Citation Nr: 1751628 Decision Date: 11/13/17 Archive Date: 11/22/17 DOCKET NO. 13-19 799 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Whether new and material evidence sufficient to reopen the claim of entitlement to service connection for fatigue has been submitted, and if so, whether the claim may be granted. 2. Whether new and material evidence sufficient to reopen the claim of entitlement to service connection for headaches has been submitted, and if so, whether the claim may be granted. 3. Whether new and material evidence sufficient to reopen the claim of entitlement to service connection for a gastrointestinal disorder has been submitted, and if so, whether the claim may be granted. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD M. Hannan, Counsel INTRODUCTION The Veteran appellant was a member of the Army National Guard for over thirty years, from 1979 to 2009, when he retired. The appellant served on active duty from July 2004 to October 2005, to include service in Southwest Asia. The appellant also served a period of active duty for training (ACDUTRA) from June 1, 1979, to August 24, 1979. This case comes before the Board of Veterans' Appeals (Board) on appeal from a May 2011 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina. In August 2016, the appellant presented testimony at a Travel Board hearing conducted at the RO before the undersigned Veterans Law Judge. The hearing transcript from that proceeding has been associated with the claims file. The Board notes that the appellant's service connection claims for fatigue, headaches and a gastrointestinal disorder were all originally denied in a December 2007 rating decision; he was notified of the denials that same month, but he did not complete the steps required to appeal those denials. The December 2007 rating decision therefore represents the last final action on the merits of the claims for service connection for fatigue, headaches and a gastrointestinal disorder. See Glynn v. Brown, 6 Vet. App. 523 (1994). The December 2007 rating decision also represents the last final decision on any basis. Evans v. Brown, 9 Vet. App. 273 (1996). Thus, the Board must consider whether any of the evidence submitted since the December 2007 rating decision constitutes new and material evidence on the issues of entitlement to service connection for fatigue, headaches and a gastrointestinal disorder. This appeal was processed using the VA paperless claims processing system. Accordingly, any future consideration of this appellant's case should take into consideration the existence of this electronic record. The issues of entitlement to service connection for fatigue and headaches are addressed in the REMAND portion of the decision below and those two matters are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The evidence submitted since the December 2007 rating decision relates to an unestablished fact and raises a reasonable possibility of substantiating the claim for service connection for fatigue. 2. The evidence submitted since the December 2007 rating decision relates to an unestablished fact and raises a reasonable possibility of substantiating the claim for service connection for headaches. 3. The evidence submitted since the December 2007 rating decision relates to an unestablished fact and raises a reasonable possibility of substantiating the claim for service connection for a gastrointestinal disorder. 4. The appellant's claimed gastrointestinal disorder has been diagnosed as irritable bowel syndrome (IBS) which constitutes a medically unexplained chronic multisymptom illness that is presumptively the result of service in Southwest Asia. CONCLUSIONS OF LAW 1. The December 2007 rating decision that denied the appellant's claim of entitlement to service connection for fatigue is final. 38 U.S.C. § 7104 (West 2012); 38 C.F.R. § 20.1103 (2017). 2. Additional evidence submitted subsequent to the December 2007 rating decision that denied the appellant's claim for service connection for fatigue is new and material and does serve to reopen the claim. 38 U.S.C. §§ 5102, 5103, 5103A, 5107, 5108 (West 2012); 38 C.F.R. § 3.156 (2017). 3. The December 2007 rating decision that denied the appellant's claim of entitlement to service connection for headaches is final. 38 U.S.C. § 7104 (West 2012); 38 C.F.R. § 20.1103 (2017). 4. Additional evidence submitted subsequent to the December 2007 rating decision that denied the appellant's claim for service connection for headaches is new and material and does serve to reopen the claim. 38 U.S.C. §§ 5102, 5103, 5103A, 5107, 5108 (West 2012); 38 C.F.R. § 3.156 (2017). 5. The December 2007 rating decision that denied the appellant's claim of entitlement to service connection for a gastrointestinal disorder is final. 38 U.S.C. § 7104 (West 2012); 38 C.F.R. § 20.1103 (2017). 6. Additional evidence submitted subsequent to the December 2007 rating decision that denied the appellant's claim for service connection for a gastrointestinal disorder is new and material and does serve to reopen the claim. 38 U.S.C. §§ 5102, 5103, 5103A, 5107, 5108 (West 2012); 38 C.F.R. § 3.156 (2017). 7. The criteria for service connection for irritable bowel syndrome (IBS) have been met. 38 U.S.C. §§ 1110, 1117, 1118, 5107 (West 2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.317 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant is seeking service connection for fatigue, headaches and a gastrointestinal disorder. He maintains that he incurred these disabilities during his period of active duty in Kuwait. He provided testimony to that effect during his August 2016 Travel Board hearing. Service connection may be established for a Persian Gulf veteran who exhibits objective indications of chronic disability which cannot be attributed to any known clinical diagnosis, but which instead results from an undiagnosed illness that became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2021. 38 C.F.R. § 3.317 (a)(1)(i). See also 81 FR 71382 (October 17, 2016). A Persian Gulf veteran is one who served in the Southwest Asia theater of operations during the Persian Gulf War. Id. The Southwest Asia theater of operations includes Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations. 38 C.F.R. § 3.317(d)(2). The appellant's service personnel records reflect that he served in Kuwait from September 2004 to September 2005, and therefore he is a Persian Gulf veteran. I. VA's Duty to Notify and Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. § 3.102, 3.156(a), 3.159, 3.326(a). In this case, as the Board is granting the appellant's attempt to reopen his claims for service connection for fatigue, headaches and a gastrointestinal disorder, the Board is granting in full the benefits (reopening of the claims) sought on appeal. (The claims of entitlement to service connection for fatigue and headaches are being remanded for additional development.) In addition, the Board is granting service connection for irritable bowel syndrome (IBS). Accordingly, any error committed with respect to either the duty to notify or the duty to assist in connection with any one of these three claims was harmless and will not be further discussed. II. Merits of the Claims In adjudicating a claim, the Board determines whether (1) the weight of the evidence supports the claim or, (2) whether the weight of the "positive" evidence in favor of the claim is in relative balance with the weight of the "negative" evidence against the claim. The appellant prevails in either event. However, if the weight of the evidence is against the appellant's claim, the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In order to establish service connection for a claimed disability, the facts, as shown by evidence, must demonstrate that a particular disease or injury resulting in a current disability was incurred during active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Furthermore, service connection may be granted for any disease diagnosed after service when all the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In addition, a disability that is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310. The United States Court of Appeals for Veterans Claims (Court) has held that the term "disability" as used in 38 U.S.C.§ 1110 should refer to "any additional impairment of earning capacity resulting from an already service-connected condition, regardless of whether or not the additional impairment is itself a separate disease or injury caused by the service-connected condition." Allen v. Brown, 7 Vet. App. 439, 448 (1995). Under 38 C.F.R. § 3.310(a), service connection may be established on a secondary basis for a disability which is proximately due to or the result of 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 (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Where a service-connected disability aggravates a non-service-connected condition, a veteran may be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Aggravation will be established by determining the baseline level of severity of the non-service-connected condition and deducting that baseline level, as well as any increase due to the natural progress of the disease, from the current level. 38 C.F.R. § 3.310(b). To establish service connection for a disability, symptoms during service, or within a reasonable time thereafter, must be identifiable as manifestations of a chronic disease or permanent effects of an injury. Further, a present disability must exist and it must be shown that the present disability is the same disease or injury, or the result of disease or injury incurred in or made worse by the appellant's military service. Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992); 38 C.F.R. § 3.303(a). A. New and Material Evidence Claims New and material evidence necessary to reopen a previously and finally disallowed claim must be secured or presented since the time that the claim was finally disallowed on any basis, not only since the time the claim was last disallowed on the merits. Evans v. Brown, 9 Vet. App. 273, 285 (1996). A claim becomes final and subject to a motion to reopen only after the appeal period has run; interim submissions before finality must be considered as part of the original claim pursuant to 38 C.F.R. § 3.156(b). Jennings v. Mansfield, 509 F.3d 1362 (Fed. Cir. 2007). The pertinent regulations require that evidence raise a reasonable possibility of substantiating a claim in order to be considered "new and material," and define material evidence as evidence, that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. 38 C.F.R. § 3.156(a). The credibility of the evidence is presumed for the purpose of reopening. Justus v. Principi, 3 Vet. App. 510 (1992). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." When evaluating the materiality of newly submitted evidence, the focus must not be solely on whether the evidence remedies the principal reason for denial in the last prior decision; rather the determination of materiality should focus on whether the evidence, taken together, could at least trigger the duty to assist or consideration of a new theory of entitlement. Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). The appellant's claims for service connection for fatigue, headaches and a gastrointestinal disorder were denied in essence because there was no evidence of record that indicated that the appellant had the claimed conditions or that the claimed conditions were related to any incident of service; any new and material evidence must relate to this. The Court has held that the threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). Furthermore, in determining whether this low threshold is met, VA must not limit its consideration to whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead must examine and determine if it could reasonably substantiate the claim were the claim to be reopened, to include by triggering the Secretary's duty to assist. Id. at 118. The evidence added to the record subsequent to the issuance of the December 2007 rating decision that denied service connection for fatigue, headaches and a gastrointestinal disorder includes written statements and testimony from the appellant; written statements from fellow soldiers; VA treatment records; the report of a VA medical examination conducted in August 2010; and various rating decisions issued by the RO. The appellant has reported that he has been experiencing problems with fatigue, headaches and diarrhea ever since his service in Kuwait and VA treatment records show that the appellant's problem list has included headaches and chronic diarrhea. The August 2010 VA Gulf War medical examination yielded a diagnosis of IBS. The RO issued a rating decision, in January 2013, in which service connection for posttraumatic stress disorder (PTSD) was granted. In May 2015, the RO granted service connection for diabetes mellitus, to include diabetic retinopathy and nephropathy. The RO subsequently included hypertension as related to the diabetes mellitus in a rating decision issued in December 2014. The Board therefore finds that the evidence submitted subsequent to the December 2007 rating decision provides relevant information as to the question of whether the appellant has fatigue and headaches related to service connected disabilities in that his fatigue has been related by a VA examiner to the service-connected diabetes (see the report of the VA examination conducted in August 2010) and in that VA treatment records reflect that the appellant had trouble sleeping related to the service-connected PTSD. In addition, the appellant has reported that his headaches are related to his elevated blood pressure; he is service-connected for hypertension. The Board finds that the evidence cited above constitutes new and material evidence sufficient to reopen the claims for service connection for fatigue and headaches based on consideration of a new theory of entitlement (secondary service connection). Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). The evidence submitted subsequent to the December 2007 rating decision provides relevant information as to the question of whether the claims could reasonably be substantiated on a theory of secondary service connection were the claims to be reopened. Furthermore, as the appellant's VA medical records include a diagnosis of chronic diarrhea on his problem list and, as the appellant was diagnosed with IBS (a medically unexplained chronic multisymptom illness) in August 2010, the evidence submitted subsequent to the December 2007 rating decision provides relevant information as to the question of whether the claim of entitlement to service-connection for a gastrointestinal disorder could reasonably be substantiated were the claim to be reopened. The Board finds that the evidence cited above constitutes new and material evidence sufficient to reopen the claim for service connection for a gastrointestinal disorder. The underlying issues of entitlement to service connection for fatigue and for headaches are addressed in the REMAND section below. The matter of entitlement to service connection for a gastrointestinal disorder, to include as due to an undiagnosed illness, will be discussed next. B. Service Connection for a gastrointestinal disorder A veteran's lay statements may be competent to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. §§ 3.303(a), 3.159(a); see Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Diarrhea and abdominal pain are the sorts of conditions that are observable by a lay person. See also Davidson v. Shinseki, 581 F.3d 1313 (2009) (noting that a layperson may comment on lay-observable symptoms). The appellant has reported that he initially experienced problems with diarrhea in service in Kuwait and that these problems have continued to the present. Establishing service connection generally requires evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). A Persian Gulf veteran who exhibits objective indications of a qualifying chronic disability may be service-connected, provided such disability became manifest either during active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2021, and by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C.A. §§ 1117; 38 C.F.R. § 3.317(a)(1). A "qualifying chronic disability" means a chronic disability resulting from an undiagnosed illness and/or a medically unexplained chronic multisymptom illness that is defined by a cluster of signs or symptoms (such as chronic fatigue syndrome (CFS), fibromyalgia, or functional gastrointestinal disorders). 38 C.F.R. § 3.317(a)(2)(i). The term "medically unexplained chronic multisymptom illness" means a diagnosed illness without conclusive pathophysiology or etiology characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multisymptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii). "Objective indications of chronic disability" include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). Disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. The six-month period of chronicity is measured from the earliest date on which the pertinent evidence establishes the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317(a)(4). Signs or symptoms that may be a manifestation of an undiagnosed illness or a medically unexplained chronic multisymptom illness include, but are not limited to the following: fatigue; signs or symptoms involving the skin; headache; muscle pain; joint pain; neurologic signs or symptoms; neuropsychological signs or symptoms; signs or symptoms involving the respiratory system (upper or lower); sleep disturbances; gastrointestinal signs or symptoms; cardiovascular signs or symptoms; abnormal weight loss; and menstrual disorders. 38 C.F.R. § 3.317(b). If signs or symptoms have been medically attributed to a diagnosed (rather than undiagnosed) illness, the Persian Gulf War presumption of service connection does not apply. VAOPGCPREC 8-98. In the case of claims based on undiagnosed illness or a medically unexplained chronic multisymptom illness under 38 U.S.C. § 1117; 3.317, unlike those for direct service connection, there is no requirement that there be competent evidence of a nexus between the claimed illness and service. See Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). Further, lay persons are competent to report objective signs and/or symptoms of the claimed disability. Id. To determine whether the qualifying chronic disability is manifested to a degree of 10 percent or more the condition must be rated by analogy to a disease or injury in which the functions affected, anatomical location or symptomatology are similar. See 38 C.F.R. § 3.317(a)(5); see also Stankevich v. Nicholson, 19 Vet. App. 470 (2006). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The appellant served in Kuwait from November 2004 to October 2005. The record indicates the onset of chronic diarrhea while the appellant was deployed to Kuwait, as he is competent to report signs and symptoms of the claimed disability. See Gutierrez, 19 Vet. App. at 8-9. Further, the appellant's VA problem list includes a diagnosis of chronic diarrhea and the August 2010 VA Gulf War examiner diagnosed IBS. Thus, the evidence establishes that it is at least as likely as not the appellant has a chronic gastrointestinal disability diagnosed as IBS that had its onset during his period of service in the Southwest Asia. Irritable bowel syndrome is a functional gastrointestinal disorder that constitutes a medically unexplained chronic multisymptom illness within the meaning of 38 C.F.R. § 3.317 and thus a chronic qualifying disability under 38 U.S.C. § 1117. As there is no affirmative evidence that the disability was not incurred during the appellant's service in Southwest Asia, service connection for IBS is warranted on a presumptive basis in accordance with the provisions of 38 U.S.C. § 1117. See 38 C.F.R. § 3.317(a)(7). ORDER New and material evidence having been presented, the application to reopen the claim of entitlement to service connection for fatigue is granted and, to that extent only, the appeal is granted. New and material evidence having been presented, the application to reopen the claim of entitlement to service connection for headaches is granted and, to that extent only, the appeal is granted. New and material evidence having been presented, the application to reopen the claim of entitlement to service connection for a gastrointestinal disorder is granted. Service connection for IBS is granted. REMAND A determination has been made that additional development is necessary with respect to the two issues remaining on appeal. Accordingly, further appellate consideration will be deferred and this case remanded for action as described below. The claims for service connection for fatigue and headaches have been reopened in the decision above, based in part on the grants of service connection for PTSD, diabetes mellitus and hypertension during the appeal period. In addition, the evidence of record suggests that the appellant's claimed fatigue and headaches are related to service-connected disability, to include by way of aggravation. The evidence of record reflects that his fatigue and headaches flare up when he is stressed; that his fatigue is related to PTSD-related nightmares and sleep disturbance; that his fatigue is related to his service-connected diabetes; and that his headaches are related to the service-connected hypertension. Judicial interpretation of the matter of secondary service connection as embodied in 38 C.F.R. § 3.310 requires consideration of whether the service-connected disability either causes or aggravates another condition. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc) (when aggravation of a non-service-connected condition is proximately due to or the result of a service-connected condition, a veteran shall be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation). The appellant is now service-connected for PTSD, diabetes mellitus and hypertension and the AOJ has not yet provided an adequate discussion of the theory of secondary service connection, to include by way of aggravation, as it relates to the fatigue and headaches. This must be addressed on remand. These considerations require the gathering of medical records and investigation by medical professionals, inasmuch as the Board is prohibited from substituting its own unsubstantiated medical opinions. See Colvin v. Derwinski, Vet. App. 171, 175 (1991). In addition, the duty to assist includes obtaining medical records and examinations where indicated by the facts and circumstances of an individual case. See Murphy v. Derwinski, 1 Vet. App. 78 (1990). The United States Court of Appeals for Veterans Claims (Court) has stated that the Board's task is to make findings based on evidence of record - not to supply missing facts. Beaty v. Brown, 6 Vet. App. 532 (1994). Thus, where the record before the Board is inadequate to render a fully informed decision, a remand to the RO is required in order to fulfill its statutory duty to assist the appellant to develop the facts pertinent to the claim. Ascherl v. Brown, 4 Vet. App. 371, 377 (1993). Therefore, to ensure that VA has met its duty to assist in developing the facts pertinent to the claims on appeal and to afford full procedural due process, the case is REMANDED for the following: 1. Ensure that all notification and development action required by statutes, regulations, and any applicable legal precedents has been completed. See 38 C.F.R. § 3.156. 2. Contact the appellant and obtain the names and addresses of all medical care providers (private, VA, or other government) who have treated him for his claimed conditions. After securing the necessary release(s), obtain all outstanding records. 3. To the extent there is an attempt to obtain these records that is unsuccessful, the claims file must contain documentation of the attempts made. The appellant and his representative must also be informed of the negative results and be given opportunity to secure the records. 4. Any additional development suggested by the evidence must be undertaken. 5. Schedule the appellant for an examination by an appropriate examiner to determine the nature, extent, onset date, and etiology of his claimed fatigue, to include consideration of whether the fatigue is part and parcel of any service-connected disability, or whether the fatigue is a separate disability caused by or aggravated by any service-connected disorder, to include PTSD, diabetes mellitus with hypertension and/or IBS. The examiner must also state whether the fatigue constitutes an undiagnosed illness. 6. Schedule the appellant for an examination by an appropriate examiner to determine the nature, extent, onset date, and etiology of his claimed headaches, to include consideration of whether the current condition, if any, is related to his service in the Gulf War, and whether the condition is aggravated by any service-connected disorder, to include PTSD, diabetes mellitus with hypertension and/or IBS. The examiner must state whether the headaches are part and parcel of any service-connected disability, or whether the headaches constitute a separate disability, to include an undiagnosed illness. 7. The claims file must be made available to and reviewed by each examiner. If any examiner does not have access to the appellant's electronic file, any relevant treatment records contained in the electronic file must otherwise be made available to the examiner for review. Any studies deemed necessary must be performed. In assessing the relative likelihood as to origin and etiology of the appellant's claimed service-connected conditions, each examiner must apply the standard of whether it is at least as likely as not (i.e., to at least a 50-50 degree of probability) that any portion of the current condition is causally or etiologically related to service or to a service-connected disability, or whether such a causal or etiological relationship is unlikely (i.e., less than a 50 percent probability), with the rationale for any such conclusion set out in the report. The examiners must address the question of whether any service-connected disability, including PTSD, diabetes mellitus with hypertension and IBS, has caused or aggravated the claimed fatigue and headaches. Note: As used above, the term "at least as likely as not" does not mean merely within the realm of medical possibility, but rather that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of causation as it is to find against it. Note: The term "aggravation" in the above context refers to a permanent worsening of the underlying condition, as contrasted to temporary or intermittent flare-ups of symptomatology which resolve with return to the baseline level of disability. A complete rationale for all requested opinions must be provided. If any examiner cannot provide the requested opinion 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. Additionally, the examiner must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. See Jones v. Shinseki, 23 Vet. App. 382 (2010). 8. Upon receipt of each one of the VA examination reports, conduct a review to verify that all requested opinions have been offered. If information is deemed lacking, refer the report to the VA examiner(s) for corrections or additions. See 38 C.F.R. § 4.2 (If the findings on an examination report do not contain sufficient detail, it is incumbent upon the rating board to return the examination report as inadequate for evaluation purposes.). 9. After all appropriate development has been accomplished, review the record, including any newly acquired evidence, and re-adjudicate the claims for service connection for fatigue and headaches. The readjudication must reflect consideration of all the evidence of record and be accomplished with application of all appropriate legal theories, to include secondary service connection and secondary service connection by way of aggravation. 10. If any benefit sought on appeal remains denied, the Veteran and his representative must be provided a Supplemental Statement of the Case (SSOC). The SSOC must contain notice of all relevant actions taken on the claims for benefits, to include a summary of the evidence and applicable law and regulations considered pertinent to the issues currently on appeal. An appropriate period of time must be allowed for response. The appellant is hereby notified that it is his responsibility to report for any scheduled examination and to cooperate in the development of the case, and that the consequences of failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158 and 3.655. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). Thereafter, the case should be returned to the Board, if in order. The Board intimates no opinion as to the ultimate outcome of this case. The appellant need take no action unless otherwise notified. 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). ______________________________________________ TANYA SMITH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs