Citation Nr: 1623788 Decision Date: 06/14/16 Archive Date: 06/29/16 DOCKET NO. 12-21 422 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Manchester, New Hampshire THE ISSUES 1. Entitlement to compensation under the provisions of 38 U.S.C.A. § 1151, for additional disability, including residuals of right total knee arthroplasty (replacement), claimed to have resulted from medical or surgical treatment by the Boston VA Medical Center. 2. Entitlement to compensation for bilateral hand dermatitis, to include as secondary to right total knee arthroplasty and under the provisions of 38 U.S.C.A. § 1151. 3. Entitlement to compensation for disability manifested by back pain as secondary to residuals of right total knee arthroplasty. 4. Entitlement to compensation for disability manifested by right leg pain as secondary to residuals of right total knee arthroplasty. 5. Entitlement to compensation for an acquired psychiatric disorder as secondary to residuals of right total knee arthroplasty. REPRESENTATION Appellant represented by: New Hampshire State Office of Veterans Services WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD A.J. Turnipseed, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from June 1965 to May 1968. This appeal comes before the Board of Veterans' Appeals (Board) from a November 2010 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Manchester, New Hampshire, that denied compensation under § 1151 for residuals of right total knee arthroplasty, as well as bilateral hand dermatitis, back pain, right leg pain and a psychiatric disorder as secondary thereto. The Veteran was afforded a personal hearing at the RO in September 2011 and he also testified before the undersigned Veterans Law Judge via video conference in November 2012. Transcripts of both hearings are associated with the record. In July 2014, the Board denied the appeal. The Veteran appealed that decision to the Veterans Claims Court. In November 2014, the Court granted a Joint Motion for Remand, vacating the Board's decision and remanding the matter for further development. Subsequently, in October 2015, the Board remanded the appeal for action consistent with the Joint Motion. All requested development has been conducted and the appeal has been returned to the Board for further consideration. For reasons discussed below, the issue of entitlement to compensation for dermatitis is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran has no additional right knee disability that is due to VA treatment in which the proximate cause was carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing care or due to an event not reasonably foreseeable. 2. Compensation under 1151 for residuals of right total knee replacement is not established; there is no legal basis to consider a back disorder, right leg disability, or an acquired psychiatric disability as secondary thereto. CONCLUSIONS OF LAW 1. The criteria for entitlement to compensation under 38 U.S.C.A. § 1151 for residuals of right total knee arthroplasty as the result of VA treatment and care are not met. 38 U.S.C.A. § 1151 (West 2014); 38 C.F.R. § 3.361 (2015). 2. The criteria for compensation for disability manifested by back pain as secondary to residuals of right total knee arthroplasty are not met. 38 U.S.C.A. § 1151 (West 2014); 38 C.F.R. §§ 3.310, 3.361 (2015). 3. The criteria for compensation for disability manifested by right leg pain as secondary to residuals of right total knee arthroplasty are not met. 38 U.S.C.A. § 1151 (West 2014); 38 C.F.R. §§ 3.310, 3.361 (2015). 4. The criteria for compensation for an acquired psychiatric disorder as secondary to residuals of right total knee arthroplasty are not met. 38 U.S.C.A. § 1151 (West 2014); 38 C.F.R. §§ 3.310, 3.361 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2014); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2015). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable AOJ decision on the claim for VA benefits. The Board finds VA has satisfied its duty to notify under the VCAA by way of letters sent to the Veteran in December 2009 and August 2010, which were sent prior to the initial unfavorable decision issued in November 2010 and advised him of the evidence and information necessary to substantiate his 1151 claims, as well as service connection claim on a secondary basis. Both letters also advised him of his and VA's respective responsibilities in obtaining such evidence, as well as the information and the evidence and information necessary to establish an effective date in accordance with Dingess/Hartman, supra. Relevant to the duty to assist, the Veteran's service treatment records and post-service VA and private treatment records have been obtained and considered. The Veteran has not identified any additional, outstanding records that have not been requested or obtained. The Board notes that the Veteran was also provided with a VA medical examination and opinion in conjunction with this appeal in July 2010, and there is no indication or allegation that either the examination or opinion are inadequate to adjudicate the claim on appeal. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. 3.103(c)(2) requires that the RO Decision Review Officer or Veterans Law Judge who chairs a hearing fulfill two duties to comply with the VCAA. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Bryant, 23 Vet. App. at 488 During both hearings, the DRO and Veterans Law Judge adequately explained the claims on appeal and the Veteran, with the assistance of his representative, provided information regarding why he believed he is entitled to compensation for his claimed disabilities. Therefore, not only were the issues "explained . . . in terms of the scope of the claim for benefits," but "the outstanding issues material to substantiating the claim," were also fully explained and discussed. In sum, the Board finds that both hearings complied with the requirements of 38 C.F.R. § 3.103. Finally, the Board finds that there was substantial compliance with the Board's prior remand directives. In particular, the Board remanded the case in order for the AOJ to obtain all outstanding VA treatment records identified by the Veteran during the September 2011 RO hearing, e.g., VA treatment records dated since June 2010. A review of the claims file shows that the AOJ obtained all outstanding VA treatment records dated from June 2010 to November 2015, as well as a copy of the informed consent form that was signed by the Veteran before the March 2007 total right knee arthroplasty performed by VA. While the Veteran's signature is not reflected on the copy of the consent form associated with the record, the Board is satisfied that the Veteran signed the consent form, as the copy associated with the record reflects that the Veteran's signature was obtained and that the full document can be accessed through Vista Imaging. Accordingly, the Board finds that there has been substantial compliance with the prior Board remand directives and, therefore, no further remand is necessary. See Stegall, supra; D'Aries, 22 Vet. App. at 104 (2008). For the above reasons, no further notice or assistance to the appellant is required to fulfill VA's duty to assist in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). Analysis The Veteran is seeking entitlement to compensation benefits under 38 U.S.C.A. § 1151 for an additional disability incurred as a result of lack of proper follow-up care after a total right knee arthroplasty (replacement) was performed by VA in March 2007. He has asserted that he developed an infection and had to have a repeat right total knee replacement, which resulted in additional disability of the right knee. Under 38 U.S.C.A. § 1151, compensation shall be awarded for a qualifying additional disability or death in the same manner as if such additional disability or death was service-connected. For purposes of this section, a disability or death is a qualifying additional disability if the disability or death was not the result of the Veteran's willful misconduct and (1) the disability or death was caused by hospital care, medical or surgical treatment, or examination furnished the Veteran under any law administered by the Secretary, and the proximate cause of the disability or death was (A) carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the Department in furnishing the hospital care, medical or surgical treatment, or examination; or (B) an event not reasonably foreseeable. 38 U.S.C.A. § 1151. In determining whether a veteran has an additional disability, VA compares the veteran's condition immediately before the beginning of the hospital care or medical or surgical treatment upon which the claim is based to the veteran's condition after such care or treatment. 38 C.F.R. § 3.361(b). To establish causation, the evidence must show that the hospital care or medical or surgical treatment resulted in the veteran's additional disability. Merely showing that a veteran received care or treatment and that the veteran has an additional disability does not establish cause. 38 C.F.R. § 3.361(c)(1). Hospital care or medical or surgical treatment cannot cause the continuance or natural progress of a disease or injury for which the care or treatment was furnished unless VA's failure to timely diagnose and properly treat the disease or injury proximately caused the continuance or natural progress. 38 C.F.R. § 3.361(c)(2). To establish that carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in furnishing hospital care, medical or surgical treatment, or examination proximately caused a veteran's additional disability or death, it must be shown that the hospital care or medical or surgical treatment caused the veteran's additional disability or death; and (i) VA failed to exercise the degree of care that would be expected of a reasonable health care provider; or (ii) VA furnished the hospital care or medical or surgical treatment without the veteran's informed consent. Determinations of whether there was informed consent involve consideration of whether the health care providers substantially complied with the requirements of 38 C.F.R. § 17.32. Minor deviations from the requirements of 38 C.F.R. § 17.32 that are immaterial under the circumstances of a case will not defeat a finding of informed consent. 38 C.F.R. § 3.361(d)(1). Whether the proximate cause of a veteran's additional disability or death was an event not reasonably foreseeable is in each claim to be determined based on what a reasonable health care provider would have foreseen. The event need not be completely unforeseeable or unimaginable but must be one that a reasonable health care provider would not have considered to be an ordinary risk of the treatment provided. In determining whether an event was reasonably foreseeable, VA will consider whether the risk of that event was the type of risk that a reasonable health care provider would have disclosed in connection with the informed consent procedures of 38 C.F.R. § 17.32. 38 C.F.R. § 3.361(d)(2). During the hearings conducted in September 2011 and November 2012, the Veteran testified that, after his surgery in March 2007, he developed a lump above the knee and advised a VA physician about it and other problems he was having with the right knee. He testified that, while he was assured there was no concern, he kept telling doctors there was something wrong with his knee until the knee became so infected that he had to have a long course of vancomycin to cure the infection. He testified that after the infection subsided, he had to have right knee replacement revision, that the knee was never normal after that point, and that it had gotten worse. The Veteran has asserted that because VA failed to exercise a reasonable degree of care while he was recuperating following the initial surgery, he has been left with a greater degree of right knee disability and has developed additional disabilities because of right knee replacement failure, including dermatitis of the hands resulting from the long administration of vancomycin, right leg pain, aggravation of back pain, and increased anxiety. Review of the record reveals that, in January 2007, the Veteran presented to the Boston VAMC for the first time for evaluation of bilateral knee degenerative arthritis, at which examiners noted his history of two previous right knee arthroscopies. While the Veteran was able to ambulate without assistive devices, he reported having frequent knee pain, buckling, catching, giving way, and bilateral effusions. Examination revealed significant arthritis of both knees, with the right being significantly worse than the left. The evidence reflects that, after the risks, benefits and alternatives were discussed, the Veteran and his wife were interested in his undergoing a right total knee replacement at that time. Thereafter, in February 2007, the Veteran was seen for a pre-op total knee replacement education visit where an education booklet was reviewed with him. In early March 2007, informed consent was given for total knee arthroplasty, at which time the procedure was explained in detail and all risks, benefits, and alternatives were explained to him. See March 2007 informed consent form. The Veteran underwent right total knee arthroplasty on March 29, 2007. On the day of surgery, it was recorded that the Veteran was informed of all risks and benefits and agreed to the procedure being performed and a valid statement of informed consent was signed and dated and made a part of his record. After the surgery was completed, medication, rehabilitation and physical therapy were prescribed. On discharge on April 3, 2007, the Veteran indicated that he was "feeling good," and he was made aware of knee precautions and encouraged to report any change in his condition. On follow-up on April 17, 2007, he was doing well, as he had no fever, chills, drainage from the incision, or other complaints. The incision was well healed, but there was minimal swelling over the knee and decreased range of motion. Staples were taken out at that time and Steri-Strips were put in place. On subsequent follow-up on April 30, the Veteran reported that he began to develop increased pain and swelling with decreased range of motion approximately 1 and 1/2 weeks before. The examiner noted that, given some changes on X-ray, there were some concerns of possible early hardware loosening, but there was no suggestion or indication of infection. Nevertheless, the Veteran was recommended to continue with physical therapy and follow-up in a week to repeat X-rays. The examiner noted that if pain continued, work-up would begin for infectious etiology. On May 7, 2007, objective examination did not reveal erythema or drainage but some swelling was observed. The surgical incision was well healed, and the Veteran stated that he was doing well, taking less pain medication and that physical therapy was going well. Subsequent VA records show the Veteran continued to complain of pain and swelling in the right knee, as well as other symptoms, including muscles spasms with activity and slight tenderness. He also inquired why he had not progressed further. Objective examination showed he continued to experience decreased range of motion but his scar was well-healed and the knee was stable; however, a bone scan conducted in October 2007 revealed some abnormalities, although the Veteran was informed that the bone scan was not able to rule out the possibility of infection. See VA treatment records dated May 29, 2007, October 16, 2007. On October 25, 2007, the Veteran presented to urgent care with signs of possible infection, including a significant swollen and red area at the distal end of the surgical scar. The Veteran reported that the blister had arisen within the past week. See also November 2007 private treatment record. Objective examination revealed a fluid-filled cyst over the inferior aspect with surrounding erythema, fluctuance, and diffuse warmness. It was noted that he had been seen in the clinic the previous week without any signs of a localized infection. The Veteran was admitted for treatment, which included drainage and aspiration of the knee joint. Examiners noted that the overall clinical scenario suggested early infection of the prosthetic joint, which was likely caused by Coagulase negative Staph organism, and that effective therapy would likely necessitate explantation of the prosthesis and six weeks of antibiotic therapy followed by reimplantation after the infection had resolved. The evidence reveals that, following a six-week course of vancomycin therapy, the Veteran underwent reimplantation of the right total knee replacement on January 16, 2008 at the Maine Medical Center. The Veteran underwent a VA examination in July 2010 where the examiner diagnosed right knee arthritis, post right total knee replacement, post methicillin-resistant staph, right knee joint infection, post vancomycin therapy, post removal of original total knee replacement, and post repeat total knee replacement arthroplasty following successful treatment of joint infection. The examiner noted the Veteran's medical history as it pertained to the right knee, including the initial total right knee arthroplasty performed in March 2007, the subsequent methicillin-resistant staph infection in the prosthetic knee joint, removal of the prosthetic knee in early November 2007, six-week course of intravenous vancomycin, and replacement arthroplasty performed in January 2008. After reviewing the record and examining the Veteran, the July 2010 VA examiner opined that it was not likely that the Veteran sustained any additional disability as the result of VA medical/surgical services received, noting that, while there was short-term disability due to the knee infection and need for subsequent surgery, current examination showed that he had fully recovered from the infection and the second knee replacement. The examiner noted that the risk of joint infection following total joint replacement was the type of risk that a reasonable health care provider would have disclosed in connection with informed consent procedures, and he referenced the orthopedic consultation on January 29, 2007 as showing that the risks, benefits and alternatives were discussed with the Veteran and his wife at that time. The examiner also stated that the current degree of disability was likely the same extent of disability that would be present as a residual of the initial total knee replacement had the infection not occurred. The July 2010 VA opinion is considered the most competent, credible, and probative evidence of record regarding whether the Veteran developed additional disability of the right knee as the result of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in providing surgical and follow-up treatment following the initial March 2007 total right knee arthroplasty. Indeed, in concluding that it was not likely the Veteran sustained any additional knee disability as the result of the VA medical/surgical services received, the VA examiner presented a detailed and comprehensive overview of the case based on careful consideration of the record and a physical examination, as detailed above. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). In this regard, the examiner addressed the evidence showing short-term worsening due to infection and abatement leading to additional surgery, noting that the Veteran had fully recovered from the infection and the second knee replacement. The examiner further opined that the Veteran's current residual symptomatology, including osteoarthritis manifested by limitation of motion and increased functional and activity restrictions, was likely to the same extent as if the infection had not occurred. The Board notes that the July 2010 VA opinion is not contradicted by any medical evidence or opinion of record. In fact, his opinion is supported by the medical evidence of record which shows that the Veteran gave informed consent for the right total knee replacement to be performed and that all attendant risks and benefits were explained to him on several occasions as recited above. The evidence also shows that, following surgery, he received regular, extensive, and continuing follow-up and treatment, including diagnostic work-up, which did not reveal findings suggestive of infection until the Veteran sought treatment for a swollen and red area near the surgical scar in late October 2007 - findings which had not been reported or observed before that date. In sum, there is no indication that the treatment provided by VA following the initial March 2007 right knee arthroscopy was lacking or that VA was inattentive to his complaints. On the contrary, the evidence reflects that he was encouraged to report his symptoms. See e.g., April 2007 VA treatment record. At this juncture, the Board notes that VA treatment records dated from December 2013 to May 2015 show the Veteran was diagnosed with lichen simplex chronicus of the right knee, which resolved in May 2015. See VA outpatient treatment records dated March, June, and May 2015. While this evidence reflects that the Veteran has a skin disability affecting his right knee, the evidence also reflects that this condition was incurred as a result of the Veteran scratching a pitting stitch from the second right knee replacement performed at the Maine Medical Center in January 2008. See Id. Given that there is no allegation or indication that the right knee skin disability was incurred as a result of VA treatment, there is no need to discuss this disability any further. In evaluating this claim, the Board has considered the lay statements submitted by the Veteran in support of his claim and notes that he is competent to report the symptoms and disability that occurred following the initial surgery in March 2007. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). In this case, the evidence reflects that he did, in fact, develop an infection after the initial surgery and, while the Veteran may feel that the infection and any other additional disability was incurred as a result of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part, this determination is a complex medical issue that is beyond his expertise. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions); see also Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Indeed, the causation, negligence/fault, and foreseeability questions presented in this case are not simple medical questions and it is not argued or shown that the Veteran is otherwise qualified through specialized education, training, or experience to offer such opinions. Instead, the July 2010 VA examiner specifically opined, based upon review of the record, examination of the Veteran, and his medical expertise, that the infection was a temporary increase in disability within the foreseeable consequences of the total knee replacement of which the Veteran had been apprised prior to surgery. Therefore, the Veteran's statements in support of his claim are outweighed by the medical opinion provided by the July 2010 VA examiner. Therefore, after careful consideration of the evidence, the Board concludes that the legal requirements for entitlement to compensation for an additional right knee disability under the provisions of 38 U.S.C.A. § 1151 are not met. The evidence of record that weighs against the Veteran's claim outweighs the evidence in favor of his claim. Indeed, the most competent, credible, and probative evidence shows that the Veteran did not develop an additional, permanent right knee disability due to carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in furnishing medical or surgical treatment or an event not reasonably foreseeable. Therefore, as the preponderance of the evidence weighs against the Veteran's claims, entitlement to compensation for residuals of right total knee arthroplasty under the provisions of 38 U.S.C.A. § 1151 is denied. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. Finally, the Board notes that, because compensation under 1151 for residuals of right knee total arthroplasty is not established, there is no legal basis to find that back pain, right leg pain, or an acquired psychiatric disorder are secondary thereto. As the law and not the evidence is dispositive in this instance, these claims must be denied as a matter of law. See Sabonis v. Brown, 6 Vet. App. 426 (1994). Unlike the claimed dermatitis disability, the evidence also fails to establish that the claimed back pain, right leg pain, or acquired psychiatric disability were directly incurred as a result of the initial March 2008 right knee arthroplasty or the treatment provided by VA thereafter. Accordingly, the Board finds that Veteran is not entitled to compensation for back pain, right leg pain, or an acquired psychiatric disability. ORDER Compensation under 38 U.S.C.A. § 1151 for residuals of repeat right knee total arthroplasty is denied. Compensation for disability manifested by back pain as secondary to residuals of right knee total arthroplasty is denied. Compensation for disability manifested by right leg pain as secondary to residuals of right knee total arthroplasty is denied. Compensation for an acquired psychiatric disorder as secondary to residuals of right knee total arthroplasty is denied. REMAND While this claim was previously styled as entitlement to compensation for dermatitis as secondary to the total right knee arthroscopy, the evidence suggests that the Veteran's dermatitis was incurred as a result of the medication therapy he was provided by VA to treat the infection that occurred following the initial right knee surgery in March 2007. Therefore, a claim of entitlement to dermatitis under the provisions of 38 U.S.C.A. § 1151 has been raised by the record. Indeed, the July 2010 VA examiner opined that the dermatitis on the Veteran's hands and fingers is at least as likely as not caused by or a result of intravenous vancomycin therapy he was given when the initial prosthetic right knee was removed in November 2007. However, the examiner characterized the dermatitis as a "minor residual" and did not provide an opinion as to whether the proximate cause of the dermatitis was (a) carelessness, negligence, or lack of proper skill, error in judgment, or similar instance of fault on the part of VA, or (b) an event not reasonably foreseeable. Both the causation and reasonably foreseeability questions must be addressed by a medical professional before a fully informed decision may be rendered, as the Board is prohibited from relying on its own unsubstantiated medical judgment in the resolution of a claim. See Colvin v. Derwinski, 1 Vet. App. 171 (1991). Therefore, a remand is needed to obtain an adequate medical opinion. Accordingly, the case is REMANDED for the following action: 1. Arrange to obtain an addendum opinion regarding dermatitis affecting the Veteran's hands and fingers. The claims file should be provided. The examiner is asked to render an opinion with respect to the following: a. Is it at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's dermatitis was incurred as a result of treatment received at the Boston VAMC in approximately November 2007 following the removal of the initial right knee prosthesis? See July 2010 VA examination report. b. If the Veteran's dermatitis is deemed to constitute additional disability incurred, the examiner should also opine whether the proximate cause of such additional disability was (a) carelessness, negligence, or lack of proper skill, error in judgment, or similar instance of fault on the part of VA; OR (b) an event not reasonably foreseeable. An opinion as to both (a) and (b) must be provided. c. The examiner should also comment as to whether, in providing the Veteran's care at the Boston VAMC, any VA health professional failed to exercise the degree of care that would be expected of a reasonable health care provider. d. In addressing the above, the examiner should consider and discuss the Veteran's development and progression of dermatitis, with consideration and discussion of all pertinent lay and medical evidence, to include the July 2010 VA examination and opinion and VA treatment records associated with the record. e. A complete, clearly-stated rationale should be provided for each conclusion. 2. Readjudicate the claim. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This 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). ______________________________________________ R. FEINBERG Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs