Citation Nr: 1730786 Decision Date: 08/02/17 Archive Date: 08/11/17 DOCKET NO. 14-15 813A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUES 1. Entitlement to a disability rating higher than 20 percent for service-connected peripheral neuropathy of the left lower extremity, sciatic nerve. 2. Entitlement to a disability rating higher than 20 percent for service-connected peripheral neuropathy of the right lower extremity, sciatic nerve. 3. Entitlement to a disability rating higher than 30 percent for service-connected transient ischemic attacks (TIA), based on adjustment disorder with anxiety and depressed mood and mild neurocognitive disorder due to vascular disease. 4. Entitlement to special monthly compensation (SMC) based on the need for regular aid and attendance, or on the basis of being housebound. 5. Entitlement to automobile and adaptive equipment, or adaptive equipment only. REPRESENTATION Appellant represented by: Mississippi State Veterans Affairs Board WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J. Meawad, Counsel INTRODUCTION The Veteran served on active duty from September 1965 to August 1968. This matter is before the Board of Veterans' Appeals (Board) on appeal of August 2013 and July 2015 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi. In January 2017, the Veteran was afforded a videoconference hearing before the undersigned. The issues of service connection for ankles, knees, wrists and elbows have been raised during the January 2017 hearing and the issues of entitlement to a higher rating for peripheral neuropathy of the right and left upper extremities have been raised by the record in a January 2017 statement. These issues have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over them, and they are referred to the AOJ for appropriate action. 38 C.F.R. § 19.9(b) (2016). 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 higher rating for service-connected TIA is addressed in the REMAND portion of the decision below and is REMANDED to the AOJ. FINDINGS OF FACT 1. The Veteran's peripheral neuropathy of the left lower extremity, sciatic nerve, is productive of moderately severe incomplete paralysis of the sciatic nerve. 2. The Veteran's peripheral neuropathy of the right lower extremity, sciatic nerve, is productive of moderately severe incomplete paralysis of the sciatic nerve. 3. The Veteran requires the regular aid and attendance of another because of his service-connected posttraumatic stress disorder (PTSD). 4. The Veteran has loss of use of the upper and lower extremities, to include the hands and feet, due to service-connected disabilities. CONCLUSION OF LAW 1. The criteria for a 40 percent disability rating, but no higher, for service-connected peripheral neuropathy of the left lower extremity, sciatic nerve, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.123, 4.124, 4.124a, Diagnostic Code 8520 (2016). 2. The criteria for a 40 percent disability rating, but no higher, for service-connected peripheral neuropathy of the right lower extremity, sciatic nerve, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.123, 4.124, 4.124a, Diagnostic Code 8520 (2016). 3. The criteria for entitlement to SMC based on the need for aid and attendance have been met. 38 U.S.C.A. §§ 1114(l), 1114(s), 1502(b) (West 2014); 38 C.F.R. §§ 3.350, 3.351, 3.352 (2016). 4. The criteria for automobile and adaptive equipment, or adaptive equipment only have been met. 38 U.S.C.A. §§ 3901, 3902, 5107, 7104 (West 2014); 38 C.F.R. §§ 3.102, 3.808 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duties to Notify and Assist VA has a duty to provide notice of the information and evidence necessary to substantiate a claim. 38 U.S.C.A. § 5103(a) (West 2014); 38 C.F.R. § 3.159(b) (2016). As the Board is granting the issues for SMC based on the need for aid and attendance as well as automobile and adaptive equipment, or adaptive equipment only, compliance as to these issues need not be further addressed. See AB v. Brown, 6 Vet. App. 35 (1993). With respect to the issues of a higher disability rating for peripheral neuropathy of the left lower extremity, sciatic nerve, and peripheral neuropathy of the right lower extremity, sciatic nerve, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2016); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). II. Increased Rating Disability ratings are intended to compensate impairment in earning capacity due to a service-connected disorder. 38 U.S.C.A. § 1155. Separate diagnostic codes identify the various disabilities. Id. It is necessary to evaluate the disability from the point of view of the veteran working or seeking work, 38 C.F.R. § 4.2, and to resolve any doubt regarding the extent of the disability in the veteran's favor. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Veteran contends that he is entitled to a higher rating for his service-connected peripheral neuropathy of the left lower extremity, sciatic nerve; and peripheral neuropathy of the right lower extremity, sciatic nerve. The Board notes that the Veteran has also been granted service connection for peripheral neuropathy of the left and right lower extremities, femoral nerve, in an April 2017 rating decision, and was assigned a 20 percent disability rating for each extremity. The Veteran's peripheral neuropathy of the left and right lower extremities, sciatic nerve, is currently rating 20 percent disabling for each extremity, under Diagnostic Code 8520. 38 C.F.R. § 4.124a. Diagnostic Code 8520 rates incomplete or complete paralysis of the sciatic nerve. Mild incomplete paralysis warrants a 10 percent disability rating; moderate incomplete paralysis warrants a 20 percent disability rating; moderately severe incomplete paralysis warrants a 40 percent disability rating; and, severe incomplete paralysis with marked muscular atrophy warrants a 60 percent disability rating. The term "incomplete paralysis" with this and other peripheral nerve injuries indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. The ratings for the peripheral nerves are for unilateral involvement; when there is bilateral involvement, the VA adjudicator is to combine the ratings for the peripheral nerves, with application of the bilateral factor. 38 C.F.R. § 4.124a. The use of terminology such as "mild," "moderate" and "severe" by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. 38 C.F.R. §§ 4.2, 4.6. In a March 2012 VA examination, the Veteran was found to have mild incomplete paralysis of the sciatic nerve bilaterally. He had decreased vibration sensation of the lower extremities and mild paresthesias and/or dysesthesias and numbness. The Veteran reported that symptoms have progressed along feet and legs that affect his balance. He also noticed progressive loss of position sense and that he was unable to feel gas pedal or brakes while driving periodically. He walked with a cane. During an April 2013 VA examination, the Veteran's peripheral neuropathy of the lower extremities were manifested by 1+ deep tendon reflex of the right and left ankles, no weakness found, and normal muscle strength. Also, there was no constant pain, moderate intermittent pain and numbness, and mild paresthesias and/or dysesthesias. Sensory examination showed decreased to light touch in the lower leg/ankle and foot/toes bilaterally. The Veteran had mild incomplete paralysis of the sciatic nerve and the external popliteal nerve. He used a walker and cane inside the house and a motorized scooter outside the house and reported that he was unable to ambulate due to lack of coordination. VA examination in December 2015 shows the Veteran had severe constant pain, intermittent pain, paresthesias and/or dysesthesias, and numbness of the lower extremities. Neurologic examination revealed strength was 1/5 for knee extension and flexion bilaterally, which represents visible muscle movement, but no joint movement, and ankle plantar flexion and dorsiflexion was 2/5 bilaterally, which represents no movement against gravity. Deep tendon reflexes and light touch was decreased for the lower extremities except for the knee or thigh, which was normal for light touch. The Veteran was found to have moderate incomplete paralysis of the sciatic nerve. The Veteran required constant use of his wheelchair and occasionally used a cane. The January 2017 examination for housebound status or permanent need for regular aid and attendance revealed that the Veteran could not bear weight or pivot and had no range of motion due to his severe bilateral neuropathy of the lower extremities. He used a power wheelchair for locomotion and his wife must pull or slide the Veteran into the chair, car seat or bed. He was unable to go anywhere without total help and only occasionally went to the grocery store with his wife. During the January 2017 hearing, the Veteran stated that he had complete numbness of his lower extremities from his feet to his knees and could not bend his ankle. As a result, he was unable to use his feet due to the severity of the peripheral neuropathy of his lower extremities. The Veteran's symptoms were predominantly moderately severe in severity based on the evidence of record. Although the Veteran's peripheral neuropathy of the lower extremities increased in severity over the course of the appellate period, he had problems walking throughout demonstrating a more severe disability. He began being unable to feel gas pedal or brakes while driving at the time of the March 2012 VA examination and his symptoms along feet and legs affected his balance requiring a cane to walk. In addition, his reflexes of both lower extremities have been decreased throughout the appellate period and at the time of the December 2015 VA examination, the Veteran's peripheral neuropathy began to affect his strength in both lower extremities. Therefore, throughout the appellate period, the Veteran's peripheral neuropathy has been more than wholly sensory. The evidence shows that the Veteran does have incomplete paralysis of other nerves of the lower extremity, which includes the femoral nerve that has been granted service connection and the external popliteal nerve noted in the April 2013 VA examination. Although incomplete paralysis of other nerves of the lower extremities has been found, the evidence does not clearly show whether the Veteran's disability of the lower extremities was due to the sciatic nerve on appeal or the other affected nerves. Therefore, it must be assumed that all impairment is due to the disability on appeal. Mittleider v. West, 11 Vet. App. 181, 182 (1998). When reasonable doubt is resolved in the Veteran's favor, the Board finds that the evidence more nearly approximates a 40 percent disability rating for moderately severe severity rather than a 20 percent rating for moderate severity for each lower extremity. The evidence does not show that the symptoms are more than moderately severe such that they would approximate an even higher rating as the Veteran does not have marked muscular atrophy as required by the 60 percent rating. Therefore, a rating higher than 40 percent for incomplete paralysis of the sciatic nerve for each lower extremity is not warranted and the preponderance of the evidence is against an even higher rating. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). III. SMC for Aid and Attendance/Housebound The appellant asserts that he is unable to perform his functions of daily living without the aid and assistance of another due to his service-connected disabilities, specifically his peripheral neuropathy of the upper and lower extremities. SMC is payable in addition to the basic rate of compensation otherwise payable on the basis of degree of disability. See 38 U.S.C.A. § 1114; 38 C.F.R. § 3.350. A Veteran will be considered to be in need of aid and attendance if he: (1) is blind or so nearly blind as to have corrected visual acuity of 5/200 or less, in both eyes, or concentric contraction of the visual field to 5 degrees or less; or (2) is a patient in a nursing home because of mental or physical incapacity; or (3) establishes a factual need for aid and attendance under the criteria set forth in 38 C.F.R. § 3.352(a). 38 C.F.R. § 3.351(c). Under 38 C.F.R. § 3.352(a), determinations as to the need for aid and attendance must be based on actual requirements of personal assistance from others. In making such determinations, consideration is given to such conditions as: inability of the claimant to dress or undress himself or to keep himself ordinarily clean and presentable; frequent need of adjustment of any special prosthetic or orthopedic appliances which, by reason of the particular disability, cannot be done without aid; inability of the claimant to feed himself through loss of coordination of upper extremities or through extreme weakness; inability to attend to the wants of nature; or incapacity, physical or mental, which requires care or assistance on a regular basis to protect the claimant from the hazards or dangers inherent in his daily environment. It is not required that all of the disabling conditions enumerated above be found to exist before a favorable rating may be made. The particular personal functions that the claimant is unable to perform should be considered in connection with his condition as a whole. It is only necessary that the evidence establish that the claimant is so helpless as to need regular aid and attendance, not that there be a constant need. 38 C.F.R. § 3.352(a). The Veteran is currently service-connected for diabetes mellitus with erectile dysfunction; peripheral neuropathy of the left lower extremity, sciatic nerve; peripheral neuropathy of the right lower extremity, sciatic nerve; peripheral neuropathy of the left lower extremity, femoral nerve; peripheral neuropathy of the right lower extremity, femoral nerve; peripheral neuropathy of the right upper extremity, radial nerve; peripheral neuropathy of the left upper extremity, radial nerve; and TIA. He has been in receipt of a total rating due to individual unemployability and special monthly compensation for loss of use of a creative organ since August 1, 2011. The salient question in this SMC claim is whether the appellant requires the aid and attendance of another person and is housebound solely as a result of his service-connected disabilities. During the October 2015 hearing, the Veteran stated that he has problems with self-care due to his numbness in his hands and feet. During the January 2017 hearing, the Veteran stated that he had complete numbness of his lower extremities from his feet to his knees and could not bend his ankle. He also had numbness from his hands to his elbows and could not grip or pinch. As a result, he was unable to use his hands and feet due to the severity of the peripheral neuropathy of his upper and lower extremities and relied on his wife to take care of him for all of his needs all day long, including bathing. VA examination in December 2015 shows the Veteran had moderate constant pain, intermittent pain, paresthesias and/or dysesthesias, and numbness of the upper extremities. He had severe constant pain, intermittent pain, paresthesias and/or dysesthesias, and numbness of the lower extremities. Neurologic examination revealed strength was 2/5 for bilateral elbow flexion and extension, which represents no movement against gravity; 3/5 for wrist flexion and extension, which represents no movement against resistance, and 1/5 for grip and pinch, which represents visible muscle movement, but no joint movement. Knee extension and flexion was 1/5, which represents visible muscle movement, but no joint movement, and ankle plantar flexion and dorsiflexion was 2/5, which represents no movement against gravity. Deep tendon reflexes and light touch was decreased for all upper and lower extremities except for the knee or thigh, which was normal for light touch. The nerves affected bilaterally were the radial, median, ulnar, sciatic and femoral, and all had moderate incomplete paralysis. The Veteran required constant use of his wheelchair and occasionally used a cane. The January 2017 examination for housebound status or permanent need for regular aid and attendance revealed that because the Veteran only had movement in his thumbs, his wife has to feed him, prepare all his food, and tends to all his hygiene needs. Due to his severe bilateral neuropathy of the lower extremities, the Veteran could not bear weight or pivot and had no range of motion. He used a power wheelchair for locomotion and his wife must pull or slide the Veteran into the chair, car seat or bed. Due to his peripheral neuropathy of the bilateral upper extremities, the Veteran had severely decreased range of motion, could not perform any fine motor skills, could not shave or feed himself, could not administer insulin, and could not use the restroom by himself. He is unable to perform any activities of daily living or go anywhere without total help and only occasionally went to the grocery store with his wife. Based on the aid and attendance examination report and examinations for peripheral neuropathy, the evidence shows that the Veteran is in need of aid and attendance of another due to his service connected peripheral neuropathy of the upper and lower extremities. The Board finds highly probative the Veteran's medical evidence of the severity of the bilateral peripheral neuropathy of the upper and lower extremities and of the impact on his inability to walk or attend the his activities of daily living without the assistance of his wife as well as his competent reports of numbness and limitation of function of his hands and feet. Significantly, the January 2017 examination report describes the functional limitations of the Veteran's hands and feet caused by his service-connected disabilities and the necessity for his wife to feed him, prepare all his food and tend to all his hygiene needs. Accordingly, SMC based on the need for aid and attendance is warranted. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). IV. Automotive and Adaptive Equipment Financial assistance may be provided to an "eligible person" in acquiring an automobile or other conveyance and adaptive equipment, or adaptive equipment only. 38 U.S.C.A. § 3902 (a)(b). In order to establish entitlement to financial assistance in purchasing an automobile or other conveyance, or adaptive equipment, the Veteran must have a service-connected disability which includes one of the following: loss or permanent loss of use of one or both feet, loss or permanent loss of use of one or both hands, permanent impairment of vision of both eyes, a severe burn injury, or amyotrophic lateral sclerosis (ALS). 38 U.S.C.A. §§ 3901, 3902; 38 C.F.R. § 3.808. The term "loss of use" of a hand or foot is defined by 38 C.F.R. § 3.350(a)(2) as that condition where no effective function remains other than that which would be equally well served by an amputation stump at the site of election below the elbow or the knee with use of a suitable prosthetic appliance. The determination will be made on the basis of the actual remaining function, whether the acts of grasping, manipulation, etc. in the case of the hand, or balance, propulsion, etc., in the case of a foot, could be accomplished equally well by an amputation stump with prosthesis. See also 38 C.F.R. § 4.63. Examples under 38 C.F.R. § 3.350(a)(2) of what constitutes loss of use of a foot or hand include extremely unfavorable ankylosis of the knee, or complete ankylosis of two major joints of an extremity, or shortening of the lower extremity of 3 and 1/2 inches or more. Complete paralysis of the external popliteal (common peroneal) nerve and consequent foot drop, accompanied by characteristic organic changes, including trophic and circulatory disturbances and other concomitants confirmatory of complete paralysis of this nerve is also considered loss of use of a foot under 38 C.F.R. § 3.350(a)(2). The Veteran is currently service-connected for diabetes mellitus with erectile dysfunction; peripheral neuropathy of the left lower extremity, sciatic nerve; peripheral neuropathy of the right lower extremity, sciatic nerve; peripheral neuropathy of the left lower extremity, femoral nerve; peripheral neuropathy of the right lower extremity, femoral nerve; peripheral neuropathy of the right upper extremity, radial nerve; peripheral neuropathy of the left upper extremity, radial nerve; and TIA. He has been in receipt of a total rating due to individual unemployability and special monthly compensation for loss of use of a creative organ since August 1, 2011. The Veteran stated during the January 2017 hearing that he is unable to use his hands and feet due to the severity of the peripheral neuropathy of his upper and lower extremities. VA examination in December 2015 shows the Veteran had moderate constant pain, intermittent pain, paresthesias and/or dysesthesias, and numbness of the upper extremities. He had severe constant pain, intermittent pain, paresthesias and/or dysesthesias, and numbness of the lower extremities. Neurologic examination revealed strength was 2/5 for bilateral elbow flexion and extension, which represents no movement against gravity; 3/5 for wrist flexion and extension, which represents no movement against resistance, and 1/5 for grip and pinch, which represents visible muscle movement, but no joint movement. Knee extension and flexion was 1/5, which represents visible muscle movement, but no joint movement, and ankle plantar flexion and dorsiflexion was 2/5, which represents no movement against gravity. Deep tendon reflexes and light touch was decreased for all upper and lower extremities except for the knee or thigh, which was normal for light touch. The nerves affected bliaterally were the radial, median, ulnar, sciatic and femoral, and all had moderate incomplete paralysis. The Veteran required constant use of his wheelchair and occasionally used a cane. The January 2017 examination for housebound status or permanent need for regular aid and attendance revealed that because the Veteran only had movement in his thumbs, his wife had to feed him, prepare all his food, and tend to all his hygiene needs. Due to his severe bilateral neuropathy of the lower extremities, the Veteran could not bear weight or pivot and has no range of motion. He used a power wheelchair for locomotion and his wife must pull or slide the Veteran into the chair, car seat or bed. Due to his peripheral neuropathy of the bilateral upper extremities, the Veteran had severely decreased range of motion, could not perform any fine motor skills, could not shave or feed himself, could not administer insulin, and could not use the restroom by himself. He is unable to perform any activities of daily living or go anywhere without total help and only occasionally went to the grocery store with his wife. Based on the evidence above, the Board finds that the Veteran's service-connected peripheral neuropathy of the right and left upper and lower extremities has resulted in the functional equivalent of loss of use of the upper and lower extremities, to include the loss of use of the hands and feet. The Board finds highly probative the Veteran's medical evidence of the severity of the effects of the bilateral peripheral neuropathy of the upper and lower extremities on his ability to walk or attend the his activities of daily living without the assistance of his wife and his competent reports of numbness and limitation of function of his hands and feet. Significantly, the January 2017 examination report describes the functional limitations of the Veteran's hands and feet caused by his service-connected disabilities. Although a physician has not specifically stated that no "effective function remains other than that which would be equally well served by an amputation stump at the site," the regulation defining "loss of use" appears to leave the definition open to some interpretation to the extent that it includes an intentionally non-exhaustive list of "example" situations which may reflect loss of use. Broadly interpreted, the Board finds the facts in this case as being sufficiently similar to those examples presented as demonstrative of the regulatory definition of loss of use. As the Board concludes that the lay and medical evidence demonstrates that Veteran has the functional equivalent of loss of use of one or both hands and feet due to a service-connected disability. Accordingly, the Veteran is eligible to acquire an automobile or other conveyance and adaptive equipment, and the appeal is granted. ORDER A rating of 40 percent, but no higher, for peripheral neuropathy of the left lower extremity, sciatic nerve; is granted, subject to the laws and regulations governing the payment of monetary awards. A rating of 40 percent, but no higher, for peripheral neuropathy of the right lower extremity, sciatic nerve; is granted, subject to the laws and regulations governing the payment of monetary awards. SMC based on the need for aid and attendance is granted, subject to the legal regulations governing the payment of monetary benefits. Entitlement to automobile and adaptive equipment is granted, subject to the legal regulations governing the payment of monetary benefits. REMAND The Veteran's TIA disability is currently rated based on adjustment disorder with anxiety and depressed mood and mild neurocognitive disorder due to vascular disease. During the appellate period, the evidence of record showed that the Veteran currently has problems swallowing and speaking, which was noted during the examination for TIA. However, none of the VA examinations addressed whether the Veteran's problems swallowing and speaking are disabilities related to his service-connected TIA, and the cause of these problems are not clear from the record. In order to properly adjudicate this appeal, a factually accurate, fully articulated, and soundly reasoned medical opinion is needed. As such, further development is necessary. Barr v. Nicholson, 21 Vet. App. 303 (2007); Stefl v. Nicholson, 21 Vet. App. 120, 125 (2007); 38 C.F.R. § 3.159(c)(4). Accordingly, the case is REMANDED for the following action: (This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Afford the Veteran a VA examination to assess the current severity of the Veteran's service-connected TIA. The entire claim file must be reviewed by the examiner and the report should state the review was conducted. All pertinent symptomatology and findings are to be reported in detail. Any indicated diagnostic tests and studies must be accomplished. The examiner must also identify all currently present manifestations of the Veteran's TIA disability, including neurological manifestations. The examiner is to specifically address the Veteran's reports of problems swallowing and talking and the presence and severity of any neurological abnormalities associated with the Veteran's service-connected TIA disability must be determined. The examiner must provide a complete rationale for all opinions expressed. If the examiner cannot provide any requested opinions without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. The examiner must indicate whether there was any further need for information or testing necessary to make a determination. The examiner must indicate whether an opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. 2. After completing the above actions, and any additional development deemed necessary, the RO must readjudicate the Veteran's claim. If any benefit on appeal remains denied, the Veteran and his representative must be provided a supplemental statement of the case and be given an adequate opportunity to respond. Thereafter, the case must be returned to the Board for 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. C. MACKENZIE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs