Citation Nr: 1751489 Decision Date: 11/09/17 Archive Date: 11/17/17 DOCKET NO. 09-04 199 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a sleep disorder, to include as secondary to posttraumatic stress disorder (PTSD) or gastroesophageal reflux disease (GERD). 2. Entitlement to an increased rating for residuals, gunshot wound (GSW) with left foot plantar fasciitis and fracture of the left fifth toe, evaluated as 10 percent disabling prior to February 21, 2017, and as 20 percent disabling from that date. 3. Entitlement to an initial evaluation in excess of 10 percent for GERD with esophagitis. 4. Entitlement to an initial evaluation in excess of 30 percent for PTSD. REPRESENTATION Appellant represented by: John S. Berry, Attorney at Law ATTORNEY FOR THE BOARD J. Barone, Counsel INTRODUCTION The Veteran had active service from January 1970 to January 1973. This appeal comes to the Board of Veterans' Appeals (Board) from June 2008, January 2009, August 2009, May 2015, and March 2017 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The June 2008 rating decision denied a compensable evaluation for residuals, GSW, fracture left fifth toe with asymptomatic scar; denied service connection for GERD, and granted service connection for PTSD and assigned a 10 percent evaluation. The January 2009 rating decision granted service connection for GERD with esophagitis and assigned a 10 percent evaluation. The August 2009 rating decision denied service connection for a sleep disability. In June 2010, the Board remanded the issues of entitlement to higher evaluations for the left foot GSW, GERD, and PTSD. While the appeal was in remand status, the Agency of Original Jurisdiction (AOJ) issued a rating decision in January 2011 that increased the evaluation of PTSD to 30 percent, effective September 14, 2007, the date of receipt of the Veteran's claim for service connection. In November 2012, the Board denied evaluations in excess of 10 percent for GERD and in excess of 30 percent for PTSD. The issues of entitlement to service connection for a sleep disorder and a compensable evaluation for the left foot GSW were remanded for development of the record. These issues were again remanded in January 2014. The Veteran appealed the Board's November 2012 decision to the United States Court of Appeals for Veterans Claims (Court). In April 2014, the Court issued a Memorandum Decision which vacated the Board's decision and remanded the matter for action consistent with its decision. In March 2015, the Board remanded the issues of entitlement to higher evalautions for GERD and PTSD for development of the record. The May 2015 rating decision granted a 10 percent increased disability rating for GSW residuals with left foot plantar fasciitis and left fifth toe fracture with asymptomatic scar effective September 14, 2007 (the day the Veteran's increased rating claim was received by VA). In a September 2015 decision, the Board denied an evaluation in excess of 10 percent for GSW residuals with left foot plantar fasciitis and left fifth toe fracture with asymptomatic scar, a separate compensable rating for the left foot scar, and service connection for a sleep disorder. The September 2015 Board decision also remanded the issues of entitlement to higher evaluations for GERD and PTSD. The Veteran appealed the September 2015 Board decision to the United States Court of Appeals for Veterans Claims (Court). In April 2016, the Court partially vacated the Board's September 2015 decision pursuant to a March 2016 Joint Motion for Partial Remand. The Veteran explicitly abandoned the appeal with regard to the issue of a separate disability rating for the left foot scar. In August 2016, the Board remanded the issues of an evaluation in excess of 10 percent for GSW residuals with left foot plantar fasciitis and left fifth toe fracture and service connection for a sleep disorder. At that time, it noted that the issues of entitlement to higher initial evaluations for GERD and PTSD remained in remand status. In a March 2017 rating decision, the AOJ awarded a 20 percent evaluation for the left foot GSW, effective February 21, 2017. Subsequently, all issues on appeal were returned to the Board for appellate consideration. The issues of entitlement to an increased rating for residuals of a GSW to the left foot and a higher initial evaluation for PTSD are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDINGS OF FACT 1. There is no competent medical evidence of a sleep disorder that is related to service or to service-connected disability. 2. Throughout the period on appeal, GERD with esophagitis has been manifested by no more than persistent heartburn, reflux, and substernal pain; it is not manifested by substernal arm or shoulder pain or anemia, and it has not been productive of considerable overall health impairment. CONCLUSIONS OF LAW 1. A sleep disorder was not incurred in or aggravated by service, and was not caused or aggravated by a service-connected disease or injury. 38 U.S.C.A. §§ 1101, 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.310 (2017). 2. The criteria for an initial evaluation in excess of 10 percent for GERD with esophagitis have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.1, 4.6, 4.20, 4.114, Diagnostic Code 7346 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2017). A letter dated in January 2008 discussed the evidence necessary to support a claim for service connection for GERD. A March 2014 letter advised the Veteran of the evidence necessary to establish service connection on a secondary basis. The Veteran was informed of the allocation of responsibilities between himself and VA and was also informed of the manner in which VA determines disability ratings and effective dates. Subsequent correspondence advised the Veteran of the status of his appeal. The Board finds that the content of the pre-adjudication notice fully complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) regarding VA's duty to notify. The appellant has been provided with every opportunity to submit evidence and argument in support of his claim. Further, the Board finds that the purpose behind the notice requirement has been satisfied because the appellant has been afforded a meaningful opportunity to participate effectively in the processing of his claim. The Board notes that this is a case in which the Veteran is challenging the initial evaluation assigned following the grant of service connection for GERD with esophagitis. In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Id. at 90-91. With respect to VA's duty to assist, service, VA, and private treatment records have been obtained and associated with the record. VA examinations were conducted, and the Board finds that they were adequate in that they were performed by medical professionals who reviewed the Veteran's history, conducted complete examinations, and provided an opinion supported by adequate rationale. The Veteran has not otherwise identified any additional evidence or information which could be obtained to substantiate the claim. The Board is also unaware of any such outstanding evidence or information. Therefore, the Board is also satisfied that VA has complied with the duty to assist requirements of the VCAA. Analysis Service Connection for Sleep Disorder The Veteran asserts that he has a sleep disorder, which he describes as insomnia, that is related to his service connected PTSD or GERD. He has reported that his sleep is interrupted by both of these disabilities. Entitlement to VA compensation may be granted for disability resulting from disease or injury incurred in or aggravated by active duty. 38 U.S.C.A. §§ 1110 (wartime service), 1131 (peacetime service); 38 C.F.R. § 3.303. To establish a right to compensation for a present disability, a claimant must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service"-the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Service connection may also be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be granted for disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). This includes any increase in disability (aggravation) that is proximately due to or the result of a service-connected disease or injury. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either caused or aggravated by a service-connected disease or injury. Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b). On VA psychological examination in May 2008, the Veteran reported that he woke up intermittently and felt tired in the morning. The examiner noted that his PTSD symptoms included persistent increased arousal, including difficulty falling or staying asleep. In September 2010, a VA psychologist noted the Veteran's report of seven to eight hours of sleep with Trazadone. He stated that sleep disturbance was mild. The Veteran reported that on a few occasions, his reflux had been severe enough to preclude sleep. In May 2015, a VA examiner indicated that the Veteran's PTSD symptoms included chronic sleep impairment. In February 2017, a VA examiner indicated that the Veteran's psychiatric symptoms included sleep disturbance. He determined that the Veteran did not have a diagnosed sleep disability; rather, he concluded that the Veteran's reported insomnia was a symptom of his service-connected PTSD. He specified that the Veteran was evaluated for nearly one and one half hours, and was afforded the opportunity to provide additional information and ask questions. Upon careful review of the record, the Board has concluded that service connection is not warranted for the claimed sleep disorder. In this regard, there is no indication of a chronic disability during service, in the years following service, or currently. While the Veteran has reported sleep disturbance, this has been identified by VA examiners as a symptom of his PTSD rather than a distinct and separate diagnosis or disability. In the absence of proof of a current disability, there can be no valid claim for service connection. Brammer v. Derwinski, 3 Vet. App. 223 (1992); see also Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998) (service connection may not be granted unless a current disability exists). The Board acknowledges the Veteran's report of sleep disturbance; however, a symptom or a finding, without a diagnosed or identifiable underlying malady or condition, does not, in and of itself, constitute a "disability" for which service connection may be granted. See Sanchez-Benitez v. West, 13 Vet. App. 282 (1999). There is no competent evidence of record diagnosing a current sleep disability. The Court has consistently held that, under the law, a "determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or a disease incurred in service." Watson v. Brown, 4 Vet. App. 309 (1993). This principle has been repeatedly reaffirmed by the Federal Circuit, which has stated that "a veteran seeking disability benefits must establish . . . the existence of a disability [and] a connection between the veteran's service and the disability." Boyer v. West, 210 F.3d 1351 (Fed. Cir. 2000). To the extent that the Veteran asserts that he has a sleep disability that is related to service or to service-connected disability, the Board observes that he may attest to factual matters of which he has first-hand knowledge, such as subjective complaints, and that his assertions in that regard are entitled to some probative weight. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). He is competent to report incidents and symptoms in service and symptoms since then. He is not, however, competent to render an opinion as to whether there is a currently existing sleep disability and whether such is linked to active duty or to a service connected disability, because he does not have the requisite medical knowledge or training, and because such matters are beyond the ability of a lay person to observe. See Rucker v. Brown, 10 Vet. App. 67, 71 (1997); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). For the reasons expressed above, the Board finds that a preponderance of the evidence is against the Veteran's claim of entitlement to service connection for a sleep disability, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Evaluation of GERD with Esophagitis Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. 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 for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. In cases where the original rating assigned is appealed, as with the Veteran's depression claim, consideration must be given to whether a higher rating is warranted at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). Records from the Mayo Clinic dating to July 2006 indicate the Veteran's report of two to three episodes of reflux per week. Testing was conducted in August 2006 based on the Veteran's complaints of GERD symptoms. The diagnosis was esophagitis. On VA examination in December 2008, the Veteran's history was reviewed. The examiner noted that there was a diagnosis of esophagitis with no Barrett's esophagus. The examiner indicated that there was no evidence of dysphagia and that the Veteran denied such. He also denied pyrosis and substernal chest or arm pain. He endorsed occasional mid-epigastric tenderness and pain. He also endorsed reflux and regurgitation. He denied nausea and vomiting. He reported that he used Omeprazole and denied side effects. He denied having been hospitalized or undergoing surgery, and also denied a history of hiatal hernia. He reported that his weight had been stable during the previous six months. On physical examination, his abdomen was soft, nontender, and nondistended. The diagnoses were GERD and esophagitis. Records from St. Vincent's Medical Center indicated that on endoscopy in December 2009, the impression was Grade A esophagitis. The findings also include a medium sized hiatal hernia. On VA examination in September 2010, the examiner indicated that GERD had been stable since onset. Regarding history, the Veteran denied hospitalization or surgery, trauma, nausea, vomiting, dysphagia, regurgitation, hematemesis, and melena. He endorsed esophageal distress accompanied by pain several times per week, and heartburn or pyrosis several times per week. He reported that he had undergone esophageal dilation once in the previous 12 months. Physical examination revealed good overall general health and no signs of anemia. There were no signs of significant weight loss of malnutrition. The Veteran reported that he lost one day of work per month due to lack of sleep caused by GERD. On remand in March 2015, the Board noted the Veteran's report of esophageal dilation, but that it was unclear whether there was an esophageal stricture. On VA examination in February 2017, the Veteran's history was reviewed. He reported that, despite taking Omeprazole, he continued to experience heartburn approximately three times per week. He endorsed pyrosis, reflux, and substernal pain. The examiner specified that the Veteran did not have stricture, spasm, or an acquired diverticulum of the esophagus. He indicated that there were no other pertinent physical findings, complications, or symptoms related to the diagnosis. He noted that upper endoscopy in October 2011 was normal. He did not remark on the results of a 2016 complete blood count. The Veteran's GERD with esophagitis is evaluated pursuant to diagnostic code (DC) 7399-7346. Notably, gastroesophageal reflux disease (GERD) is not a listed disability in the rating schedule. 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. 38 C.F.R. § 4.20. According to the policy in the schedule, when a disability is not specifically listed, the Diagnostic Code will be "built up," meaning that the first 2 digits will be selected from that part of the schedule most closely identifying the part of the body involved, and the last 2 digits will be "99." 38 C.F.R. § 4.27. For example, Diagnostic Code 7399 is used to identify unlisted digestive system disabilities. Regulations provide that ratings under Diagnostic Codes 7301 through 7329, 7331, 7342, and 7345 to 7348, inclusive, will not be combined with each other. 38 C.F.R. § 4.114. Rather, a single rating will be assigned under the diagnostic code that reflects the predominant disability picture, with elevation to the next higher rating where the severity of the overall disability warrants such elevation. DC 7346, for hiatal hernia (to which GERD is found to be analogous), provides a 10 percent disability rating for two or more of the symptoms indicated for a 30 percent disability rating but with less severity. A 30 percent disability rating is warranted for persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A maximum schedular 60 percent disability rating is warranted 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. Having reviewed the evidence relating to the Veteran's gastrointestinal disability, the Board has concluded that an evaluation in excess of 10 percent is not warranted. Initially, the Board finds that the Veteran's predominant symptoms are that associated with his GERD and esophagitis. To that end, the Veteran's symptoms are largely heartburn, reflux, and substernal pain. A higher, 30 percent evaluation requires evidence demonstrating persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. Such is not shown by the record. While the Board acknowledges the Veteran's report of substernal pain associated with his gastrointestinal disability, this symptom is not associated with persistently recurrent epigastric distress, or combined with symptoms that produce considerable impairment of health. Moreover, the evidence is against a finding of material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. Accordingly, the Board finds that the current 10 percent evaluation for the Veteran's gastrointestinal disability is appropriate. In summary, while the Board acknowledges the Veteran's reported gastrointestinal symptoms and their impact, it winds that the overall disability picture does not more nearly approximate the criteria for the next higher evaluation. The Board thus concludes that the currently assigned 10 percent evaluation for this disability is appropriate. 38 U.S.C.A. § 5107(b) (West 2014). ORDER Entitlement to service connection for a sleep disability is denied. Entitlement to an initial evaluation in excess of 10 percent for GERD with esophagitis is denied. REMAND Evaluation of Left Foot Disability In the August 2016 remand, the Board noted that the parties to the March 2016 Joint Motion for Partial Remand agreed that the Board did not address favorable evidence, specifically a May 2014 VA examination report noting the Veteran's report of decreased range of motion of his left foot during flare-ups, which was relevant to the Board's finding that the Veteran's range of motion was within normal limits. The Board further noted that a November 2012 Board remand directed on VA examination, range of motion testing should be conducted, and if possible, the VA examiner should report (in degrees) the point in range of motion testing where motion was limited by pain. The VA examiner was asked to opine as to the degree of additional functional loss (if any) due to weakness, fatigue, and incoordination, including during flare-ups. At the May 2014 VA examination, the Veteran reported a scar in the arch of the left foot secondary to the GSW that limited his ability to flex the left foot. He reported difficulty with climbing stairs/ladders and constant left foot pain. He endorsed flare-ups impacting the function of the left foot with the most limiting factor being range of motion during he avoided activities involving putting pressure on the left foot. In August 2016, the Board pointed out that while the May 2014 examiner addressed the presence of pain with movement, weight bearing, and repeated use, it was unclear whether range of motion testing was performed. Moreover, the Board noted that the examiner did not provide an opinion as to the degree of additional functional loss (if any) due to weakness, fatigue, and incoordination, including on repetition or during flare-ups. Finally, the Board observed that in Correia v. McDonald, the Court held that the final sentence of 38 C.F.R. § 4.59 (2016) required that all VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. The Board pointed out that it was unclear whether joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing was conducted at the May 2014 VA examination or that it was compared to measurements from the opposite (right) undamaged joint. As such, the Board remanded this issue for an additional VA examination. The Veteran was afforded muscle and foot examinations in February 2017. Unfortunately, neither examination report is completely responsive to the Board's previous remand instructions. In this regard, the examination reports do not describe active and passive range of motion testing of the ankles of the sort contemplated by the Board's previous remand directives. A remand by the Board confers on the claimant, as a matter of law, the right to compliance with the remand orders. Stegall v. West, 11 Vet. App. 268, 271 (1998). Accordingly, this issue must be again remanded for compliance with previous Board directives, as set forth below. Evaluation of PTSD In the March 2015 remand, the Board noted that in addition to PTSD, the Veteran had been diagnosed with dysthymic disorder. It noted that the Court's April 2014 Memorandum Decision indicated that it should be determined whether the Veteran was entitled to a separate disability rating for dysthymic disorder. In this regard, the Court has held that, when it is not possible to separate the effects of the service-connected condition from a nonservice-connected condition, 38 C.F.R. § 3.102, which requires that reasonable doubt on any issue be resolved in the Veteran's favor, clearly dictates that such signs and symptoms be attributed to the service-connected condition. See Mittleider v. West, 11 Vet. App. 181 (1998). The Board directed that the Veteran be afforded a VA examination to address whether it was possible to separate the effects of the Veteran's service-connected PTSD from the nonservice-connected dysthymic disorder and, if so, such symptoms attributable to each psychiatric diagnosis be specifically identified. On VA examinations in May 2015 and February 2017, the examiners provided a diagnosis of PTSD, and indicated that there were no other psychiatric diagnoses. Neither included a discussion of the evidence of a diagnosis of dysthymic disorder, or why such was not diagnosed on examination. This deficiency must be addressed. The Board also notes that the Veteran's attorney has submitted the June 2017 report of a private psychological evaluation. This report includes diagnoses of PTSD, major depressive disorder, and panic disorder. The psychologist also described symptoms of a severity not indicated by the February 2017 VA examination report. Because of this discrepancy, and based on the deficiencies noted in the May 2015 and February 2017 VA examination reports, the Board concludes that the record should be reviewed by the February 2017 VA examiner, who should address the varying diagnoses in the record as well as the severity of the Veteran's psychiatric symptoms. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA examination to determine the severity of the service-connected left foot disability. The record should be made available to and reviewed by the examiner. Any and all studies, tests, and evaluations should be performed. All pertinent symptomatology and findings should be reported in detail, including range of motion (ROM) testing. The examiner should set forth the Veteran's range of motion findings and note any pain, pain on use, weakness, incoordination, or excess fatigability. If feasible, the examiner should portray any additional functional limitation of the knees due to these factors in terms of degrees of additional loss of motion. If not feasible, this should be stated and discussed in the examination report. If the Veteran does not have pain or any of the other factors, that fact should be noted as well. The examiner should also test the range of motion of the left and right knees in active motion, passive motion, weight-bearing, and nonweight-bearing. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. The complete rationale for any conclusion reached should be provided. 2. Obtain an addendum opinion from the February 2017 examiner to determine whether psychiatric diagnoses other than PTSD are appropriate, and if so, whether the symptoms of each separate diagnosis can be identified. The record should be made available to and reviewed by the examiner. If the examiner who conducted the January 2011 VA examination is not available, arrange to have the above reference opinions to be provided by a suitably qualified health care professional. No additional examination of the Veteran is required unless the examiner determines examination is necessary. All findings should be reported in detail. Following a review of the claims file, the examiner should specify whether the evidence supports diagnoses of dysthymic disorder, major depressive disorder, or panic disorder. If so, the examiner should indicate whether the symptoms attributable to any such disorder can be specifically identified, or whether this is not possible. The examiner should also discuss the severity of the Veteran's PTSD symptoms and how the findings contained in his February 2017 examination report comport with the findings reported by the private psychologist in June 2017. The examiner is asked to explain the reasons underlying any opinions expressed and conclusions reached. In discussing her rationale, the examiner should specifically address the evidence of record, to include evidence regarding the diagnosis of dysthymic disorder previously noted by the Board, as well as the June 2017 evaluation report by the private psychologist. If the examiner is unable to offer any of the requested opinions, it is essential that the examiner offer a rationale for the conclusion that an opinion cannot be provided without resort to speculation, together with a statement as to whether there is additional evidence that might enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. See Jones v. Shinseki, 23 Vet. App. 382 (2010). 3. Review the examination/addendum reports to ensure that they are in compliance with the Board's remand directives. Any deficiencies should be addressed prior to recertification to the Board. 4. Then, readjudicate the Veteran's claim, with application of all appropriate laws, regulations, and case law, and consideration of any additional information obtained as a result of this remand. If the decision remains adverse to the Veteran, he and his representative should be furnished a supplemental statement of the case and afforded an appropriate period of time within which to respond thereto. The appellant 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). 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). ______________________________________________ G. A. WASIK Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs