Citation Nr: 1648155 Decision Date: 12/27/16 Archive Date: 01/06/17 DOCKET NO. 12-14 281 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUE Entitlement to service connection for a low back disability, to include degenerative disc disease of the lumbar spine. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD Jack S. Komperda, Associate Counsel INTRODUCTION The Veteran served on active duty from April 1955 to April 1958. This matter comes before the Board of Veterans' Appeals (Board) on appeal from May 2009 and June 2010 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina. In October 2014, the Veteran testified at a videoconference hearing before the undersigned; a transcript of that hearing is of record. The Veteran's appeal was previously before the Board in February 2015 at which time a decision denying the Veteran's claim seeking entitlement to service connection for a low back disability was issued. The Veteran appealed to the United States Court of Appeals for Veterans Claims (Court). In a June 2016 memorandum decision, the Court vacated the Board's decision and remanded the Veteran's appeal to the Board for readjudication. 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 appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND The Veteran seeks entitlement to service connection for a low back disability he has claimed is due to an incident sometime during active duty service in which he jumped off a truck and either landed on a drain or fell in a ditch. He stated he immediately suffered low back pain that worsened overnight. In its June 2016 memorandum decision, the Court determined that the Board erred in its decision denying the Veteran's service connection claim by failing to address favorable evidence connecting his in-service injury to his present low back disability. Specifically, the Court pointed to a September 1957 service treatment record which noted the Veteran presented with "tenderness in LS (presumably, lumbosacral) area." (The Board notes that the Court interpreted the handwritten treatment record as stating the tenderness experienced by the Veteran was in the L-5 area.) Further, the treatment record noted the Veteran had "severe limitation [of] motion [of the] R[ight] lower [extremity]." Further, the Court stated that the Board provided an inadequate statement of reasons or bases for relying on VA examinations in the claims file dated in February and May 2007 as evidence against the Veteran's service connection claim when neither examination report referenced the September 1957 service treatment record noting tenderness. The Court stated that remand was required for the Board to provide an adequate statement of reasons or bases for relying on the February and May 2007 VA examinations in denying the Veteran's low back claim, or to provide a new examination that addressed the Veteran's in-service back symptoms. The Board agrees that the VA examinations of record did not address the September 1957 service treatment record noting symptoms of tenderness in the back. As such, the Board will obtain a more responsive opinion that considers this evidence in determining whether the Veteran's current back disability is related to his active duty service. Since the claims file is being returned it should be updated to include any outstanding VA treatment records. See 38 C.F.R. § 3.159(c)(2); see also Bell v. Derwinski, 2 Vet. App. 611 (1992). Pursuant to the June 2016 memorandum decision, the Veteran should also be afforded an opportunity to submit any additional evidence and arguments not already in the claims file. 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. Obtain the names and addresses of all medical care providers who treated the Veteran for his back since February 2015. After securing the necessary release, take all appropriate action to obtain these records, and any outstanding VA treatment records. 2. After completion of the foregoing, refer the Veteran's claims file to an appropriate VA examiner to determine the likely etiology of the Veteran's back disability. The claims folder and any pertinent medical records should be made available for review by the examiner. In this regard, the examiner's attention is drawn to the following evidence (citations to the VBMS record or records that support the fact are provided): * A handwritten service treatment record dated September 7, 1957, which notes that the Veteran denied any previous illness. He reported that the prior night, he developed severe headache and generalized aches and pains. He stated that his entire body hurt. The examiner wrote that in the morning, the Veteran reported weakness in his right upper extremity and the inability to move his right arm. The examiner stated that the Veteran's temperature was 102 degrees. His heart, lungs, and abdomen were normal. Upon physical examination, there was tenderness in the Veteran's lumbosacral area and some limitation of motion in his right lower extremity, which the examiner noted that the Veteran moved slowly and carefully, but would not raise from the bed. There were no pathological reflexes. The neck was supple and lungs were both negative. The examiner noted that the Veteran had what appeared to be an early acute and [illegible] rhino pharyngitis. Spinal tap showed "crystal clear liquid." The Veteran was seen three days later on September 10, 1957. The examiner noted that the Veteran reported generalized aches but no definite weakness or paralysis. He wrote that the Veteran had no complaints on this date. Physical examination was "normal." See STR - Medical, received 06/15/2014, at p. 25. * The January 1958 Report of Medical Examination (completed at the time of the Veteran's discharge from service) shows that clinical evaluations of the spine and lower extremities were normal. Under "Significant or Interval History," the examiner noted there was "No significant history." The report showed that the Veteran had been assigned all 1s in the Physical Profile Serial of PULHES. P stands for physical capacity or stamina, U stands for upper extremities, L stands for lower extremities, H stands for hearing and ears, E stands for eyes, and S stands for psychiatric. The 1 under P and L represents a high level of fitness for physical capacity or stamina and lower extremities. See STR, received 01/22/1958, at p. 1, items # 37, 38, 73, 76. * A September 1967 VA hospitalization summary, which showed that the Veteran had been in an automobile accident. The summary indicates that the Veteran was admitted with multiple body contusions. He had lacerations over the left check, mid forehead, and the skin over the left knee, all of which were sutured. There were no neurological abnormalities, and there was no clinical evidence of a bone injury. There was evidence of a minimal effusion over the left knee and multiple contusions over the skin of the chest, the area over the left knee, and the right ankle. The Veteran complained of some chest pain and pain on motion of the cervical spine. Multiple x-rays were taken, which "failed to reveal any bone injury." He was hospitalized for five days and had no complaints at time of discharge. See VA 10-1000, Hospital Summary, received 09/24/1967. * In May 1968, the Veteran submitted a claim for service connection for "Residuals of back injury, 1956, [with] resulting pains in legs." He indicated he was treated for this at Fort Belvoir in 1956, the VA hospital in September 1967, and by a private physician in January 1968. See VA 21-526 Veterans Application for Compensation or Pension, received 05/31/1968, at p. 2. * A September 1971 VA outpatient treatment record shows that the Veteran was seen with low back pain and radiation down the right leg for one year. The examiner noted that there was a history of an acute accident in 1967. See VA 10-10 Forms, received 09/22/1971. * A September 1971 VA outpatient treatment record shows that the Veteran was seen with complaints of a low backache with right-sided radiation for the past week. The examiner wrote that the Veteran reported having this problem when he was in the Army in 1957. Gait was normal. Flexion was 100 degrees, extension was 20 degrees, and side flexion was 40 to 50 degrees. The examiner wrote there was no sensory change, and reflexes were 2+. Straight leg raising tests were 80 degrees. The Veteran complained of some pain in the back, but no radiation. There was no paravertebral spasm, and no apparent list. X-ray showed a separation in the region of inferior and anterior aspect of L-5 with a spur at the anterior inferior aspect of the region, anterior-inferior wall of the vertebrae and anterior superior part of S-1, which seemed to be somewhat sclerosed. The examiner noted that, "This might be an old injury from the ilium." See VA 10-10 Forms, received 11/14/1971, at p. 2-3. * An October 1971 VA outpatient treatment record indicates that the Veteran was seen again with low back pain, noting that it was somewhat improved. The examiner noted that the Veteran had removed his shirt and there was no list and that he walked with no list. Gait was normal. The examiner wrote that the Veteran walked on his toes and heel without difficulty and was able to bend at the hips with the knees fully extended to 90 degrees and was able to touch the floor. Straight leg raising was 80 degrees without pain, but the Veteran was able to go to 90 degrees. Laseague's test and Fabre's tests were both negative. There were no sensory changes. The examiner noted that the x-rays were reviewed with another physician, who agreed that there was definitely spondylolysis at L-5, S-1 with no slipping. It was noted that the Veteran had a spur on the inferior and anterior aspect of L-5 and some decreased disc space between L-5, S-1, with the higher vertebral interdisc spaces. The impression was Spondylolysis, L-5, S-1. See Medical Treatment Record - Government Facility, received 04/18/1972, at p. 3. * A March 1972 private medical record indicates that the Veteran was in an automobile accident and sustained multiple lacerations to the face and to the left knee, a contusion of the right lung, and pneumothorax of the right lung. He had a thoracotomy tube inserted, which was subsequently drained. He was transferred to a hospital for further care. See Medical Treatment Record - Non-Government Facility, received 11/07/1974, at p. 4. * A March 1972 private "Report of Examination" shows that Veteran underwent an examination. The examiner noted that the Veteran was in an automobile accident on March 7, 1972, and that while in the hospital, he was not treated by an orthopaedist. The examiner examined the Veteran's neck, dorsal, and lumbar spine. He wrote that there was moderate muscle spasm "in the neck, the dorsal and lumbar spine" and that the Veteran was limited because of pain. The examiner added that there was "peaking and splinting upon all motions of the back[,] which [we]re limited to about 50%." Neurological examination of the lower extremities was normal. The examiner noted that the Veteran "suffered a wreck injury in 1968." X-rays of the lumbosacral spine were negative for fracture, dislocation, or abnormality. See Medical Treatment Record - Non-Government Facility, received 03/24/1972. * A September 1972 private medical record shows that the Veteran reported that his back was "about the same, no worse." The Veteran reported that his back bothered him in the morning but after a while, when he would put on his brace, it would get better. He was seen the following month in October 1972 with complaints of pain in his back and that the brace made it no better or worse. The examiner recommended the Veteran not wear the brace. The Veteran was seen in November 1972 and reported he had been hurting "down his back" and had to wear the brace. The examiner stated that he felt the Veteran would not be able to return to his work in the steel mill. In a December 1972 entry, the examiner noted that x-rays of the lumbosacral spine showed narrowing and sclerosis of the lumbosacral joint, but otherwise no essential abnormality." See Medical Treatment Record - Non-Government Facility, received 11/07/1974, at p. 2-3. * A June 1973 VA treatment record shows that the examiner noted the Veteran had a history of low back pain "for years." He wrote the Veteran had good range of motion and no neurological deficits. The prognosis was a lumbo-sacral corset. See VA 10-1000 Hospital Summary and/or the Compensation and Pension Exam Report, received 06/18/1973. * An April 1974 private medical record shows that the Veteran reported he had been to VA and been taken care of and provided a brace. The Veteran reported he had pain and still could not sleep well or do anything. The examiner noted the Veteran had "very little muscle spasm in his lumbar area." The Veteran was able to touch his toes "fairly well, without any peaking or any indication that there is severe pain, and he extend[ed] well." The examiner added that twisting motions were normal in the standing position and that the neurological exam of the lower extremities was normal. The examiner concluded that it had been two years since the Veteran had been in an accident and estimated a physical incapacitation of 10 percent, given the Veteran's narrowing of the L5-S1 joint. See Medical Treatment Record - Non-Government Facility, received 11/07/1974, at p. 1. * A November 1974 VA treatment record shows that the Veteran was seen for low back pain as a follow-up from 1971. The examiner wrote that the Veteran had a long history of low back pain, which was described as chronic and constant. The Veteran was able to flex to 90 degrees, extend to 20 degrees, lateral bend to 30 degrees, and do straight leg raising to 90 degrees, bilaterally. The examiner recommended "WFE" and a brace. See Medical Treatment Record - Government Facility, received 12/18/1974. * A February 1975 VA treatment record shows that the Veteran was seen with low back pain, where he reported that his legs felt "funny." The examiner noted the Veteran had been seen in November 1974 for degenerative arthritis and had been given a brace that he wore. The Veteran also complained of chest pain. The assessment was low back syndrome secondary to degenerative arthritis. See VA 10-10 Forms, received 02/20/1975. * A document submitted to Social Security in approximately February 1975 shows that the Veteran completed a "Medical History and Disability Report." When the Veteran was asked for his illness or injury, he wrote "Chest and Back." When asked when his illness or injury first bothered him, he wrote, "3/[19]72." When asked when did his illness or injury finally prevented him from working, he wrote, "3/[19]72." When asked to explain why he stopped working, the Veteran wrote, "Car wreck causing severe back pain when he attempts to work." The document indicates that a lawyer completed the form for him. Some of the pages were scanned upside down. See SSA/SSI letter, received 03/22/2004, at p. 1. * A March 1979 VA treatment record shows that the Veteran was seen with low back pain. The Veteran reported that the pain radiated into his legs and that his legs were especially painful. He reported having a long history of back problems. The examiner wrote that the Veteran had generalized aching low back and both legs but that it was not compatible with nerve root pain. Straight leg raising was negative to pain, and neuro was "OK." The examiner diagnosed degenerative disc disease L5-S1 with degenerative joint disease. Some of the clinical findings are illegible to the undersigned, so not all are reported. The examiner should see VA 10-10 Forms, received 03/15/1979, for more detailed clinical findings. * An April 1980 VA treatment record shows that the Veteran was seen with complaints of low back pain radiating down both legs. The examiner wrote there was no paraspinal tenderness and no motor or sensory loss in his legs. The assessment was chronic back pain. See VA 10-10 Forms, received 04/16/1980. * An April 1981 VA treatment record shows that the Veteran was seen with multiple complaints, which included low back pain. The Veteran reported longstanding lumbosacral back pain. The examiner stated that the Veteran had normal deep tendon reflexes without sensory or gross motor deficit. The Veteran could bend to touch toes and walk on his heels and tip toes without difficulty. The diagnosis was probably musculoskeletal pain of undetermined etiology. See VA 10-10 Forms, received 04/20/1981. * A January 1982 VA treatment record shows that the Veteran reported an injury to his lumbosacral spine in 1957 and 1972. See VA 10-10 Forms, received 01/04/1982. * A March 1983 private exam report shows that the Veteran was referred for a disability secondary to injuries sustained in an automobile accident in 1972. The examiner noted that the Veteran had been receiving disability benefits since that time. As to the Veteran's back, the examiner wrote that the Veteran complained of osteoarthritis of the lumbar spine and having difficulty bending over. The Veteran reported he could not lift heavy objects and denied symptoms of herniated nucleus pulposis. "Specifically, he has no sharp shooting pains, no bowel or bladder symptoms, and no weakness or numbness." Physical exam revealed that straight leg raising was positive at 45 degrees, bilaterally. The examiner noted that when the Veteran was sitting up, the examiner was able to raise the Veteran's legs to 90 degrees without producing the same symptoms. The examiner concluded, "This therefore is a glaring inconsistency in this examination." The examiner wrote that when bending over, the Veteran was unable to reach the floor by a full 24 inches. The Veteran was able to do heel walking and toe walking without restriction. Neurological findings were without abnormality. The impression related to the back was mild osteoarthritis of the lumbar spine with inconsistent findings on examination. See Medical Treatment Record - Non-Government Facility, received 03/01/1982, at p. 1-4. * In a February 1984 letter, a private attorney wrote a letter to the Department of Health and Human Services, Social Security District Office, and noted that the Veteran had severe injuries resulting from an automobile wreck in "about 1972" and had a severe back condition as well as significant dizziness as a result of head and back injuries that the Veteran had sustained in the automobile wreck. See Third Party Correspondence, received 03/01/1982. * A February 1985 VA treatment record shows that the examiner wrote that the Veteran was complaining of lower back pain for 10 years. The examiner noted that a 1984 x-ray showed spondylosis L5, S1. See VA 10-10 Forms, received 02/25/1985. * A November 1985 VA treatment record shows that the Veteran reported low back pain that radiated to the legs for the past month. The examiner noted that the Veteran ambulated without a problem and that flexion was slightly limited. The examiner wrote that there was low back pain without leg pain, bilaterally, at 70 degrees, and that deep tendon reflexes and sensory were intact. The diagnosis was lumbar spondylosis. See VA 10-10 Forms, received 11/04/1985. * In a March 1986 statement, the Veteran wrote that he injured his back when exiting a truck. See VA 21-4138 Statement in Support of Claim, received 03/17/1986. * In a March 1987 memorandum written in connection with the Veteran's claim for disability benefits with the Department of Health and Human Services, Social Security Administration, the Veteran's attorney wrote, "[A]ll of the previous medical evidence in the record supports the finding that [the Veteran] has suffered from severe back problems since 1971. This has been found to be true by every medical doctor treating claimant and by every x-ray report in the record." See SSA/SSI letter, received 03/23/2004, at p. 11. * A document in the file has multiple x-rays of the lumbar spine that cover a nine-year period. See Medical Treatment Record - Government Facility, received 04/15/1986. For example, a November 1975 x-ray shows narrowing of the lumbosacral disc with degenerative changes. P. 15. A March 1979 x-ray of the lumbar spine showed no evidence of recent or old fracture. There was narrowing of L5-S1 interspace with degenerative changes at this level. Remaining joint spaces were normal. Height of vertebral bodies was normal. P. 11. An April 1984 x-ray of the lumbar spine revealed some spondylosis of the lower lumbar spine and is moderately narrowed disc space at L5-S1 and degenerative change of facet at L5-S1. Remainder of study was unremarkable. P. 10. * An August 1990 VA hospitalization report shows that the Veteran was diagnosed with lumbar 4-5 herniated nucleus pulposus. The examiner wrote that the Veteran had a 20 to 25-year history of low back pain that radiated down the anterior aspect of both heights into the proximal aspect of the feet. The examiner noted that the Veteran had been disabled since 1973. The Veteran noted having a hernia repair in 1958. He underwent an L4-5 laminectomy and discectomy at that time. See Medical Treatment Record - Government Facility, received 08/08/1990. * In a February 1994 statement, the Veteran's mother wrote that the Veteran had injured his back in service in 1957 and that after he got out of the hospital, he went home for two weeks. She stated the Veteran continued to have low back pain following service discharge. See VA Form 21-4138 Statement In Support of Claim, received 02/15/1994. * In a January 2005 statement, a VA examiner wrote that she had reviewed the Veteran's service treatment records and that it was her professional medical opinion that it was more likely than not that the low back pain is directly related to injuries - fall - that the Veteran incurred while in service. See Medical Treatment Record - Government Facility, received 01/03/2005. * A September 2005 VA examination report shows that the Veteran reported he fell in a ditch in 1957, which he blamed was the cause of the chronic back pain he had had ever since. He reported having a motor vehicle accident in 1972 and, again, had low back pain at that time as well. He claimed he had been using a wheelchair since 1998 and that the pain affected both legs. The examiner commented that the Veteran was showing functional overlay. For example, he wrote that the when showing the Veteran the kinds of movements he had to do, the Veteran was able to do them standing up "very well." There was no motor or sensory findings, and deep tendon reflexes were equal and regular. The impression was low back pain due to disk disease, which problem was as likely as not the cause of the Veteran's low back pain, which originated in 1957. See VA Examination, received 09/20/2005. * In a November 2005 addendum, a VA examiner wrote that the he had reviewed the claims file with the examiner who provided the September 2005 opinion and that there was nothing in the service medical records, which pertained to a low back injury. This examiner noted that the discharge physical exam did not reflect any low back problem at the time and that based upon a review of this additional information, it was less likely than not that the Veteran's current back disability was related to his military service. See VA Examination, received 11/17/2005. * A February 2007 VA examination report shows that the Veteran reported that he fell in 1957 during the process of jumping down from a truck. He stated he was seen at the hospital in Ft. Belvoir, Virginia, and was hospitalized for several days on that occasion. The Veteran stated he was put on a profile and told not to carry out any lifting and never resumed full duty. He was uncertain if x-rays were taken. He reported he had been told he had disks and pus in the spine. The Veteran denied injuring his back after service discharge. At that time, he complained of constant low back pain, which radiated to both legs and limited his ability to walk. He described having incapacitating episodes, which confined him to bed, but he was unable to identify a specific number of episodes in the past year. Physical examination revealed that the Veteran entered the examination area using a walker and required the walker for simple standing. The examiner was unable to test range of motion or repetitive activity because of continuous pain. The examiner concluded that it was less likely than not that the Veteran's present condition was related to the injury in service. The rationale was that there was no documentation of any form of injury in the service treatment records despite the story told by the Veteran. See VA Examination, received, 02/12/2007. * A May 2007 VA examination report shows that the examiner reviewed the claims file "thoroughly." The Veteran reported that his job in the military was that of airborne and engineer in the Army. He stated he began having low back pain in 1956, at which time he jumped off a truck and landed on a drain. Upon landing, he had the sudden onset of low back pain. The Veteran described having some mild discomfort at that time, but said that his pain significantly worsened overnight and that the next morning, he could not get out of bed. He was taken to the hospital but does not remember being given a specific diagnosis. The Veteran described having back problems on and off ever since. He denied having any back pain prior to service and had not had any significant injuries since military discharge. The Veteran was in a wheelchair at the time of this examination and was unable to participate in any range of motion testing. The Veteran had deep tendon reflexes of 3+ in all four extremities and sensation was intact, as best as the examiner could tell. The examiner concluded that the Veteran's back pain was due to severe degenerative disc disease, which showed the central canal stenosis and thecal sac compression. The examiner stated the Veteran had significant lumbosacral spine disease, but that in his opinion, the disease was less likely than not related to his active service. He explained that he was unable to find any documentation to credibly link the diagnosis to service. He added that he thought it was "very unlikely" that the Veteran sustained an injury in 1956 that led to his current severe degenerative disc disease. The examiner noted that the Veteran did not have surgery on his lumbosacral spine until 1990, which is a "huge gap between his military career and an increase in his severity of his pain to the point that he required intervention." See VA Examination, received 05/08/2007. * In a July 2011 statement, a physician who claimed to be the Veteran's treating physician signed a note that read the following: "I have reviewed [the Veteran]'s service medical records which document he was treated for a lumbar spine condition while on active duty. I have also reviewed his current treatment records that document his current diagnosis of chronic low back pain. After careful review, it is my medical opinion that it is more likely than not that the current condition had its onset while the patient was on active duty, and has continued since his release from service." See Medical Treatment Record - Non-Government Facility, received 12/11/2014. * An August 2011 VA examination report shows that the Veteran reported that in 1957 he had jumped off the back of a truck and fell into a ditch and injured his back. The Veteran reported he was taken to the hospital the next day because he could not move. He stated he had received treatment for three weeks. The Veteran stated from that time until he was discharged in 1958, he was on a profile of light duty. The examiner noted the Veteran was a wheelchair and declined to move or to transfer to the examining table because of weakness in the legs and low back pain. The examiner diagnosed lumbosacral Spondylosis. See VA Examination, received 08/18/2011. * The Board notes that it does not find that the Veteran's report of an in-service injury, such as falling on a drain or falling into a ditch, to be credible. It accepts that the Veteran had tenderness in his lumbosacral spine, as documented by a medical professional in the September 1957 service treatment record. While the Board has laid out a lot of evidence, it asks that the examiner review the file in its entirety. Following a review of the record, and any necessary testing, the examiner is requested to address the following questions: (a) Please identify all diagnoses related to the Veteran's complaints of back problems. (b) The examiner should opine as to whether it at least as likely as not (i.e., probability of 50 percent or greater) that any diagnosed back condition had its onset in service or is otherwise related to active duty service. The opinions provided thus far on this determinative issue have not included the required level of explanation or rationale. For example, in attempting to comment on this determinative issue of causation, prior VA examiners have neglected to address evidence in the record, namely, a handwritten service treatment record dated September 7, 1957, which shows that the Veteran experienced tenderness in his lumbosacral area with some limitation of motion in his right lower extremity. The examiner should address whether this September 1957 medical record supports the Veteran's contentions that his present back problems had their onset or are otherwise related to his active duty service. The examiner should also address all other relevant medical evidence in the record concerning the Veteran's back problems. A full rationale is to be provided for all stated medical opinions. If the examiner concludes that the requested opinion cannot be provided without resort to speculation, the examiner should so state and explain why this opinion would be speculative and what, if any, additional evidence would permit such an opinion to be made. If the examiner cannot provide opinions without examining the Veteran, then an examination should be scheduled. If an examination is scheduled, the examiner should perform any diagnostic tests deemed necessary. 3. Then readjudicate the Veteran's claim. If any benefit remains denied, issue an appropriate Supplemental Statement of the Case (SSOC), and give the Veteran and his representative an appropriate opportunity to respond. The case should then be returned to the Board, if otherwise in order, for further appellate review. 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). _________________________________________________ A. P. Simpson Acting Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2014), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2015).