Citation Nr: 1750122 Decision Date: 11/03/17 Archive Date: 11/13/17 DOCKET NO. 12-02-716 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to a rating in excess of 10 percent for post operative right fifth toe with hammertoe correction and nerve damage. 2. Entitlement to a rating in excess of 10 percent for gastroesophageal reflux disease (GERD) with hiatal hernia, gastric ulcer, and gastritis (previously claimed as acute pancreatitis and chest pain). 3. Entitlement to a compensable rating for hemorrhoids. 4. Whether new and material evidence has been received to reopen a claim for service connection for headaches, currently claimed as migraines. 5. Entitlement to service connection for headaches, currently claimed as migraines. 6. Entitlement to a total rating based on individual unemployability due to service-connected disability (TDIU). REPRESENTATION Appellant represented by: Jeffrey Marion, Attorney at Law ATTORNEY FOR THE BOARD A. Shawkey, Counsel INTRODUCTION The Veteran served on active duty from October 1976 to April 1979, and from May 1979 to October 1998. This matter comes to the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. The issues of entitlement to a rating in excess of 10 percent for post operative right fifth toe with hammertoe correction and nerve damage and entitlement to a rating in excess of 10 percent for GERD with hiatal hernia, gastric ulcer, and gastritis (previously claimed as acute pancreatitis and chest pain) were previously before the Board in September 2014 at which time the case was remanded to the RO for further development. This appeal was processed using the Veterans Benefits Management System (VBMS) and Legacy Content Manager Documents (formerly Virtual VA) electronic claims file. The underlying issue of entitlement to service connection for headaches, currently claimed as migraines, as well as the issue of entitlement to a rating in excess of 10 percent for post operative right fifth toe with hammertoe correction and nerve damage are being remanded and are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. In August 2017, prior to the promulgation of a decision in the appeal, the Board received notification from the Veteran's representative that the Veteran wished to withdraw the issue of entitlement to a TDIU. 2. Throughout the duration of this appeal, the Veteran's GERD with hiatal hernia, gastric ulcer, and gastritis, has been manifested by persistently recurring epigastric distress with reflux, pyrosis, regurgitation, and substernal pain, productive of considerable impairment of health. 3. Throughout the duration of this appeal, the Veteran's hemorrhoids have resulted in no more than mild or moderate symptomatology, to include itching, pain, and occasional bleeding, without evidence that such were large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences, or resulted in persistent bleeding, secondary anemia, or fissures. 4. A September 2005 rating decision that denied the claim of entitlement to service connection for headaches was not appealed and no new and material evidence was submitted during the appeal period; the decision is final. 5. The evidence received since the September 2005 rating decision relates to an unestablished fact and raises a reasonable possibility of substantiating the claim for service connection for headaches, currently claimed as migraines. CONCLUSIONS OF LAW 1. The criteria for withdrawal of the appeal by the appellant (or his or her authorized representative) for a TDIU have been met. 38 U.S.C.A. § 7105 (b)(2), (d)(5) (West 2014); 38 C.F.R. § 20.204 (2017). 2. The criteria for a 30 percent rating, but no higher, for GERD with hiatal hernia, gastric ulcer, and gastritis, are met throughout the duration of this appeal. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.321, 4.1-4.14, 4.114, Diagnostic Code 7346 (2017). 3. The criteria for a compensable rating for hemorrhoids have not been met at any point during the pendency of this appeal. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.321, 4.1-4.14, 4.114, Diagnostic Code 7336 (2017). 4. The September 2005 rating decision that denied service connection for headaches is final. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. § 20.1103 (2017). 5. New and material evidence has been submitted to reopen the claim of entitlement to service connection for headaches, currently claimed as migraines. 38 U.S.C.S. §§ 5108, 7105 (West 2014); 38 C.F.R. § 3.156 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Withdrawn Issue The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C.A. § 7105 (West 2014). An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204 (2017). Withdrawal may be made by the appellant or by his or her authorized representative. 38 C.F.R. § 20.204. In the present case, the Veteran, through his representative, withdrew the issue of entitlement to a TDIU in writing in August 2017 and, hence, there remain no allegations of error of fact or law for appellate consideration regarding this issue. Accordingly, the Board does not have jurisdiction to review this issue and it is dismissed. II. Increased Rating Claims A. General Rating Provisions Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. In general, it is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet App 119 (1999). The analysis in the following decision is therefore undertaken with consideration of the possibility that further staged ratings may be warranted for different time periods. B. Rating in Excess of 10 Percent for GERD with Hiatal Hernia, Gastric Ulcer and Gastritis Pertinent Criteria There are diseases of the digestive system, particularly within the abdomen, which, while differing in the site of pathology, produce a common disability picture characterized in the main by varying degrees of abdominal distress or pain, anemia and disturbances in nutrition. Consequently, certain coexisting diseases in this area do not lend themselves to distinct and separate disability evaluations without violating the fundamental principle relating to pyramiding as outlined in § 4.14. 38 C.F.R. § 4.113. GERD is not specifically listed in the rating schedule, but is evaluated as analogous to hiatal hernia. See 38 C.F.R. § 4.20 (when an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous). Hiatal hernia is evaluated as follows: A 60 percent rating is assigned for symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health; a 30 percent rating requires persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health; a 10 percent rating is assigned for two or more of the symptoms for the 30 percent evaluation of less severity (10 percent). 38 C.F.R. § 4.114, Code 7346. VA regulations define "minor weight loss" as a weight loss of 10 to 20 percent of the individual's baseline weight maintained for three months or longer. "Baseline weight" means the average weight for the two year period preceding onset of the disease. VA defines "substantial weight loss" as a loss of greater than 20 percent of an individual's baseline weight. Ratings under diagnostic codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348 inclusive will not be combined with each other. A single evaluation will be assigned under the diagnostic code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such evaluation. 38 C.F.R. § 4.114. Facts Medical records from Womack Army Medical Center show that the Veteran underwent an upper GI endoscopy in August 2010 and was found to have atrophic gastritis (without mention of hemorrhage), gastric ulcer unspecified as acute or chronic without mention of hemorrhage or perforation or obstruction, and dysphagia unspecified. In addition, a biopsy was performed at the site of the gastric antral ulcer revealing reactive gastropathy. In November 2010, the Veteran filed a claim for an increased rating for his gastrointestinal disorder, asserting that the disability had worsened resulting in chronic gastritis and gastric ulcers. At a QTC examination in March 2011, the Veteran reported problems keeping food down and having stomach and chest pains when he ate. He said he had lost ten pounds over the past two months. He also reported heartburn, epigastric pain, scapular pain, arm pain, reflux and regurgitation of stomach contents and nausea and vomiting. He denied dysphagia, hematemesis and passing of black tarry stools. He was noted to be taking Omeprazole for over 13 years at 20 mg which was increased to 40 mg daily in February 2011. He was also noted to be taking Aciphex 20 mg twice daily and Dicyclomme for stomach pain. He said that he did not experience an overall functional impairment from this condition. Medical records from VAMC Fayetteville from 2012 to 2015 reflect diagnoses of GERD and show periodic medication adjustments. The Veteran's gastrointestinal symptoms at a May 2016 VA examination were noted to have persisted with character unchanged, but with some increased frequency and increased severity over time. Noted signs and symptoms include dysphagia, pyrosis, reflux, regurgitation, and pain. Sleep disturbance was also noted due to esophageal reflux, and the Veteran had nausea four or more times a year lasting less than one day. He was not found to have esophageal stricture, spasm of esophagus (cardiospasm or achalasia), or an acquired diverticulum of the esophagus. The examiner reported that the Veteran did not have any other pertinent physical findings, complications, conditions, signs or symptoms related to gastrointestinal disorders. He opined that the Veteran's esophageal conditions did not impact his ability to work. The May 2016 examiner issued an addendum in May 2016 noting that the Veteran's test results were not consistent with hiatal hernia. He explained that the Veteran's gastric ulcers had improved, but there was persistent gastritis on testing in September 2010 and he noted that the Veteran's reported symptoms were consistent with GERD both at time of separation and at present. Discussion The evidence outlined above is consistent with the Veteran's November 2010 claim that his gastrointestinal symptoms have worsened. In this regard, findings at the May 2016 VA examination show that he had persistent gastritis as well as persistent GERD symptoms. These symptoms include dysphagia, pyrosis, regurgitation and pain. The Veteran similarly reported pain at the March 2011 examination, including epigastric pain, scapular pain, and arm pain. He also had reflux and regurgitation of stomach contents. Although he denied dysphagia at this examination, he was noted to have chronic dysphagia at a VA outpatient clinic visit a few months earlier in June 2010. In light of this evidence, the Board finds that the Veteran's overall disability picture since the date that he filed a claim for an increased rating in November 2010 more nearly approximates the criteria for a 30 percent rating. 38 C.F.R. § 4.7. A rating in excess of 30 percent is not, however, warranted for the Veteran's gastrointestinal disability under Code 7346 at any point during the appeal period. In order for the maximum schedular evaluation of 60 percent to be assigned, the evidence of record must demonstrate symptoms of pain, vomiting, material weight loss, and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. 38 C.F.R. § 4.114, Diagnostic Code 7346. Other than the Veteran's report at the March 2011 QTC examination of vomiting, he was not found at any other point during the appeal period to have this symptom or any other symptom listed under Code 7346 for a 60 percent rating. Also, his reported 10 pound weight loss at the March 2011 examination (from 185 pounds to 175 pounds) is less than 10 percent and is thus not considered to be a material weight loss. In addition, he was not found to have hematemesis or melena, with moderate anemia. Moreover, the March 2011 examiner found that the Veteran's gastrointestinal disability did not result in overall functional impairment, and the May 2016 examiner found that the condition did not impact the Veteran's ability to work. Also, the majority of VA outpatient records for this period show that the Veteran's GERD was stable on medication. In short, the Veteran is not shown by the evidence of record to meet the criteria under Code 7346 for a 60 percent rating or to have other symptom combinations productive that meet such criteria. In other words, his overall disability picture as shown by the evidence outlined above is more consistent with considerable impairment of health than severe impairment of health. In addition, the Veteran's gastrointestinal disability picture does not warrant a higher evaluation under any other pertinent diagnostic code. A higher rating of 40 percent is not warranted under the pertinent diagnostic codes for ulcers since the evidence does not show anemia, or recurrent incapacitating episodes average 10 days or more in duration at least four or more times a year. Rather, as noted, the March 2011 examiner said that the Veteran did not experience an overall functional impairment due to his gastrointestinal condition, and the May 2016 examiner said that it did not impact his ability to work. Also, while there was one report of vomiting, the evidence does not establish transient episodes of vomiting or melena. 38 C.F.R. § 4.114, Codes 7305, 7306. With respect to the criteria for gastritis, a higher rating, of 60 percent, is not warranted under this code since there is no showing of severe hemorrhages, or large ulcerated or eroded areas. 38 C.F.R. § 4.114, Code 7307. For the foregoing reasons, the evidence supports a 30 percent, but no higher, disability rating for (GERD) with hiatal hernia, gastric ulcer, and gastritis throughout the rating period. 38 C.F.R. § 4.114, Code 7346. C. Compensable Rating for Hemorrhoids Pertinent Criteria Under DC 7336, hemorrhoids are assigned a zero percent rating where there is evidence of mild to moderate symptomatology. A 10 percent rating is warranted where there is evidence of large or thrombotic hemorrhoids, which are irreducible, with excessive redundant tissue, evidencing frequent recurrences. Finally, a 20 percent rating, the maximum schedular rating, is warranted where hemorrhoids are present, with persistent bleeding and secondary anemia, or with fissures. Words such as "mild," "moderate," "moderately severe," and "severe" are not defined in the Rating Schedule or in the regulations. Consequently, the Board must evaluate all of the evidence to ensure that its decisions are "equitable and just." 38 C.F.R. § 4.6. Facts An August 2015 outpatient record from Womack Army Medical Center reflects the Veteran's complaint of worsening hemorrhoids for the past two months. He reported occasional blood when wiping, and he said that he used over-the-counter preparation H with minimal relief. He was seen again in September 2015 and October 2015 for continued symptoms. His weight in September 2015 was 176.4 pounds. At a VA examination in August 2015, the Veteran reported that his hemorrhoid condition had worsened over the last six months with more frequent flare ups and pain. He reported episodes of severe pain on his bottom and he said that he could feel the hemorrhoids "pop out". He noted some blood on the paper with wiping on occasion. He said he took Metamucil to prevent hard stools and that he used over-the-counter Preparation H with some relief of the itching, but no relief from the pain. On examination skin tags were noted, but there were no external hemorrhoids. The Veteran denied having a flare up at that time. He reported that his job in Human Resources requires him to sit and this makes the hemorrhoids flare up. He said that during the flare ups the pain distracts him and makes it difficult to concentrate. He also said he has to take more bathroom breaks due to the pain and itching. He added that he is self conscious of blood oozing on his pants from the hemorrhoids. He said that when he is in a meeting he squirms and cannot concentrate due to the discomfort. He assessed the Veteran as having mild or moderate hemorrhoids based on colonoscopy results in 2013 that revealed grade I internal hemorrhoids. In January 2016, the Veteran underwent a sigmoidoscopy which revealed grade I internal hemorrhoids. Discussion The Veteran contends that his service connected hemorrhoid disability warrants a compensable rating. He asserted in February 2016 that the condition is "chronic and severe" and affects the quality of his life. The Board has carefully reviewed the record pertaining to this claim and has determined that a compensable rating for hemorrhoids is not warranted. A higher rating is warranted when there are large or thrombotic hemorrhoids that are irreducible with excessive redundant tissue evidencing frequent occurrences. Although the Veteran reported that his hemorrhoid disability worsened in 2015 with increased flareups and discomfort, the severity of this disability since his August 2015 claim has not been shown to be more than moderate in severity. Findings at the December 2015 VA examination showed skin tags, but no hemorrhoids. Although the examination was not conducted during a flare up, the Veteran did not describe symptoms such as thrombotic or irreducible hemorrhoids with excessive redundant tissue, persistent bleeding, secondary anemia, or fissures. In terms of bleeding, he did report occasional bleeding on the paper when wiping, but he did not report nor has he been shown to have persistent bleeding. Moreover, the December 2015 VA examiner assessed the severity of the Veteran's hemorrhoids as "mild to moderate", and results of the sigmoidoscopy performed in January 2016 revealed grade I internal hemorrhoids. The Board has considered the Veteran's contentions and evidence regarding his worsening hemorrhoid disability with increased flareups and discomfort. However, after reviewing the specific symptoms that he describes, in addition to the actual test and examination findings, the Board finds that his symptomatology does not meet the criteria for a higher, compensable rating. Rather, his symptomatology more closely approximates the criteria for his present noncompensable rating. Therefore, the lay and medical evidence is against a compensable rating. The Board has also considered the applicability of the benefit of the doubt doctrine. However, because the preponderance of the evidence is against a compensable rating, the benefit of the doubt doctrine is not for application. 38 U.S.C.A. § 5107 (b). IV. Claim to Reopen Service Connection for Headaches The Veteran initially filed a claim for service connection for headaches in April 2005. The AOJ denied this claim in September 2005 on the basis that the Veteran did not have a headache disability. Rather, the AOJ found that his headache complaints in service were symptoms of other disorders. This appeal stems from a November 2014 determination that denied reopening the Veteran's claim for service connection for headaches, currently claimed as migraines, on the basis that no new and material evidence had been submitted. Generally, if a claim of entitlement to service connection has been previously denied and that decision has become final, the claim can be reopened and reconsidered only if new and material evidence is presented with respect to that claim. 38 U.S.C.S. § 5108. While it appears that the RO subsequently reopened the claim in the May 2016 Statement of the Case and considered it on the merits, the Board has a jurisdictional responsibility to consider whether it was proper for a claim to be reopened, regardless of what the RO has determined. See Jackson v. Principi, 265 F. 3d 1366, 1369 (Fed. Cir. 2001). New evidence is defined as existing evidence not previously submitted to agency decision makers. Material evidence means evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence previously of record, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156 (a). The threshold to reopen a claim is low. Shade v. Shinseki, 24 Vet. App. 110, 118 (2010). Additionally, for the purposes of evaluating a request to reopen a previously denied claim, the credibility of new evidence will be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). The evidence on file at the time of the final decision in September 2005 includes the Veteran's service treatment records showing various headache complaints. More specifically, these records show that he was seen in July 1979 complaining of headaches with dizziness for 10 days. In December 1979, he was seen on two occasions with complaints including headaches. On one occasion he was diagnosed as having otitis media, and on the other occasion he was diagnosed as having tension headaches. In July 1988, he was found to have headaches in connection with a sore throat and diarrhea, and in February 1996 he was noted to have a headache in connection with a viral infection. He denied having a history of frequent or severe headaches at his retirement examination in June 1998, and had normal head and neurological clinical evaluations at that time. Also on file in September 2005 are VA outpatient medical records showing an initial complaint of headaches in May 2005. The Veteran reported at this time having a headache over the temporal region. He said that the headaches usually occur in the mornings upon waking and were "the same" in the military. He said he had had good results with aspirin, but that over the last month the aspirin had not been working. He was also noted to have a history of allergic rhinitis. The examiner assessed him as having early morning headaches that were possibly due to hypertension, anti-inflammatory medication, or allergies. The examiner ordered a computed tomography (CT) scan of the Veteran's head that revealed sinus disease. Evidence on file after September 2005 includes VA outpatient records from November 2005 through October 2011 which note that the Veteran had a history of headaches and a CT scan that was consistent with sinusitis. In addition, there are treatment reports from Womack Army Medical Center reflecting diagnoses of headache syndrome and migraine headaches. As noted, the basis of the AOJ's initial denial of service connection for headaches in September 20015 was that the Veteran was not shown to have a headache disability; rather his complaints were noted to be linked to other disorders. With that said, records from Womack Army Medical Center that were received after September 2005 reflect diagnoses of headache syndrome and migraines and thus establish a previously missing element to the service connection claim, namely, a current disability. The language of 38 C.F.R. § 3.156 (a) creates a low threshold, viewing the phrase "raises a reasonable possibility of substantiating the claim" as "enabling rather than precluding reopening." Shade v. Shinseki, 24 Vet. App. 110 (2010). In sum, the Board finds that the additional evidence received since the September 2005 denial shows a present headache disability and is thus new and material within the meaning of 38 C.F.R. § 3.156(a). Accordingly, the claim for service connection for headaches, currently claimed as migraines, is reopened. Id. ORDER Entitlement to a TDIU is dismissed. A 30 percent rating disability rating, but no higher, for (GERD) with hiatal hernia, gastric ulcer, and gastritis is granted, subject to the regulations governing the award of monetary benefits. A compensable rating for hemorrhoids is denied. New and material evidence having been received, the application to reopen the claim for service connection for headaches is granted. REMAND Turning to the merits of the now reopened claim for service connection for headaches, currently claimed as migraines, the Board finds that additional evidentiary development is necessary to fulfill VA's duty to assist the Veteran in this appeal. In May 2016, the Veteran was afforded a VA examination for his headache disability claim. 38 U.S.C.A. § 5103A(d). However, the examiner's medical opinion regarding the likelihood of a relationship between the Veteran's postservice headaches and his headache complaints in service is inadequate for rating purposes thus requiring another medical opinion. Id. In this regard, the examiner concluded that due to a lack of evidence and an inability to establish chronicity, it was less likely than not that the Veteran's chronic migraine headaches were incurred in or are proximately due to active duty military service. Indeed, the first indication that the Veteran had migraines was not until May 2009 when he was initially diagnosed as having migraines. However, his documented complaints of headaches date back to 2005, and treatment records reflect diagnoses of headache syndrome in addition to migraine headaches. In this regard, he was assessed in December 2011 as having headache syndrome, mixed for tension and migraines. This is noteworthy when considering that he was diagnosed in service in December 1979 as having a tension headache. Also, the Veteran is competent to report on the incurrence of his headache disorder and the continuity of symptomatology. The examiner must take this into consideration when rendering an opinion. Accordingly, the Veteran must be afforded a new VA examination in order to properly assess the nature and etiology of his claimed headache disorder. 38 U.S.C.A. § 5103A(d). In February 2017, the Veteran filed a claim for service connection for sciatica of his right foot and leg secondary to his service-connected lumbar spine disability. Evidence pertinent to this claim includes VA examination reports in May 2016 and April 2017. In May 2017, the AOJ granted service connection for sciatica of the left foot and leg as secondary to the Veteran's service-connected lumbar spine disability. However, the AOJ did not adjudicate the claim for service connection for sciatica of the right foot and leg. Consequently, this claim is still pending and is inextricably intertwined with the present claim for a higher than 10 percent rating for the Veteran's service connected post operative right fifth toe with hammertoe correction and nerve damage. It follows that the issue of entitlement to a rating in excess of 10 percent for post operative right fifth toe with hammertoe correction and nerve damage must be deferred pending the outcome of the claim for service connection for sciatica of the right foot and leg, claimed as secondary to the Veteran's service-connected lumbar spine disability. See Parker v. Brown, 7 Vet. App. 116 (1994); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (issues are 'inextricably intertwined' when a decision on one issue would have a 'significant impact' on a claim for the second issue).) In light of the above, the case is REMANDED for the following action: 1. Afford the Veteran a VA examination in order to assess the nature and etiology of his claimed headache disorder. The record, to include a copy of this Remand, must be made available to and be reviewed by the examiner. All appropriate tests and studies should be accomplished and all clinical findings should be reported in detail. Based on an interview with the Veteran, a review of the record, and a physical examination, the examiner should offer an opinion as to the following: (A) Identify all currently diagnosed headache disorders. (B) For each diagnosed headache disorder, the examiner should offer an opinion as to whether it is at least as likely as not (50 percent probability or greater) that such is related to the Veteran's military service. In offering an opinion, the examiner must consider the Veteran's lay statements regarding the incurrence of his headache disorder and the continuity of symptomatology. The rationale for any opinion offered should be provided. 2. Upon completion of any outstanding development and issuance of a rating decision regarding claim of entitlement to service connection for sciatica of the right foot and leg, claimed as due to service-connected lumbar spine disability, readjudicate the appeal for entitlement to a rating in excess of 10 percent for post operative right fifth toe with hammertoe correction and nerve damage in addition to the claim for service connection for headaches, claimed as migraines. If any benefit sought on appeal is not granted, issue the Veteran and his representative a supplemental statement of the case and provide the Veteran an opportunity to respond. The case should be returned to the Board for further appellate consideration, if otherwise in order. The Veteran and his representative have 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). These claims 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). ______________________________________________ ANTHONY C. SCIRÉ, JR. Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs