracts, glaucoma, or dry eye were diagnosed prior to 2007. (See, e.g., June 2011 VA treatment record (noting a 4-year history of glaucoma) and June 2012 private treatment record (noting, for the first time, diagnoses of cataracts and dry eye syndrome.) Therefore, the Board finds that it is probative medical evidence weighing against the Veteran's claim. (The Board has considered whether an opinion is required as to whether (under Clemons, supra) the Veteran's allergic conjunctivitis, in particular, is related to service. However, the Board finds that there is no evidence (to include the Veteran's lay testimony) that symptoms of an allergic disability affecting the eyes manifested during, or is otherwise related to, active service. Having considered all medical and lay evidence, and absent any competent and credible evidence suggesting a link between such disability and any incident during service, a VA medical opinion to address the possibility of such etiology is not necessary. McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also Waters v. Shinseki, 601 F.3d 1274, 1278 (2010) (mere conclusory generalized lay statement that service event or illness caused the claimant's current condition is insufficient to require an examination)). In summary, the lay testimony of record reporting injury during active service is contradicted by the contemporaneous medical evidence of record and is, therefore not credible and does not support the claim. Likewise, the medical evidence of record either does not address etiology (from a medical perspective) or is against the Veteran's claims. In light of the foregoing, the Board finds that the preponderance of the evidence is against the claim of service connection for bilateral eye disability. Accordingly, the benefit of the doubt doctrine does not apply; the appeal in this matter must be denied. The Board is grateful to the Veteran for his honorable service, and regrets that a more favorable outcome could not be reached. ORDER Service connection for bilateral eye disability is denied. REMAND GI Disability, Ankle Rash, Lumbar Spine Disability In April 2014 correspondence (submitted on a VA Form 9 (substantive appeal) after VA issued a March 2014 supplemental statement of the case), the Veteran requested a Travel Board hearing to present testimony on these issues. A November 2014 VA Form 8 (certification of appeal) notes the Travel Board hearing request. A July 2015 VA Form 8 states that the request was withdrawn in July 2015, but the July 2015 correspondence referenced was the substantive appeal for issues on appeal from a separate claim stream, and did not constitute a withdrawal, in writing or on the record, of the Travel Board request associated with the claims of service connection for GI and ankle rash or of the rating assigned for service-connected lumbar spine disability. Furthermore, in February 2015 correspondence, VA attempted to notify the Veteran that he had been placed on the Travel Board hearing waiting list, but the correspondence was returned as undeliverable; the Board notes that subsequent correspondence has been sent to a different mailing address. The Veteran has requested a Travel Board hearing to present testimony on these issues; the request has not been withdrawn. Because the Board may not proceed with an adjudication of his claims without affording him the opportunity for such a hearing, and because Travel Board hearings are scheduled by the AOJ, a remand is required. See 38 U.S.C.A. § 7107(b); 38 C.F.R. § 20.700(a). Hearing Loss and Tinnitus On April 2012 VA audiological examination, the examiner noted that puretone threshold test results were not valid due to inconsistent and unreliable results and declined to provide a nexus opinion as to either claimed disability. Service connection for hearing loss was denied due to a lack of evidence of hearing loss disability, and service connection for tinnitus was denied due to a lack of nexus. A February 2011 VA treatment record indicates that an audiological testing was performed and hearing aids prescribed; the audiogram results are not of record. The VA treatment records notes that the Veteran has profound sensorineural hearing loss. Furthermore, tinnitus is a disability capable of lay observation. Consequently, the Board finds that remand is required to associate the February 2011 audiogram (which is constructively of record) with the record and to obtain a new audiological examination with nexus opinion as to both hearing loss and tinnitus. Psychiatric Disability On February 2011 VA psychiatric examination, the examiner opined that the Veteran did not have any acute mood or anxiety disorder. However, VA treatment records indicate that the Veteran is receiving regular treatment, to include prescribed medication, for psychiatric disability diagnosed as PTSD, anxiety disorder, and memory loss. (See, e.g., December 2014 VA mental health treatment record). In addition, on VA examination, the Veteran reported several stressors related to his active service, to include: being stationed near the Korean demilitarized zone (DMZ), seeing soldiers being killed, a good friend not returning from combat, and fearing encounters with land mines. Development to confirm these stressors has not yet been conducted. Also, he reported that the in-service stressors led to behavior changes, including use of drugs and alcohol, and that he received an Article 15 hearing, demotion, and confinement in the brig for striking a superior. The personnel records currently associated with the claims file do not include evidence of an Article 15 hearing or confinement, but do indicate that his rank was PFC in July 1953 and PVT in November 1953; the reason for the reduction in rank is not evident. The Board finds that the evidence current of record suggests that some corroborative evidence might be outstanding. On remand, the AOJ should arrange for exhaustive development is required to obtain: (1) all personnel records (to include any associated with the demotion suggested by the existing record), (2) the necessary development to attempt to corroborate the Veteran's stressors, and (3) a VA examination that addresses the current psychiatric diagnoses of record. Migraines/Headaches The Veteran has claimed entitlement to service connection for migraines/headache disability. He has asserted that he experienced migraines while on active duty (see, e.g., July 2015 substantive appeal), and that he has headaches today. STRs note his report of frequent headaches at entry to service and one complaint of headache during service. Private treatment records note his complaints of frequent headaches; he has not been diagnosed with a chronic headache disability/migraines or been afforded a VA examination in conjunction with this claimed disability. Because there is evidence that the Veteran experienced headaches (which are capable of lay observation) prior to, during, and after separation from active service, the Board finds that the "low threshold" standard as to when an examination to secure a nexus opinion is required is met for this issue, and development for such an examination is warranted. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). Upper Extremities VA and private treatment records confirm that the Veteran has been diagnosed with carpal and cubital tunnel syndromes. In addition, he reports that he has had trouble with his left arm since service (see, e.g., January 2011 statement), and that his doctor had diagnosed peripheral neuropathy of the upper extremities related to his service-connected lumbar spine disability. (He is competent to report symptoms capable of lay observation and diagnoses reported by qualified medical professionals.) However, other medical evidence of record suggests that his upper extremity disabilities are related to (non-service-connected) cervical spine disability. (See, e.g., October 2013 VA cervical spine examination, noting severe radiculopathy of the right upper extremity related to C7 and C8/T1 nerve involvement). The Board finds that the "low threshold" standard as to when an examination to secure a nexus opinion is required is met for this issue, and development for such an examination (to resolve the conflicting evidence of record) is warranted. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). 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. The AOJ should confirm the Veteran's mailing address and schedule the Veteran for a Travel Board hearing before a Veterans Law Judge to address the issues of (1) service connection for a GI disability, (2) service connection for an ankle rash disability, and (3) the rating assigned for lumbar spine disability. The Veteran and his representative are to be notified by letter of the date, time, and place of that hearing. Thereafter, that issue should be processed in accordance with established appellate practices 2. The AOJ should ask the Veteran to identify the provider(s) of any and all evaluations and/or treatment he has received for his (1) hearing loss, (2) tinnitus, (3) psychiatric disability, (4) migraine disability, and (5) upper extremity disability, and to provide authorizations for VA to secure records of any such private treatment. The AOJ should secure for the record complete clinical records of all pertinent evaluations or treatment (records of which are not already associated with the record) from the providers identified, to include all VA records (and, specifically, the February 2011 audiogram). If any records sought are unavailable, the reason for their unavailability must be noted in the record. If a private provider does not respond to the AOJ's request for identified records sought, the Veteran must be so notified, and reminded that ultimately it is his responsibility to ensure that private treatment records are received. 3. The AOJ should arrange for exhaustive development to secure for association with the record copies of the Veteran's complete service personnel file, to specifically include records associated with his apparent demotion in 1953. All facilities where such records may be stored should be searched. If such records have been destroyed or are irretrievably lost, it must be so certified for the record, and the Veteran should be so notified. The scope of the search must be noted in the record. 4. After the above development is completed, the AOJ should also arrange for exhaustive development to verify the Veteran's account of the claimed stressor events. Specifically, the Veteran has asserted that he was stationed near the Korean DMZ, that he saw soldiers being killed, that a good friend did not return from combat, and that he feared encounters with land mines. If the information of record, to include that obtained pursuant to the development ordered above, is insufficient to corroborate the stressors, the Veteran should be notified of the specific information that is needed to allow for verification and afforded an opportunity to respond. Any response indicating that verification was not possible (i.e. that records could not be located) should specify what exactly cannot be located or verified. The AOJ should thereafter make a formal finding for the record regarding each of the Veteran's claimed stressor events, indicating whether or not each is indeed corroborated by credible supporting evidence. If any development sought in this matter cannot be completed, the reason why completion is not possible must be explained, and the scope of the attempt must be described. 5. After the above-sought development is completed, the AOJ should arrange for the Veteran to be examined by an appropriate psychologist or psychiatrist to ascertain the nature and likely etiology of his psychiatric disability/ies. The Veteran's entire record (to include this remand and the AOJ's formal findings of whether any of the claimed stressor event are corroborated) must be reviewed by the examiner in connection with the examination. Following examination and interview of the Veteran and review of the pertinent medical history, the examiner should offer opinions that respond to the following: (a) Please identify (by diagnosis) each psychiatric disability found. Specifically, does the Veteran have a diagnosis of PTSD based on a corroborated stressor event (if any is found by the AOJ) or a fear of hostile military or terrorist activity? If PTSD is not diagnosed, indicate clearly what symptom(s) needed for such diagnosis is/are lacking. (b) In addition to the above, please identify the likely etiology for each acquired psychiatric disability other than PTSD that is diagnosed, to include the diagnoses of anxiety disorder and memory loss noted in VA treatment records. Specifically, is it at least as likely as not (a 50 % or better probability) that any are related to the Veteran's military service or events therein, or to service-connected disability? The examiner must explain the rationale for all opinions in detail, citing to supporting clinical data and/or medical literature, as appropriate. 6. The AOJ should also arrange for a VA audiology examination of the Veteran to determine the nature and likely etiology of his current bilateral hearing loss/tinnitus. Based on review of the entire record (to include this remand), including any VA treatment records received pursuant to the development ordered above, and the Veteran's reports of acoustic trauma during service (which should be deemed credible for the purpose of examination), the consulting audiologist should offer opinions that respond to the following: (a) Does the Veteran currently have a hearing loss disability (as defined in 38 C.F.R. § 3.385) in either ear and/or tinnitus? (b) Please identify the etiology of any hearing loss disability or tinnitus. Specifically, is it at least as likely as not (a 50 percent or better probability) that such disability is related to the Veteran's service, to include as due to/aggravated by acoustic trauma therein? The examiner must explain the rationale for all opinions, citing to supporting factual data and medical literature, as appropriate. If the requested opinion cannot be provided without resort to speculation, the examiner must explain why that is so. 7. The AOJ should also arrange for the Veteran to be examined by an appropriate physician to determine the nature and likely etiology of any headache disability, including migraine headaches. The Veteran's claims file (including this remand) must be reviewed by the examiner in conjunction with the examination. Based on examination of the Veteran and review of his claims file, the examiner should provide an opinion that responds to the following: (a) Please identify (by diagnosis) each headache disability entity found. (b) What is its most likely etiology for each headache disability diagnosed? Specifically, is there (i) clear and unmistakable (obvious, manifest, and undebatable) evidence that a currently diagnosed headache disability preexisted the Veteran's service and (ii) if so, is there clear and unmistakable (obvious, manifest, and undebatable) evidence that any preexisting headache disability WAS NOT aggravated (i.e., permanently worsened) during service (or, it is clear and unmistakable (obvious, manifest, and undebatable) that any increase was due to natural progress)? (c) If there is no clear and unmistakable evidence that a currently diagnosed headache disability preexisted service, is it at least as likely as not (a 50% or greater probability) that such disability is directly related to or was incurred in/had its onset during his active duty service? The examiner must explain the rationale for all opinions, citing to supporting factual data as appropriate. 8. The AOJ should also arrange for the Veteran to be examined by an orthopedist or neurologist to determine the nature and likely etiology of his claimed upper extremity disabilities. The entire record must be reviewed by the examiner in conjunction with the examination, and any tests or studies indicated must be completed. Based on review of the record, and examination and interview of the Veteran, the examiner should provide opinions that respond to the following: (a) Please identify (by diagnosis) any (and each) upper extremity disability found. (b) Please identify the likely etiology for each disability diagnosed. Specifically, is it at least as likely as not (a 50 percent or greater probability), that any such disability is related to the Veteran's service or to service-connected lumbar spine disability? The examiner must explain the rationale for all opinions, citing to supporting factual data as appropriate. 9. The AOJ should then review the record and readjudicate the claims. If any remain denied, the AOJ should issue an appropriate supplemental statement of the case and afford the Veteran and his representative opportunity to respond. The case should then be returned to the Board for further review. 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). These claims 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). ______________________________________________ VICTORIA MOSHIASHWILI Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs