Citation Nr: 1628139	
Decision Date: 07/14/16    Archive Date: 07/28/16

DOCKET NO.  08-31 543	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in Atlanta, Georgia


THE ISSUES

1.  Entitlement to an initial rating in excess of 10 percent for left shoulder rotator cuff tendonitis with degenerative changes.

2.  Entitlement to an initial rating in excess of 20 percent for lumbar spine hypertrophic osteoarthritis.

3.  Entitlement to an initial rating in excess of 30 percent for carpal tunnel syndrome, right upper extremity.

4.  Entitlement to an initial rating in excess of 20 percent for carpal tunnel syndrome, left upper extremity.

5.  Entitlement to an initial compensable rating for erectile dysfunction associated with posttraumatic stress disorder (PTSD).

6.  Entitlement to an effective date earlier than May 6, 2014, for the grant of service connection for carpal tunnel syndrome, right upper extremity.

7.  Entitlement to an effective date earlier than May 6, 2014, for the grant of service connection for carpal tunnel syndrome, left upper extremity.

8.  Entitlement to an effective date earlier than June 9, 2008, for the grant of service connection for erectile dysfunction associated with PTSD.

9.  Entitlement to an effective date earlier than April 23, 2012, for the grant of special monthly compensation for loss of use of a creative organ.

10.  Entitlement to service connection for ulcers in the ileum (claimed as abdominal pain with Crohn's disease, irritable colon syndrome, or ulcerative colitis).

11.  Entitlement to service connection for vascular disorder of the bilateral lower extremities, to include varicose veins, post-phlebotic syndrome, and venous stasis.

12.  Entitlement to service connection for residuals of a hernia, to include an umbilical hernia.

13.  Entitlement to service connection for sleep apnea, to include as secondary to service-connected PTSD.


REPRESENTATION

Veteran represented by:	John S. Berry, Jr., Attorney


ATTORNEY FOR THE BOARD

M. C. Wilson, Associate Counsel



INTRODUCTION

The Veteran had active military service from August 1978 to August 1981, from March 1983 to February 1987, and from July 2004 to November 2005, which includes service in an imminent danger area in Kuwait and Iraq.

These matters come before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Offices (ROs) in Nashville, Tennessee, and Atlanta, Georgia.

Issues 1-2 and 10-13 were most recently before the Board in April 2015, at which time the Board denied the Veteran's claims for increased ratings for left shoulder rotator cuff tendonitis with degenerative changes and lumbar spine hypertrophic osteoarthritis, and denied additional claims which are no longer in appellate status.  Also in April 2015, the Board remanded the service connection claims that are listed on the title page of this decision (issues 10-13).  Pursuant to the April 2015 remand directives, VA obtained outstanding treatment records, obtained medical opinions, and readjudicated the matters that were on appeal at that time.  

The Veteran appealed the April 2015 decision to the United States Court of Appeals for Veterans Claims (Court) with regard to the Board's denial of his claims for increased initial ratings for left shoulder rotator cuff tendonitis with degenerative changes and lumbar spine hypertrophic osteoarthritis.  Pursuant to a September 2015 Joint Motion for Partial Remand (JMR), the Court remanded the Board's April 2015 decision for action consistent with the terms of the JMR.

In light of the evidence presented, the Board has recharacterized the claim for service connection for residuals of an umbilical hernia as a claim for service connection for residuals of a hernia, to include an umbilical hernia.  Clemons v. Shinseki, 23 Vet. App. 1 (2009).

The following issues are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ): the Veteran's entitlement to (1) an initial rating in excess of 10 percent for left shoulder rotator cuff tendonitis with degenerative changes; (2) an initial rating in excess of 20 percent for lumbar spine hypertrophic osteoarthritis; (3) an initial rating in excess of 30 percent for carpal tunnel syndrome, right upper extremity; (4) an initial rating in excess of 20 percent for carpal tunnel syndrome, left upper extremity; (5) an initial compensable rating for erectile dysfunction associated with PTSD; (6) an effective date earlier than May 6, 2014, for the grant of service connection for carpal tunnel syndrome, right upper extremity; (7) an effective date earlier than May 6, 2014, for the grant of service connection for carpal tunnel syndrome, left upper extremity; (8) an effective date earlier than June 9, 2008, for the grant of service connection for erectile dysfunction associated with PTSD; (9) an effective date earlier than April 23, 2012, for the grant of special monthly compensation for loss of use of a creative organ; and (10) service connection for ulcers in the ileum.


FINDINGS OF FACT

1.  The Veteran's vascular disorder of the bilateral lower extremities had its clinical onset during service.
 
2.  The Veteran's ventral hernia had its clinical onset during service.

3.  The evidence is in equipoise as to whether the Veteran's sleep apnea was caused or aggravated by his service-connected PTSD.


CONCLUSIONS OF LAW

1.  The criteria for service connection for a vascular disorder of the bilateral lower extremities have been met.  38 U.S.C.A. §§ 1101, 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303 (2015).
 
2.  The criteria for service connection for a ventral hernia, status post ventral herniorrhapy with residual scarring, have been met.  38 U.S.C.A. §§ 1101, 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303 (2015).

3.  The criteria for service connection for sleep apnea have been met.  38 U.S.C.A. §§ 1101, 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303 (2015).


REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

In this decision, the Board finds that service connection is warranted for varicose veins, sleep apnea, and ventral hernia, status post ventral herniorrhapy with residual scarring.  As such, no discussion of VA's duty to notify or assist is necessary.

Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability.  Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604   (Fed. Cir. 1996) (table).

In addition, a disability that is proximately due to or the result of a service-connected disease or injury shall be service-connected.  38 C.F.R. § 3.310(a) (2015).  When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition.  Id.  

The Veteran in this case served in the Southwest Asia theater of operations during the Persian Gulf War (Gulf War) and thus is also entitled to consideration of his claims under 38 C.F.R. § 3.317, which provides that compensation may be warranted on a presumptive basis for disabilities due to undiagnosed illnesses and medically unexplained chronic multi-symptom illnesses.  See 38 C.F.R. § 3.317(a).  Under 38 C.F.R. § 3.317(a), VA will pay compensation to a Gulf War veteran who exhibits objective indications of a qualifying chronic disability, provided that such disability became manifest either during active military, naval, or air service in the Southwest Asia theater of operations, or to a degree of 10 percent or more not later than December 31, 2016; and by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis.  A qualifying chronic disability means a chronic disability resulting from an undiagnosed illness and/or a medically unexplained chronic multisymptom illness that is defined by a cluster of signs or symptoms, such as functional gastrointestinal disorders, which are commonly characterized by symptoms including abdominal pain, nausea, and altered bowel habits.  38 C.F.R. § 3.317(a)(2)(i).

In particular, the term medically unexplained chronic multisymptom illness means a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities.  38 C.F.R. § 3.317(a)(2)(ii).  Thus, even if a multi-symptom illness has a diagnosis, consideration should still be given as to whether the disability has no known etiology, or has a known, partially understood etiology.

Further, in the case of a veteran who engaged in combat with the enemy in active service, VA shall accept as sufficient proof of service connection of any disease or injury alleged to have been incurred in or aggravated by such service satisfactory lay or other evidence of service incurrence or aggravation of such injury or disease.  38 U.S.C.A. § 1154(b) (West 2014).

A.  Vascular Disorder

The Veteran's service treatment records (STRs) include an April 2004 report of medical examination that was conducted to assess the Veteran's fitness for retention purposes and which indicates that his vascular system was normal at that time.

However, shortly after his separation from service in November 2005, a VA examiner reported in January 2006 that the Veteran experienced occasional swelling of the legs and that he had pedal edema.  Records of the Veteran's treatment in April 2006 document a diagnosis of venous stasis, a need for compression stockings, and trace ankle edema.

In April 2012, a VA examiner noted that the Veteran's lower leg edema was diagnosed as venous stasis insufficiency in April 2006 and that he was diagnosed with varicose veins in 2006.  The examiner reasoned that the Veteran's venous stasis insufficiency has no direct or indirect service connection because there is no documentation of injury to his legs or evidence of vascular disorders in his STRs.  Further, the examiner noted that the Veteran did not have vascular arterial disease or post-phlebotic syndrome at that time, as an April 2012 ABI study was normal.

During a June 2015 VA examination, the Veteran reported that symptoms such as swelling and weakness had their onset in January 2005 and that he noticed swelling of his legs while serving in Iraq.  The examiner noted that there is no diagnosis of a vascular disorder, post-phlebotic syndrome, or venous stasis with regard to either lower extremity because there is no pathology to render a diagnosis, but that the Veteran has varicose veins.

In November 2015, an examiner opined that it is less likely than not that the Veteran's vascular disorder of the bilateral lower extremities, to include varicose veins, post-phlebotic syndrome, and venous stasis, was incurred in or caused by service.  Further, the examiner opined that this condition was not aggravated beyond its natural progression by a service-connected condition.

The Board finds that the Veteran is competent to report that he experienced swelling of the legs and varicose veins that had their onset during his military service in Iraq based on his ability to observe the reported symptoms with his own senses.  Davidson, 581 F.3d at 1316; Layno v. Brown, 6 Vet. App. 465, 470 (1994).  In addition, the Board finds the Veteran's lay testimony regarding having problems with varicose veins and swelling in his legs since his service in Iraq is both competent and credible evidence of an ongoing problem with this disability since service because his symptoms are observable by a lay person.  Id.  Thus, resolving all reasonable doubt in the Veteran's favor, the Board finds that the evidence is at least in equipoise as to whether the Veteran has a vascular disorder of the bilateral lower extremities that had onset in service.  38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (2009).  The appeal is granted as to this claim.
B.  Residuals of a Hernia

The Veteran's STRs include a September 1979 note that documents swelling in his left inguinal area, but a hernia was not noted.  An April 2004 retention examination report indicates that the Veteran's abdomen and viscera were abnormal at that time due to a ventral hernia.

Postservice, VA treatment records dated in May 2010 document a left inguinal hernia and an umbilical hernia in addition to subsequent surgical repair of the umbilical hernia in May 2010.

In April 2012, a VA examiner noted the Veteran's report that he underwent surgical repair of a symptomatic umbilical hernia in 2010 after experiencing a bulge around his umbilicus in 2009.  The examiner opined that there is no direct or indirect relationship between this condition and the Veteran's active service because the STRs do not document this condition, any other gastrointestinal conditions, or an abdominal injury.  In light of multiple STRs that document gastrointestinal symptoms and an in-service hernia, the Board finds that this opinion is inadequate and of little probative value.  See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding "[a]n opinion based upon an inaccurate factual premise has no probative value.").

During a June 2015 VA examination, the Veteran reported that he "noticed a protrusion in the belly button area" in 2005 and was diagnosed with an umbilical hernia in 2006.  The examiner evaluated the Veteran and noted that a large and persistent ventral hernia was present on examination.  Noting the April 2004 in-service finding of a ventral hernia, the June 2015 examiner opined that it was at least as likely as not that the Veteran's ventral hernia, status post ventral herniorrhapy with residual scarring, was incurred in or caused by service.  Notably, although referenced in the standard examination report, the examiner did not endorse a finding of an inguinal hernia and endorsed that there were no other pertinent physical findings or conditions related to a hernia condition.

In light of in-service and current findings of a ventral hernia in addition to a positive nexus opinion regarding the etiology of this condition, the Board finds that service connection for ventral hernia, status post ventral herniorrhapy with residual scarring, is warranted.

C.  Sleep Apnea

In December 2008, the Veteran submitted an Internet article titled, "Sleep Problems, PTSD Widespread Following Sept. 11," which indicates that "[b]etween 50 percent and 80 percent of PTSD patients have significant sleep problems."  In January 2009, the Veteran submitted the medical journal article "Posttraumatic Stress Disorder and Obstructive Sleep Apnea Syndrome" in which it was suggested that there is a "possibility of a connection between sleep-disordered breathing and PTSD."  Further, in the article "Apnea Elevated in Vets With PTSD," it was noted that "almost all combat veterans with . . . [PTSD] (98%) have a sleep disorder-with more cases of sleep apnea than might otherwise be expected" and "just more than half (54%) of these military PTSD patients were diagnosed with obstructive sleep apnea" whereas the rate of obstructive sleep apnea is 20% in the general population.

In April 2012, a VA examiner opined that the Veteran's sleep apnea is not likely due to any in-service events, exposures, or injury because it developed decades after his separation from the military, occurring as a result of his aging, smoking, and increased weight gain.

During a June 2015 VA examination, the Veteran reported that he has had "bad snoring ever since returning from Iraq in [November 2005]" and that he was diagnosed with sleep apnea in 2006.  

In October 2015, non-VA clinician G.G.U. noted that the Veteran currently has obstructive sleep apnea, the Veteran's wife complained about the Veteran's constant snoring starting in 2006, the Veteran was first diagnosed with obstructive sleep apnea in 2007, and the Veteran was later prescribed a continuous positive airway pressure (CPAP) machine following a 2009 sleep study.  G.G.U. opined that it is at least as likely as not that the Veteran's current obstructive sleep apnea is secondary to, related to, and/or aggravated by his service-connected PTSD and/or PTSD medications.  G.G.U. reasoned that the Veteran does in fact suffer from obesity, which is a known risk factor for obstructive sleep apnea, but noted that depression is a major factor in the development of daytime somnolence, which is a condition that typically precedes the development of obstructive sleep apnea, and cited a scientific study on veterans that indicates that veterans with obstructive sleep apnea and its concordant risk factors also exhibited significantly elevated rates of PTSD and depression.

In November 2015, a VA examiner noted that the Veteran had a normal sleep study with no evidence of sleep apnea in January 2007 and he was subsequently diagnosed with obstructive sleep apnea in July 2009.  The examiner opined that it is less likely than not that the Veteran's sleep apnea is proximately due to or the result of PTSD because the Veteran was diagnosed with sleep apnea in July 2009, which was more than three years after his discharge from service, and the 2007 sleep study was normal.  Notably, the examiner "conceded that PTSD and sleep apnea may be related," but also noted that "causation has not been established."

Based on the foregoing, the Board finds that the evidence is at least in equipoise as to whether the Veteran's sleep apnea is related to his last period of active service.  Resolving all reasonable doubt in his favor, the Board finds that service connection for sleep apnea is warranted.  38 U.S.C.A. § 5107; 38 C.F.R. § 3.102.  


ORDER

Service connection for a vascular disorder of the bilateral lower extremities is granted.

Service connection for ventral hernia, status post ventral herniorrhapy with residual scarring, is granted.

Service connection for sleep apnea is granted.
REMAND

Unfortunately, another remand is required in this case.  Although the Board sincerely regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide the Veteran's claims so that he is afforded every possible consideration.

The following claims remain before the Board: (1) entitlement to an initial rating in excess of 10 percent for left shoulder rotator cuff tendonitis with degenerative changes; (2) entitlement to an initial rating in excess of 20 percent for lumbar spine hypertrophic osteoarthritis; (3) entitlement to an initial rating in excess of 30 percent for carpal tunnel syndrome, right upper extremity; (4) entitlement to an initial rating in excess of 20 percent for carpal tunnel syndrome, left upper extremity; (5) entitlement to an initial compensable rating for erectile dysfunction associated with PTSD; (6) entitlement to an effective date earlier than May 6, 2014, for the grant of service connection for carpal tunnel syndrome, right upper extremity; (7) entitlement to an effective date earlier than May 6, 2014, for the grant of service connection for carpal tunnel syndrome, left upper extremity; (8) entitlement to an effective date earlier than June 9, 2008, for the grant of service connection for erectile dysfunction associated with PTSD; (9) entitlement to an effective date earlier than April 23, 2012, for the grant of special monthly compensation for loss of use of a creative organ; and (10) service connection for ulcers in the ileum.

Entitlement to Increased Initial Ratings for Left Shoulder Rotator Cuff Tendonitis with Degenerative Changes and Lumbar Spine Hypertrophic Osteoarthritis

In the September 2015 JMR, it was noted that the April 2012 VA medical examination that the Board cited in its April 2015 decision may not have accounted for functional loss due to flare-ups with regard to the Veteran's left shoulder and lumbar spine disabilities.   As review of the record reveals that the examiner who evaluated the Veteran in April 2012 failed to adequately account for any degree of functional loss experienced due to flare-ups and express any such functional loss in terms of the degree of loss in the Veteran's ranges of motion, the Board finds that additional examinations must be provided on remand.

Entitlement to Increased Ratings and/or Earlier Effective Dates for Bilateral Carpal Tunnel Syndrome, Erectile Dysfunction, and Special Monthly Compensation

In June 2014, the RO granted service connection for carpal tunnel syndrome of the bilateral upper extremities and erectile dysfunction, and granted special monthly compensation for loss of use of a creative organ.  Thereafter, in May 2015, the Veteran submitted a timely Notice of Disagreement (NOD) with the ratings and effective dates assigned in June 2014, but a Statement of the Case (SOC) has not been issued with regard to these claims.  Where, as here, there has been an initial AOJ adjudication of a claim and an NOD as to its denial, the claimant is entitled to an SOC.  See Manlincon v. West, 12 Vet. App. 238 (1999).  Thus, remand for issuance of an SOC is needed.

Entitlement to Service Connection for Ulcers in the Ileum (Claimed as Abdominal Pain with Crohn's Disease, Irritable Colon Syndrome, or Ulcerative Colitis)

In April 2012, a VA examiner noted that the Veteran has been diagnosed with Crohn's disease and cholelithiasis.  That examiner opined that the Veteran's Crohn's disease is not service connected because it is an autoimmune disease of unknown etiology.  The examiner also noted that there is no documentation of Crohn's disease, ulcerative colitis, cholecystitis, or any other gastrointestinal conditions occurring during his military service years.  Thereafter, in November 2015, an examiner opined that it is less likely than not that the Veteran's claimed condition was incurred in or caused by service.  Further, the November 2015 examiner opined that this condition was not aggravated beyond its natural progression by service or a service-connected condition.

In light of the April 2012 examiner's indication that Crohn's disease is an autoimmune disease of unknown etiology and the Veteran's Gulf War service, the Board finds that VA must provide a VA Gulf War examination to assess whether the Veteran's claimed condition is a medically unexplained chronic multisymptom illness under 38 C.F.R. § 3.317.

Accordingly, the case is REMANDED for the following action:

1.  Associate with the claims file outstanding records of the Veteran's VA treatment.  Any additional records identified by the Veteran during the course of the remand should also be obtained, following the receipt of any necessary authorizations from the Veteran, and associated with the claims file.

2.  After associating any records obtained by way of the above development, schedule the Veteran for a VA shoulder examination to determine the current severity of his service-connected left shoulder disability.  The claims file, and any newly associated evidence, must be made available to and reviewed by the examiner and the examiner should annotate the report as to whether the claims file was reviewed.  All pertinent symptomatology and findings should be reported in detail.  Any necessary diagnostic tests and studies should be conducted and the examiner is asked to comment on any relevant VA or private treatment records in his or her report.  As to all information requested below, the examiner should fully explain any opinion stated.

The examiner should determine the range of motion of the Veteran's left shoulder, in degrees.  It should be indicated whether any associated pain could significantly limit functional ability during flare-ups or during periods of repeated use.  The degree of additional range of motion loss or favorable or unfavorable ankylosis due to pain on use, weakened movement, excess fatigability, or incoordination should be indicated.

3.  Schedule the Veteran for a VA spine examination to determine the current severity of his service-connected lumbar spine disability.  The claims file, and any newly associated evidence, must be made available to and reviewed by the examiner and the examiner should annotate the report as to whether the claims file was reviewed.  All pertinent symptomatology and findings should be reported in detail.  Any necessary diagnostic tests and studies should be conducted and the examiner is asked to comment on any relevant VA or private treatment records in his or her report.  As to all information requested below, the examiner should fully explain any opinion stated.

The examiner should determine the range of motion of the Veteran's lumbar spine, in degrees.  It should be indicated whether any associated pain could significantly limit functional ability during flare-ups or during periods of repeated use.  The degree of additional range of motion loss or favorable or unfavorable ankylosis due to pain on use, weakened movement, excess fatigability, or incoordination should be indicated.

The examiner should also comment as to whether there are any associated neurologic abnormalities.  It should be noted whether the Veteran has intervertebral disc syndrome (IVDS) of the lumbar spine, and if so, whether it has been productive of incapacitating episodes.  If the Veteran has experienced incapacitating episodes, the examiner should report the frequency and total duration of such episodes over the course of the past 12 months.  Please note that for VA purposes, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician.

4.  Schedule the Veteran for a VA Gulf War examination to determine the etiology of his ulcers in the ileum (claimed as abdominal pain with Crohn's disease, irritable colon syndrome, or ulcerative colitis).  The examiner is asked to review the pertinent evidence, including the Veteran's lay assertions regarding his symptomatology, and undertake any indicated studies.  Then, based on the results of the examination, the examiner is asked to address each of the following questions:

   (a) Please state whether the symptoms of the claimed condition are attributable to a known clinical diagnosis.  If the Veteran does not now have, but previously had any such condition, when did that condition resolve?

   (b) Is the Veteran's disability pattern consistent with: (1) a diagnosable but medically unexplained chronic multisymptom illness of unknown etiology, (2) a diagnosable chronic multisymptom illness with a partially explained etiology, or (3) a disease with a clear and specific etiology and diagnosis. 

   (c) If, after examining the Veteran and reviewing the claims file, you determine that the Veteran's disability pattern is either (2) a diagnosable chronic multi-symptom illness with a partially explained etiology, or (3) a disease with a clear and specific etiology and diagnosis, then please provide an expert opinion as to whether it is related to a presumed environmental exposures experienced by the Veteran during service in Southwest Asia.

   (d) Is it at least as likely as not that any diagnosed disorder had its onset directly during the Veteran's service or is otherwise causally related to any event or circumstance of his service, including environmental exposures during service in Southwest Asia during the Persian Gulf War?

   (e) If not directly related to service on the basis of questions (b)-(d), is any medical condition proximately due to, the result of, or caused by a service-connected disability?

   (f) If not caused by another medical condition, has any disorder been aggravated (made permanently worse or increased in severity) by a service-connected disability?  If yes, was that increase in severity due to the natural progress of the disease?

In answering all questions (a) to (f), please articulate the reasons underpinning your conclusions.  That is, (1) identify what facts and information, whether found in the record or outside the record, support your opinion, and (2) explain how that evidence justifies your opinion.  A report of the examination should be prepared and associated with the Veteran's VA claims file.

5.  After completing any additional development deemed necessary, readjudicate the issues on appeal.  If the benefits requested on appeal are not granted in full, issue the Veteran a Statement of the Case or Supplemental Statement of the Case.  After providing an opportunity to respond thereto, the case should then be returned to the Board for further appellate consideration, if in order.  By this remand, the Board intimates no opinion as to any final outcome warranted.

The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded.  Kutscherousky v. West, 12 Vet. App. 369 (1999).

This claim must be afforded expeditious treatment.  The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner.  See 38 U.S.C.A. §§ 5109B, 7112 (West 2014).



______________________________________________
S. C. KREMBS
Veterans Law Judge, Board of Veterans' Appeals



Department of Veterans Affairs