Citation Nr: 1727111 Decision Date: 07/13/17 Archive Date: 07/25/17 DOCKET NO. 10-19 792 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for pancreatitis. 2. Entitlement to service connection for type II diabetes mellitus, to include as secondary to claimed pancreatitis. 3. Entitlement to an increased rating, in excess of 10 percent, for acne. 4. Entitlement to a higher initial rating for bilateral plantar fasciitis, in excess of 10 percent prior to May 31, 2016 and in excess of 50 percent thereafter. 5. Entitlement to a total disability rating based on individual employability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Christine C. Kung, Counsel INTRODUCTION The Veteran served on active duty from November 1983 to November 1986, from October 1996 to September 2000, from February 2003 to October 2003, from April 2005 to January 2006, and from December 2006 to September 2007, and she served in the Pennsylvania Army National Guard (ARNG) from April 1992 to March 1994. This matter comes on appeal before the Board of Veterans' Appeals (Board) from July 2008, October 2009 and June 2010 rating decisions of the Department of Veterans Affairs (VA) Regional Office in St. Petersburg, Florida (RO). The Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge in August 2014. The hearing transcript is of record. The Board remanded the appeal in November 2014. The Board finds that the Agency of Original Jurisdiction (AOJ) substantially complied with the Board's remand order, and the Board finds that it may proceed with a decision on the increased rating issues at this time. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (Fed. Cir. 2002). With respect to the appeals for service connection and a TDIU, the Board finds, unfortunately, that an additional remand is warranted. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2016). 38 U.S.C.A. § 7107(a)(2) (West 2014). The issue of entitlement to a TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the AOJ. FINDINGS OF FACT 1. The Veteran's acne is superficial and affects less than 40 percent of the face and neck. 2. Prior to May 31, 2016, bilateral plantar fasciitis is shown to be severe, characterized by objective evidence of pronation in both foot, pain on manipulation and use, swelling on use, and characteristic callosities. 3. From May 31, 2016, the Veteran is in receipt of the maximum available rating under Diagnostic Code 5276. CONCLUSIONS OF LAW 1. The criteria for an increased rating, in excess of 10 percent, for acne are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2015); 38 C.F.R. §§ 4.3, 4.7, 4.118, Diagnostic Code 7828 (2016). 2. Prior to May 31, 2016, the criteria for a higher initial 30 percent rating for bilateral plantar fasciitis are met. 38 U.S.C.A. §§ 1155, 5107 (West 2015); 38 C.F.R. §§ 4.3, 4.7, 4.71a, Diagnostic Codes 5276 (2016). 3. From May 31, 2016, the criteria for a higher initial rating in excess of 50 percent for bilateral plantar fasciitis are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2015); 38 C.F.R. §§ 4.3, 4.7, 4.71a, Diagnostic Codes 5276 (2016). 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, 5126 (West 2015); 38 C.F.R. §§ 3.102, 3.156(a), 3.326(a) (2015); see also Dingess v. Nicholson, 19 Vet. App. 473 (2006). The RO issued preadjudicatory notice letters to the Veteran in September 2007, April 2009, and May 2009 which met the VCAA notice requirements. VA has made reasonable efforts to obtain relevant records and evidence. The information and evidence that has been associated with the claims file includes lay statements and testimony, service treatment records and service personnel records, VA and private medical records, vocational rehabilitation records, social security administration (SSA) records, and VA examinations and opinions. The Board finds that the AOJ substantially complied with the November 2014 Board remand directives in obtaining outstanding evidence, a VA examination, and medical opinions, and in confirming the Veteran's active service dates. While specific dates for active duty training, ADT, between April 1992 to March 1994 were not confirmed the Veteran does not contend either diabetes mellitus or pancreatitis were incurred during this period of service, and delineation of the dates of active duty for training would not impact the present claims for an increased rating. Accordingly, the Board finds that an additional remand for verification of ADT dates is not necessary. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran are to be avoided). During the August 2014 hearing, the undersigned assisted the Veteran in explaining the issues and identifying identified possible sources of evidence that may have been overlooked. 38 C.F.R. 3.103 (c)(2) (2016); Bryant v. Shinseki, 23 Vet. App. 488 (2010). The Board finds that May 2016 VA examinations adequately address the relevant rating criteria. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion has been met. 38 C.F.R. § 3.159 (c)(4). For these reasons, the Board finds that VA has fulfilled the duties to notify and assist the Veteran. Increased Rating Law and Analysis Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. The percentage ratings are based on the average impairment of earning capacity and individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2016). If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2016). Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3 (2016). For an initial rating claim, VA must assess the level of disability from the date of initial application for service connection and determine whether the level of disability warrants the assignment of different disability ratings at different times over the life of the claim, a practice known as a "staged rating." See Fenderson v. West, 12 Vet. App 119 (1999). The Court has held that staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board has considered whether a staged rating is warranted; however, the Board finds that the evidence of record does not establish distinct time periods where the service-connected acne results in symptoms that would warrant different ratings. With regard to plantar fasciitis, the Veteran has been assigned an initial staged rating. The Board finds, however, that it is not factually ascertainable that an increase in the severity of plantar fasciitis occurred prior to May 31, 2016, to warrant a higher initial rating. Pyramiding, that is the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when evaluating a Veteran's service-connected disability. 38 C.F.R. § 4.14 (2016). However, it is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes; the critical element in permitting the assignment of several evaluations under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261- 62 (1994). In rendering a decision on appeal the Board must also analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Acne The Veteran is in receipt of a 10 percent rating for acne under Diagnostic Code 7828. See 38 C.F.R. § 4.118 (2016). A 0 percent rating is assigned for superficial acne (comedones, papules, pustules, and superficial cysts). A 10 percent rating is assigned for deep acne (deep inflamed nodules and pus-filled cysts) affecting less than 40 percent of the face or neck, or deep acne other than on the face and neck and a maximum 30 percent rating is assigned for deep acne (deep inflamed nodules and pus-filled cysts) affecting 40 percent or more of the face or neck. Diagnostic Code 7828 provides that acne can alternately be rated as a disfigurement of the head, face, or neck or scars, depending upon the predominant disability. 38 C.F.R. § 4.118, Diagnostic Code 7828. The Board finds that the Veteran did not submit a notice of disagreement to the July 2008 rating decision which assigned a 10 percent initial rating for acne. The Veteran was afforded a new VA examination in August 2009 to address service-connected acne, and she appealed the October 2009 rating decision which denied an increased rating in excess of 10 percent for acne. For these reasons, the Board finds that the August 2009 VA examination served as an informal claim for an increased rating and the relevant appeal period is from the time period one year prior to the August 2009 informal claim to present. See Hart v. Mansfield, 21 Vet. App. 505 (2007). During an August 2009 VA examination, the Veteran reported that the severity of her acne was about the same since her last VA examination in June 2008. Acne was present constantly with cystic acne present on the face and back. The Veteran was treated with antibiotics. Acne was described as superficial (with comedones, papules, pustules, and superficial cysts) and affected less than 40 percent of the face and neck. The upper back was also affected. In an August 2014 videoconference hearing, the Veteran contends that acne affects more than 40 percent of her face. She indicated that she had pitted acne scars covering the majority of her face and neck, and reported that the scars itched. A May 2016 VA skin examination shows that acne is superficial (with comedones, papules, pustules, or superficial cysts) and affected less than 40 percent of the face and neck. The Veteran's acne was treated with a benzoyl peroxide wash and Retin-A cream. Acne affected less than five percent of total body area, and the Veteran did not have acne present on her back at the time of the May 2016 VA examination. Despite worsening of acne described by the Veteran at the time of the May 2016 VA examination, her acne was shown to be superficial, as opposed to deep, characterized by deep inflamed nodules and pus-filled cysts, and affecting less than 40 percent of the face and neck. The Board finds that the VA examiners have identified the presence of superficial, and not deep acne, and finds that VA examiners, in this case, are more qualified, at distinguishing between the presence of superficial acne versus deep acne, and at estimating the area affected by acne. The weight of the evidence does not indicate that the Veteran has deep acne which affects more than 40 percent of the face and neck. Instead, the weight of the evidence identifies superficial acne affecting less than 40 percent of the face and neck for the entire rating period. For these reasons, the Board finds that the criteria for an increased 30 percent rating under Diagnostic Code 7828 have not been met or more nearly approximated at any time during the rating period. See 38 C.F.R. § 4.118, Diagnostic Code 7828. In an August 2014 Board hearing, the Veteran indicated that she had pitted acne scars covering the majority of her face and neck, and reported that the scars itched. However, a May 2016 VA examination shows that the Veteran's acne does not cause scarring or disfigurement of the head, face or neck. Thus, the Board finds that an alternate rating under Diagnostic Code 7800 for disfigurement of the head, face, or neck is not warranted. While the Board finds that the Veteran is credible in identifying the presence of acne scars, the Board finds that the reported scars are not shown to be disfiguring within the meaning of Diagnostic Code 7800, nor are they shown to be unstable or painful to warrant an evaluation under Diagnostic Code 7804. For these reasons, the Board finds that an increased rating, in excess of 10 percent, is not warranted for service-connected acne. In making this determination, the Board has considered the provisions of 38 U.S.C.A. § 5107 (b) regarding benefit of the doubt, however, as the preponderance of the evidence is against the Veteran's appeal for an increased rating, the doctrine is not for application. Plantar Fasciitis Bilateral planter fasciitis has been rated at 10 percent under Diagnostic Code 5276, prior to May 31, 2016 and at 50 from May 31, 2016. Diagnostic Code 5276 provides ratings for acquired flat foot. A 10 percent rating is assigned for moderate flat foot, with the weight-bearing line over or medial to the great toe, inward bowing of the tendo achillis, pain on manipulation and use of the foot, either bilaterally or unilaterally. A 30 percent evaluation is warranted for severe bilateral acquired flatfoot manifested by marked deformity (pronation, abduction, etc.), accentuated pain on manipulation and use of the feet, indications of swelling on use of the feet, and characteristic callosities. A 50 percent evaluation is warranted for pronounced bilateral acquired flatfoot manifested by marked pronation, extreme tenderness of the plantar surfaces of the feet, and marked inward displacement and severe spasm of the tendo achilles on manipulation which is not improved by orthopedic shoes or appliances. 38 C.F.R. § 4.71a . A June 2008 VA examination shows that the Veteran has bilateral plantar fasciitis characterized by chronic pain over both feet as well as swelling, stiffness, fatigability, weakness, lack of endurance, numbness and tingling. The Veteran did not have flare-ups, but was unable to stand for more than a few minutes. She was able to walk 1/4 of a mile, and used orthotic inserts and corrective shoes. Efficacy of the shoes and inserts was stated to be fair. Physical examination showed objective evidence of tenderness along the course of the plantar fascial band, instability shown by decreased arch height and a pronated foot on standing, some weakness, and characteristic callosities indicating abnormal weight-bearing. There were no hammertoes, no hallux valgus or rigidus, no pes cavus, no evidence of malunion or nonunion, and no muscle atrophy or other foot deformity on examination. X-rays showed a plantar calcaneal spur bilaterally, mild pronation of the left foot, and mild to moderate pronation of the right foot. Plantar fasciitis prevented standing for long periods of time and had severe effects on the Veteran's ability to do chores and shopping, and prevented exercise. An August 2009 VA examination of the feet showed pain in both feet, with additional pain while walking. The Veteran was able to stand for 15 to 30 minutes, and was able to walk 1/4 of a mile. She used a walker and splints and the efficacy of these corrective devices were stated to be fair. Examination showed tenderness on the bottom of the bilateral feet. There were no hammertoes, no hallux valgus or rigidus, no pes cavus, no malunion or nonunion of the tarsal or metatarsal bones, and no muscle atrophy or other foot deformity. The Veteran had flat feet with inward bowing of the feet with weight bearing, correctable with manipulation. There was no midfoot malalignment and no pronation. The arch was not present on weight bearing. Her bilateral foot disability was noted to have significant effects on occupational activities due to pain. A May 2016 VA examination identified a diagnosis of bilateral plantar fasciitis. The Veteran described symptoms of pain, swelling, difficulty with wearing shoes, and some difficulty walking. Physical examination of the feet showed pain, accentuated on use, pain accentuated on manipulation, and swelling on use of the feet. There were no characteristic callouses associated with pes planus. The Veteran had extreme tenderness of the planter surfaces of both feet, decreased longitudinal arch height of both feet, and objective evidence of marked deformity of both feet, described as marked pronation of the feet. The weigh-bearing line of both feet fell over the medial to great toe. The Veteran did not have inward bowing of the Achilles tendon or marked inward displacement and severe spasm of the Achilles tendon on manipulation. There was no metatarsalgia, hammer toe, hallux valgus, hallux rigidus, pes cavus, or other conditions of the feet not already described. There was no history of foot surgery. The Veteran had pain in both feet, pain on weight-bearing, swelling, disturbance of locomotion, interference with standing, and lack of disturbance due to her foot disability. There were no flare-ups of pain which impacted the function of the foot. The Veteran used a wheelchair and a walker for ambulation. Functioning in the feet was not so diminished that amputation with prosthesis would equally serve the Veteran. With regard to the functional impact of the Veteran's disability, the VA examiner indicated that she had moderate pain with standing and walking. For the entire rating period prior to May 31, 2016, the Board finds that the Veteran's bilateral plantar fasciitis more nearly approximates that criteria for a higher 30 percent rating based on severe disability, characterized by objective evidence of pronation in both foot, pain on manipulation and use, swelling on use, and characteristic callosities. While an August 2009 VA examiner found that the Veteran did not have pronation of the feet, and August 2008 VA examiner noted mild pronation of the left foot, and mild to moderate pronation of the right foot on x-rays. Both VA examiners identified objective evidence of pain on manipulation and use, and severe or significant effects on the Veteran's occupational or daily functioning due to plantar fasciitis. Swelling on use and characteristic callosities were also identified in the August 2008 VA examination. Resolving reasonable doubt in favor of the Veteran with regard to these findings, the Board finds that for the entire rating period prior to May 31, 2016 a 30 percent rating is warranted for bilateral plantar fasciitis. From May 31, 2016, the Veteran was in receipt of a 50 percent rating for bilateral plantar fasciitis based on findings of pronounced disability, marked pronation of the feet, extreme tenderness of the plantar surfaces of the feet, and pain accentuated on manipulation and use, not improved by orthopedic shoes. The Board finds that prior to May 31, 2016, it is not factually ascertainable that an increase in the Veteran's plantar fasciitis had occurred to warrant the next higher 50 percent rating. Evidence dated prior to May 31, 2016 does not approximate a rating based on pronounced disability with marked pronation in the feet, extreme tenderness of the feet, marked inward displacement and severe spasm of the tendo Achilles on manipulation, not improved by orthotic shoes. Instead, pronation of the feet was shown by an June 2008 VA examiner to be mild to moderate in degree, tenderness or pain on manipulation and use accentuated and swelling were considered by the criteria described for a 30 percent rating. There was no evidence of marked inward displacement or severe spasm of the tendo achilles on manipulation, and efficacy orthotics and other devices was noted to be fair. For these reasons, the Board finds that prior to May 31, 2016, the next higher 50 percent is not warranted. From May 31, 2016, the Veteran is in receipt of the maximum available 50 percent rating under Diagnostic Code 5276 for bilateral flatfoot. Higher ratings are not available under other provisions of the diagnostic code pertaining to the feet under 38 C.F.R. § 4.71a, to include Diagnostic Code 5284 for other foot injuries. The Board finds that a separate rating would not be warranted under Diagnostic Code 5284 for a moderate to severe foot injury, where the diagnostic code would consider the same symptoms encompassed by the Veteran's current rating under Diagnostic Code 5276 for a severe to pronounced plantar fasciitis. Additionally, VA examinations show that the Veteran does not have evidence of weak foot, claw foot, metatarslagia, hallux valgus, hallux rigidus, hammer toe, or malunion or nonunion of the tarsal or metatarsal bones to warrant a separate rating under other provisions of the diagnostic code. While the Veteran's foot disability is currently shown to be pronounced in degree, a May 2016 VA examination shows that functioning in the feet was not so diminished that amputation with prosthesis would equally serve the Veteran. Thus, a rating based on loss of use of the foot under Diagnostic Code 5167 is not warranted. For these reasons, the Board finds that from May 31, 2016, a higher initial rating in excess of 50 percent is not warranted for bilateral plantar fasciitis. In making this determination, the Board has considered the provisions of 38 U.S.C.A. § 5107 (b) regarding benefit of the doubt, however, as the preponderance of the evidence is against the Veteran's appeal for an increased rating from May 31, 2016, the doctrine is not for application. ORDER An increased rating in excess of 10 percent for acne is denied. Prior to May 31, 2016, a higher initial 30 percent rating for bilateral plantar fasciitis is granted. From May 31, 2016, higher initial rating for bilateral plantar fasciitis, in excess of 50 percent is denied. REMAND Service treatment records indicate that pancreatitis was incurred during the Veteran's last period of active duty service from December 2006 to September 2007. A May 2007 periodic examination completed a few months prior to service separation and an associated July 2007 report of medical history show that the Veteran identified a history of pancreatitis which was first diagnosed in March 2007 at the Lackland Regional Medical Center. Attached May 2007 physical examination notes also indicate a recent diagnosis of pancreatitis, and the Veteran identified a history of emergency room treatment for pancreatitis at that time. Private treatment records dated shortly after separation from service in January 2008 also indicate that the Veteran was diagnosed with pancreatitis a year prior. A May 2016 VA examiner incorrectly identified the Veteran's separation from service as being in January 2006 in opining that that it was less likely as not pancreatitis was attributable to any verified period of service; thus, that opinion is not probative. However, the VA examiner also opined that chronic pancreatitis was most likely due to alcohol abuse, correctly noting diagnoses of alcohol abuse or alcohol dependence were shown in 2004 and 2007. The examiner reasoned that alcohol abuse was the number one cause of pancreatitis. Private treatment records also identify a diagnosis of chronic pancreatitis due to long term alcohol abuse. With respect to claims filed after October 31, 1990, an injury or disease incurred during active service will not be deemed to have been incurred in line of duty if the injury or disease was a result of the person's own willful misconduct, including abuse of alcohol or drugs. 38 U.S.C.A. § 105 (West 2015); 38 C.F.R. § 3.1 (m) (2016). The isolated and infrequent use of drugs by itself will not be considered willful misconduct; however, the progressive and frequent use of drugs or alcohol to the point of addiction will be considered willful misconduct. 38 C.F.R. § 3.301(c) (2016). In this case, the Veteran is service-connected for PTSD, but service-connected has not been established for an alcohol abuse disability. Nonetheless, the Federal Circuit Court held, in Allen v. Principi, 237 F.3d 1368 (Fed. Cir. 2001), the that there can be service connection for compensation for an alcohol/drug abuse disability acquired as secondary to, or as a symptom of, a non-willful misconduct, service-connected disability. In further clarifying this, the Federal Circuit Court explained that Veterans may only recover if they can "adequately establish that their alcohol or drug abuse disability is secondary to or is caused by their primary service-connected disorder." Id., at 1381. An award of compensation on such a basis would only result "where there is clear medical evidence establishing that the alcohol or drug abuse disability is indeed caused by a Veteran's primary service-connected disability, and where the alcohol or drug abuse disability is not due to willful wrongdoing." Id. While a May 2016 VA examiner opined that the Veteran's alcohol abuse was less likely than not caused by her military service, it is medically unclear whether the Veteran's service-connected PTSD caused or aggravated her alcohol dependence. El-Amin v. Shinseki, 26 Vet. App. 136, 140 (2013). In such a case, her alcohol abuse would not be considered to be willful misconduct and could be a basis for a finding of service connection for the alcohol-induced pancreatitis. Accordingly, the Board finds that a remand is warranted for a supplemental opinion to address whether the Veteran's alcohol dependence is secondary to service-connected PTSD. A remand is required prior to adjudication of the claim for service connection for diabetes mellitus and the claim for a TDIU. The Veteran contends in an August 2014 Board hearing that service connection for diabetes mellitus is warranted as secondary to claimed pancreatitis. The Board is remanding the appeal for service connection for pancreatitis. Additionally, as a determination on these issues could substantially affect the TDIU claim on appeal, the Board finds that these issues are inextricably intertwined. See Harris v. Derwinski, 1 Vet. App. 180 (1991). Therefore, the Board's determination as to the claims for service connection for diabetes mellitus and the claim for a TDIU must be deferred. SSA records, VA Aid and Attendance examinations, and the Veterans testimony and statements indicating that she was unable to stay in school or complete a vocational rehabilitation program show that the Veteran is currently unemployable due to a combination of service-connected and nonservice-connected disabilities. It is not clear, however, if the Veteran is disabled due to her service-connected disabilities alone. Accordingly on remand, the AOJ should take any additional development necessary to address the claim for a TDIU, to include requesting a medical opinion to address the functional impact or combined effect of her service-connected disabilities. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. The AOJ should obtain a supplemental medical opinion from the May 2016 VA psychiatric examiner or other appropriate examiner, to address whether the Veteran's alcohol abuse, which preceded her in-service diagnosis pancreatitis, was caused or aggravated by service-connected PTSD. Specifically, the examiner is asked to provide an opinion that addresses the following questions: a). Is it at least as likely as not (50 percent or greater probability) that the Veteran's alcohol abuse was caused by, or is a symptom of, his PTSD? b). If the answer to (a) is "No," is it at least as likely as not (50 percent or greater probability) that the Veteran's abuse of alcohol is aggravated (i.e., has progressed at an abnormally high rate) due to or as a result of his PTSD? In this context, "aggravation" has occurred when it has been medically determined that the Veteran's alcohol abuse has undergone an identifiable permanent increase in its severity that is proximately due to or the result of his PTSD. The term "at least as likely as not" does not mean "within the realm of medical possibility." Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of that conclusion as it is to find against it. A complete rationale for all opinions and conclusions should be provided. 2. Thereafter, the AOJ should review the evidence and make a preliminary determination on the question of whether the Veteran's alcohol abuse in service was secondary to PTSD. If so, the AOJ should obtain a supplemental VA opinion to address whether diagnosed diabetes mellitus is caused or aggravated by alcohol-induced pancreatitis. An examination is not required; however, if the VA examiner indicates that he or she cannot respond to the question without examination of the Veteran, such should be afforded the Veteran. The record should be made available for review in connection with this request. The VA examiner should provide an opinion as to whether it at least as likely as not that a currently diagnosed diabetes mellitus is caused or aggravated (permanently worsened in severity beyond the normal progress of the disease) by pancreatitis. If the opinion is that there is aggravation, to the extent that is possible, the examiner is requested to provide an opinion as to approximate baseline level of severity of the nonservice-connected disorder before the onset of aggravation. "Aggravation" is defined for legal purposes as a worsening of the underlying condition versus a temporary flare-up of symptoms. The examiner should provide a rationale for his or her opinion with reference to the evidence of record. 3. After the above development has been completed, the AOJ should obtain a VA a medical opinion to address the functional impact or combined effect of the Veteran's service-connected disabilities. An examination is not required; however, if the VA examiner indicates that he or she cannot respond to the question without examination of the Veteran, such should be afforded the Veteran. The record should be made available for review in connection with this request. 4. After all development has been completed, the AOJ should review the claims for service connection for pancreatitis, service connection for diabetes mellitus, and entitlement to a TDIU again based on the additional evidence. If the benefits sought are not granted, the AOJ should furnish the Veteran and his representative with a Supplemental Statement of the Case, and should give the Veteran a reasonable opportunity to respond before returning the record to the Board for further review. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ K. PARAKKAL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs