Citation Nr: 1753035 Decision Date: 11/17/17 Archive Date: 11/22/17 DOCKET NO. 10-00 340A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for left ear hearing loss. 2. Entitlement to service connection for left ear hearing loss 3. Entitlement to service connection for a left ankle disability, to include as due to knee disabilities. 4. Entitlement to service connection for a right ankle disability, to include as due to knee disabilities. 5. Entitlement to service connection for scars of the left upper extremity. 6. Entitlement to service connection for a cardiac disability. 7. Entitlement to service connection for hay fever. 8. Entitlement to service connection for sinusitis. 9. Entitlement to service connection for chronic bronchitis, to include as secondary to sinusitis and service-connected allergic rhinitis. 10. Entitlement to service connection for a sleep disorder other than sleep apnea, to include narcolepsy as secondary to service-connected sleep apnea. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Robert J. Burriesci, Counsel INTRODUCTION The Veteran served on active duty from January 1983 to January 2003. The Veteran had Persian Gulf service. This case comes before the Board of Veterans' Appeals (Board) on appeal from June 2008 and October 2010 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. The claims are currently within the jurisdiction of the St. Petersburg RO. In June 2011 the Board remanded the case for further action by the originating agency. The Veteran testified before the undersigned Veterans Law Judge at the RO in May 2013. He also testified before a decision review officer (DRO) at the RO in September 2009. Transcripts of both hearings are of record. In July 2013 and September 2015 the Board again remanded the case for further development. The issues of entitlement to service connection for a left and right ankle disabilities 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 an unappealed April 2005 adjudication, the RO denied an application to reopen a claim of entitlement to service connection for hearing loss. 2. Evidence added to the record since the last final denial is new and material and raises a reasonable possibility of substantiating the Veteran's claim for service connection for left ear hearing loss. 3. The competent and probative evidence is, at least, in relative equipoise as to whether the Veteran has left ear hearing loss due to service. 4. The competent and credible evidence is against a finding that the Veteran has a left upper extremity scar disability causally related to, or aggravated by, active service. 5. The competent and credible evidence is against a finding that the Veteran has a cardiac disability causally related to, or aggravated by, active service. 6. The Veteran is in receipt of service connected benefits for allergic rhinitis and the Veteran's hay fever has been identified as the same disability. 7. The competent and credible evidence is against a finding that the Veteran has a sinusitis disability causally related to, or aggravated by, active service. 8. The competent and credible evidence is against a finding that the Veteran has a chronic bronchitis disability causally related to, or aggravated by, active service, or due to or aggravated by a service-connected disability. 9. The competent and probative evidence is, at least, in relative equipoise as to whether the Veteran has narcolepsy due to service. CONCLUSIONS OF LAW 1. As evidence received since the April 2005 RO adjudication is new and material; the claim for entitlement to service connection for left ear hearing loss is reopened. 38 U.S.C. §§ 5108, 7105 (2012); 38 C.F.R. § 3.156, 20.302, 20.1103 (2017). 2. The criteria for entitlement to service connection for left ear hearing loss are met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.385 (2017). 3. The criteria for service connection for a left upper extremity scar disability have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304 (2017). 4. The criteria for service connection for a cardiac disability have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304 (2017). 5. The criteria for service connection for a separate hay fever disability have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304 (2017). 6. The criteria for service connection for a sinusitis disability have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1117, 1131, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.317 (2017). 7. The criteria for service connection for a chronic bronchitis disability have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1117, 1131, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.310, 3.317 (2017). 8. The criteria for entitlement to service connection for narcolepsy are met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Application to Reopen In a February 2003 rating decision, the RO denied entitlement to service connection for hearing loss because the evidence of record did not reveal audiometric findings that meet the criteria for a grant of service connection for defective hearing. In an April 2005 rating decision, the RO declined to reopen the claim. VA examination in April 2016 reveals audiological testing results that meet the VA criteria for hearing loss in the left ear pursuant to 38 C.F.R. § 3.385. The Board finds that this examination report represents new and material evidence and, therefore, the claim of entitlement to service connection for left ear hearing loss is reopened. See 38 C.F.R. § 3.156. II. Service Connection Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a link between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); Hickson v. West, 12 Vet. App. 247 (1999). Under 38 C.F.R. § 3.310, service connection may be granted for disability that is proximately due to or the result of a service-connected disease or injury, or for the degree of disability resulting from aggravation of a nonservice-connected disability by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). Under 38 C.F.R. § 3.317, a Persian Gulf Veteran who exhibits objective indications of a qualifying chronic disability may be service-connected, provided that such disability (1) 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, 2020, and (2) by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. A "qualifying chronic disability" has been defined to mean a chronic disability resulting from any of the following (or any combination of the following): (A) an undiagnosed illness; (B) a medically unexplained chronic multi-symptom illness (such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome) that is defined by a cluster of signs or symptoms, or (C) any diagnosed illness that the Secretary determines warrants a presumption of service connection. See 38 U.S.C. § 1117 (a)(2)(A), (B), (C); 38 C.F.R. § 3.317 (a)(2)(i)(B). When determining whether a qualifying chronic disability became manifest to a degree of 10 percent or more, the Board must explain its selection of analogous Diagnostic Code. Stankevich v. Nicholson, 19 Vet. App. 470, 472 (2006). The term "medically unexplained chronic multi-symptom illness" means a diagnosed illness without conclusive pathophysiology or etiology, that is 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. 38 C.F.R. § 3.317 (a)(2)(ii). Chronic multi-symptom 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 that 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 multi-symptom 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). A. Left Ear Hearing Loss The Veteran seeks entitlement to service connection for left ear hearing loss. Under 38 C.F.R. § 3.385, for the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. Service treatment records reveal that the Veteran had hearing loss for VA purposes in both ears in September 2002. In a December 2007 VA treatment note it was reported that the Veteran's military noise exposure is more likely as not a contributing factor to the Veteran's hearing impairment. The Veteran was afforded a VA examination with regard to hearing loss in April 2016. On the authorized audiological evaluation pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 LEFT 10 10 10 20 40 Speech audiometry revealed speech recognition ability of 94 percent in the left ear. The Board finds that entitlement to service connection for left ear hearing loss is warranted. Audiological evaluation at a VA examination in April 2016 revealed that the Veteran had left ear hearing loss for VA purposes. In December 2007 a VA provider associated the Veteran's hearing loss with his exposure to noise during active service. As such, entitlement to service connection for left ear hearing loss is granted. B. Scars of the Left Upper Extremity The Veteran seeks entitlement to service connection for scars of the left upper extremity. At the hearing before the DRO the Veteran reported that while on duty in Thailand, he lost his balance and put his hand through a window when he reached out to catch himself. He reported that the injury was "butterflied with Band-Aids." At the hearing before the undersigned in May 2013 the same incident was described by the Veteran. It was noted that the Veteran had multiple scars on the forearm and on the little finger. The Veteran was afforded a VA examination in September 2014. The Veteran was noted to have multiple scars on the left upper extremity. The examiner was unable to determine if the scars on the Veteran's left arm were related to the Veterans self-reported injury in Thailand in 1998 without resorting to speculation. The examiner stated that there was no documentation in the Veteran's service treatment records of the incident. The Veteran's separation physical did not identify any scars on his left arm. There was no documentation in the Veteran's post separation medical record of any painful scars. A VA medical opinion was obtained in February 2016. The examiner again was unable to determine if the scars on the veterans left arm were related to the Veteran's self-reported injury in Thailand in 1998 without resorting to speculation. The examiner reasoned that there was no documentation in the Veteran's service treatment records of the incident. The Veteran's separation physical did not mention any scars on his left arm. Lastly, there was no documentation in the Veteran's post separation medical records of any painful scars. A VA medical opinion was obtained in May 2017. The examiner noted that the Veteran's scars of the left upper extremity were less likely than not secondary to events that occurred in military service. Although the Veteran reported injuring his left arm with resultant scars, the examiner was unable to locate any service treatment records to that effect. In addition, the examiner noted that the separation physical examination of the skin in October 2002 did not note scars of the left arm. The examiner finally noted that as the evaluation was done without physical examination of the Veteran (ACE process), the examiner was unable to comment as to the appearance of the scars. The Board finds that entitlement to service connection for left upper extremity scars is not warranted. Initially, it is noted that the examiner in May 2017 did not comment on the appearance of the Veteran's scars and that the prior Board remand indicated that the examiner should do so. However, the prior Board remand ordered that an opinion be obtained and that further examination was only necessary if indicated by the examiner rendering the opinion. As the examiner was able to render an opinion without description of the scars, the Board finds that there has been substantial compliance with the prior remand. See Dyment v. West, 13 Vet. App. 141 (1999). The Board acknowledges the report that he injured himself in service and developed resulting scars. However, upon examination at separation from service in October 2002 the Veteran was not reported to have any scars of the left upper extremity. VA medical opinions have found that it is less likely as not that the Veteran has left upper extremity scars incurred in active service based upon the lack of scars noted in service, upon examination at separation from service, and in the Veteran's post service treatment records. As it is not at least as likely as not that the Veteran has left upper extremity scars incurred in service, service connection is denied. C. Cardiac Disability The Veteran seeks entitlement to service connection for a cardiac disability. Service treatment records reveal palpitations in February 1985. In addition, in February 1985 the Veteran complained of a rapid heart rate. The Veteran was treated in service for chest pain with findings of paroxysmal atrial tachycardia (PAT) and early repolarization upon electrocardiograms. In May 1988 the Veteran was noted to have possible ischemia. The Veteran had marked sinus bradycardia in October 1989. Post service treatment records reveal that the Veteran was treated for chest complaints. Treatment records reveal that the Veteran has been diagnosed with sinus bradycardia and right bundle branch block. See, e.g., December 2012 and January 2016. The Veteran was afforded a VA examination in September 2009. The examiner noted that the Veteran had an episode of chest pain during the service but he had a workup done including a stress test and they were negative. He was not diagnosed with myocardial infarction and was not found to have any chronic heart disease. The examiner noted that the Veteran was found to have an abnormal electrocardiogram in recent records showing a right bundle branch block with no symptoms. The examiner could not relate this or any other cardiac problem the Veteran has to service because the Veteran did not have a cardiac diagnosis in his problem list and was not on cardiac medications. After VA examination in September 2013 and in a VA medical opinion in February 2016, it was noted that the Veteran did not have a chronic cardiac disability. The examiner noted that the Veteran had several workups for chest pain, all of which have been within normal limits. A VA medical opinion was obtained in May 2017. The examiner rendered the opinion that the Veteran's cardiac condition (atrial fibrillation) was not related to events that occurred in military service. The Veteran was diagnosed with atrial fibrillation 14 years after separation. It was not caused by the treatments in military service. The Veteran had episodes of sinus bradycardia, sinus arrhythmia and possible paroxysmal atrial tachycardia in service. The examiner noted that these conditions are not causative for the development of atrial fibrillation years later. The examiner noted that the Veteran had risk factors, most notably hypertension, that were associated with atrial fibrillation. The Board finds that entitlement to service connection for a cardiac disability is not warranted. The Board acknowledges that the Veteran was treated for chest complaints in service and that a VA examiner has reported that the Veteran is currently diagnosed with atrial fibrillation. As such, the Veteran does not have a chronic undiagnosed cardiac disability for consideration pursuant to 38 C.F.R. § 3.317. The Veteran's current atrial fibrillation has been found to not have been incurred in service. It was diagnosed years afterward and a VA examiner has rendered the opinion that it is not related to the Veteran's in service treatment. Therefore, entitlement to service connection is denied. D. Hay Fever The Veteran seeks entitlement to service connection for hay fever. The Veteran was afforded a VA examination in September 2013. The examiner reported that the Veteran is service connected for allergic rhinitis and that this is the same diagnosis as hay fever and chronic seasonal allergic disability. The examiner stated that these are not separate entities. A VA medical opinion was obtained in February 2016. Again it was noted that the Veteran was in receipt of compensation benefits for allergic rhinitis. This was reported to be the same diagnosis as hay fever and chronic seasonal allergic disability. They were noted to not be separate entities. Another VA medical opinion was obtained in May 2017. The examiner noted that the Veteran's chronic seasonal allergic rhinitis cannot be separated from his allergic rhinitis. The examiner was unable to locate any mention of the Veteran being diagnosis with chronic perennial rhinitis and symptomology overlap is such that it would be impossible to determine if the Veteran has two separate conditions. The Board finds that as the Veteran is already in receipt of service-connected benefits for allergic rhinitis and as the hay fever has been noted to be the same disability, not a separate disability, the issue has already been granted and, therefore, the appeal is dismissed. See generally 38 U.S.C. § 7105 (The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed.); Grantham v. Brown, 114 F.3d 116 (Fed. Cir. 1997); Barrera v. Gober, 122 F.3d 1030 (Fed. Cir. 1997). E. Sinusitis The Veteran seeks entitlement to service connection for sinusitis. Service treatment records reveal treatment for sinus complaints. In October 1985 the Veteran was noted to have a diagnosis of sinusitis. At the hearing before the DRO the Veteran reported that he always carried over the counter medication for his sinus complaints, both in service and at the time of the hearing. Post service treatment records reveal treatment for sinusitis and questionable sinusitis. See, e.g., December 2005, September 2007, January 2009, and February 2011. A February 2009 computed tomography scan revealed an impression of no sinusitis. The Veteran was afforded a VA examination in September 2009. With regard to sinusitis and allergic rhinitis, the examiner noted that the Veteran was diagnosed by his doctor as having rhinitis after service. A computed tomography scan of the sinuses in 2009 did not show sinusitis. The Veteran complained of symptoms of congestion around his nose and nasal discharge for which he takes Nasonex nasal spray which helps. He associated these things to seasonal allergies. He had it during the pollen season and during the spring time. He had frequent episodes. He did not use antibiotics for them and he did not have sinus headaches. The examiner noted that from the history and the computed tomography scan the Veteran likely had rhinitis which was likely to be allergic rhinitis. It was stated in the general remarks that the Veteran was seen several times in the service for a similar condition. Thus the examiner rendered the opinion that it is as likely as not that the Veteran's allergic rhinitis was related to service. After discussion of the Veteran's record, the examiner reported that any sinusitis cannot be related to service and that the Veteran's computed tomography scan did not show sinusitis. The Veteran was afforded a VA examination in September 2013. The examiner found that the Veteran did not have chronic sinusitis. Radiographs done in 2009 were noted show normal sinuses and no suggestion of a chronic sinus condition. A VA medical opinions was obtained in February 2016. The examiner rendered the opinion that the Veteran did not have chronic sinusitis. Again, radiographs from 2009 were noted to not reveal a chronic sinus condition. Another VA medical opinion was obtained in May 2017. The examiner reported that the Veteran did not have chronic sinusitis. The Veteran did not meet the diagnostic criteria for the condition and there was no notation of the condition in the medical problem list. Entitlement to service connection for sinusitis is not warranted. The Board acknowledges that the Veteran reports that he has carried since service over the counter medications to treat self-treated sinus symptoms. In addition, the Board acknowledges that the treatment records reveal multiple treatments for sinus complaints and diagnoses of sinusitis, both in service and after service. However, multiple medical opinions have been obtained indicating that the Veteran does not have a chronic sinusitis disability based upon computed tomography results. The Board notes that the Veteran is currently in receipt of service connected benefits for allergic rhinitis and in the September 2009 examination report, the Veteran's symptoms were attributed to his allergic rhinitis. As the Veteran's symptoms have been associated with the Veteran's allergic rhinitis, the Veteran does not have a chronic undiagnosed illness for consideration of 38 C.F.R. § 3.317. In addition, as the preponderance of the evidence is against a finding that the Veteran has a chronic sinusitis disability associated with active service, service connection for sinusitis is denied. F. Chronic Bronchitis The Veteran seeks entitlement to service connection for chronic bronchitis, to include as secondary to sinusitis and service-connected allergic rhinitis. Service treatment records reveal that the Veteran was treated for bronchitis in April 1992. Post service treatment records reveal multiple notations and diagnoses of bronchitis and chronic bronchitis. These treatments include a notation in April 2007 of three occasions of acute bronchitis over the past year and a diagnosis of chronic bronchitis and a diagnosis of chronic bronchitis in July 2007. The Veteran was afforded a VA examination in September 2009. After discussion of the record and, as noted above, finding that the Veteran had rhinitis based upon the symptoms reported, the examiner was unable to relate the Veteran's bronchitis to service without resort to speculation. The Veteran was afforded a VA examination in September 2013. The examiner found that the Veteran found that the Veteran did not have chronic bronchitis. The examiner noted that a pulmonary consultation in 2009 showed a diagnosis of asthma (not service related) not chronic bronchitis. A VA medical opinion was obtained in February 2016. The examiner found that the Veteran did not have chronic bronchitis. The examiner noted that a pulmonary consultation in 2009 showed a diagnosis of asthma, not chronic bronchitis. A VA medical opinion was obtained in May 2017. Again, it was found that the Veteran did not have chronic bronchitis. The Veteran did not meet the diagnostic criteria for the condition. Entitlement to service connection for chronic bronchitis is not warranted. The Board acknowledges that the Veteran reports that he has carried since service over the counter medications to treat sinus symptoms. In addition, the Board acknowledges that the treatment records reveal multiple treatments for sinus complaints and diagnoses of sinusitis, both in service and after service. However, multiple medical opinions have been obtained indicating that the Veteran does not have a chronic bronchitis disability. The Board notes that the Veteran is currently in receipt of service connected benefits for allergic rhinitis and in the September 2009 examination report, the Veteran's symptoms were attributed to his allergic rhinitis. As the Veteran's symptoms have been associated with the Veteran's allergic rhinitis, the Veteran does not have a chronic undiagnosed illness for consideration of 38 C.F.R. § 3.317. In addition, as the preponderance of the evidence is against a finding that the Veteran has a chronic bronchitis disability, service connection based upon being associated with service or as secondary to allergic rhinitis is denied. G. Sleep Disorder Other Than Sleep Apnea The Veteran seeks entitlement to service connection for a sleep disorder other than sleep apnea, to include narcolepsy as secondary to service-connected sleep apnea. A VA medical opinion was obtained in February 2016. The examiner reported that the Veteran manifested narcolepsy that was separate and distinct from the service-connected obstructive sleep apnea. The examiner relied upon a note from a doctor dated in October 2009 in rendering the opinion. The examiner continued to render the opinion that it was at least as likely as not that the narcolepsy was etiologically related to an incident of active duty service the Veteran's treatment for sleeping difficulties in 1984. The rationale provided was that this was per mainstream medical literature. The examiner continued to provide citations. Entitlement to service connection for narcolepsy is warranted. Although VA examiners have variously found that the Veteran does not have narcolepsy due to active service, the VA examiner in February 2016 rendered the opinion that the Veteran has narcolepsy related to his active service. As the evidence is in relative equipoise, service connection for narcolepsy is granted. ORDER The application to reopen a claim of entitlement to service connection for left ear hearing loss, is granted. Service connection for left ear hearing loss is granted. Service connection for scars of the left upper extremity is denied. Service connection for a cardiac disability is denied. The claim of entitlement to service connection for hay fever is dismissed. Service connection for sinusitis is denied. Service connection for chronic bronchitis, to include as secondary to sinusitis and service-connected allergic rhinitis, is denied. Service connection for narcolepsy is granted. REMAND The Veteran seeks entitlement to service connection for left and right ankle disabilities, both to include as secondary to service-connected bilateral knee disabilities. Review of the claims file reveals multiple VA examinations and medical opinions regarding the Veteran's claim; however, these examinations and opinions do not address whether the Veteran's ankle disabilities are due to or aggravated by the Veteran's service-connected knee disabilities. As such, the Board finds that the medical opinions are inadequate and the claims must be remanded for an adequate VA medical opinion. See Allen v. Brown, 7 Vet. App. 439 (1995); El-Amin v. Shinseki, 26 Vet. App. 136 (2013); Barr v. Nicholson, 21 Vet. App. 303 (2007). On remand, VA treatment records dated since July 2017 must be obtained and associated with the claims file. 38 C.F.R. § 3.159. Accordingly, the case is REMANDED for the following action: 1. Obtain and associate with the claims file complete VA treatment records regarding the Veteran dated since July 2017. Any additional pertinent records identified by the Veteran during the course of the remand should also be obtained, following the receipt of any necessary authorizations from the Veteran, and associated with the claims file. 2. Thereafter, forward the claims file to an appropriate VA medical examiner to obtain a medical opinion regarding the etiology of the Veteran's right and left ankle disabilities. The claims file and copies of all pertinent records should be made available to the examiner for review. If the examiner determines that an opinion cannot be provided without an examination, the Veteran should be scheduled for an examination. Based on a review of the record, the examiner should address the following: (i) Is it at least as likely as not that the Veteran's right and/or left ankle disability was incurred in or related to service? (ii) Is it at least as likely as not that the Veteran's right and/or left ankle disability is due to or aggravated by his service-connected right and left knee disabilities? The examiner is informed that aggravation here is defined as any increase in disability. If aggravation is present, the clinician should indicate, to the extent possible, the approximate level of disability (baseline) before the onset of the aggravation. (iii) In answering the questions, the examiner must consider, and discuss as necessary, the prior examinations. A complete rationale must be provided for all opinions. If the examiner cannot provide an opinion without resort to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. 3. Then, readjudicate the appeal. If the benefits sought on appeal remain denied, the Veteran and his representative should be provided with a Supplemental Statement of the Case. An appropriate period of time should be allowed for response. 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). 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. §§ 5109B, 7112 (2012). ______________________________________________ M. E. LARKIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs