Citation Nr: 1753732 Decision Date: 11/24/17 Archive Date: 12/01/17 DOCKET NO. 12-04 864A ) DATE ) ) Received from the Department of Veterans Affairs Medical and Regional Office Center in Wichita, Kansas THE ISSUES 1. Whether new and material evidence has been received to reopen a claim for service connection for tinnitus. 2. Whether new and material evidence has been received to reopen a claim for service connection for hypertension. 3. Entitlement to service connection for tinnitus. 4. Entitlement to service connection for hypertension, to include as secondary to service-connected PTSD. 5. Entitlement to service connection for an aortic heart valve disorder, to include as secondary to service-connected PTSD. 6. Entitlement to service connection for an aortic aneurysm, to include as secondary to service-connected PTSD (claimed as thoracic aneurysm). 7. Entitlement to an evaluation in excess of 50 percent for service-connected posttraumatic stress disorder (PTSD). 8. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL The Veteran and G.N. ATTORNEY FOR THE BOARD S. Krunic, Counsel INTRODUCTION The Veteran served on active duty in the United States Army from May 1970 to January 1972. This case comes before the Board of Veterans' Appeals (Board) on appeal from July 2009 and April 2010 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. Jurisdiction has subsequently been transferred to the RO in Wichita, Kansas. A videoconference hearing was held before the undersigned Veterans Law Judge in March 2016. A transcript of the hearing is included in the claims file. Following the hearing, the Veteran submitted additional evidence along with a waiver of initial RO consideration of the evidence. The Veteran's appeal initially included the issue of entitlement to service connection for a heart disorder. However, during the appeal period, in an April 2011 rating decision, the RO in Waco, Texas granted service connection for coronary artery disease and assigned a 10 percent evaluation effective from November 24, 2004. Although the record shows that the Veteran submitted a claim for increased evaluation for coronary artery disease in August 2016, the Veteran did not appeal the initial rating or effective date assigned by the RO in the April 2011 rating decision; therefore, the matter is not in appellate status. See Grantham v. Brown, 114 F. 3d 1156, 1158 (Fed. Cir. 1997) (holding that a separate notice of disagreement must be filed to initiate appellate review of "downstream" elements such as the disability rating or effective date assigned). The Board notes that in the July 2009 rating decision, the RO denied, among other things, the claim for service connection for hypertension on the basis that new and material evidence was not submitted. In December 2009, prior to the expiration of the appeal period, the Veteran requested to reopen the claim for hypertension based on a December 2009 medical statement from his cardiologist. In an April 2010 rating decision, the RO confirmed and continued the denial of hypertension. The Board notes that 38 C.F.R. § 3.156 (b) provides that new and material evidence received within the one year period prior to a rating decision becoming final is to be considered as having been received in connection with the claim which was pending at the beginning of the appeal period. In such situations, the applicable rating action will not become final, and any subsequent decision based on such evidence will effectively be considered as part of the original claim. Buie v. Shinseki, 24 Vet. App. 242, 252 (2010). As such, the July 2009 rating decision did not become final. Accordingly, the claim on appeal with respect to whether new and material evidence has been received to reopen the claim for hypertension stems from the July 2009 rating decision. 38 C.F.R. § 3.156 (b); Bond v. Shinseki, 659 F.3d 1362, 1367-68 (Fed. Cir. 2011). The issues of entitlement to service connection for an aortic valve disorder, aortic aneurysm, hypertension, and entitlement to TDIU 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 a March 2006 rating decision, the Cleveland RO denied the Veteran's claims of service connection for tinnitus and hypertension. The Veteran did not initiate an appeal or submit new and material evidence within the appeal period regarding the claim for hypertension. 2. The Veteran filed a timely Notice of Disagreement (NOD) with the March 2006 rating decision regarding the claim for tinnitus; however, he did not file a timely Substantive Appeal following the May 2008 Statement of the Case (SOC). As such, the March 2006 rating decision is final. 3. The evidence received since the March 2006 rating decision relates to unestablished facts and raises a reasonable possibility of substantiating the claims of service connection for tinnitus and hypertension. 4. The Veteran's current tinnitus had its onset during combat service. 5. During the appeal period, the Veteran's service-connected PTSD more nearly approximates occupational and social impairment with deficiencies in most areas due to psychiatric symptoms; it has not resulted in total occupational and social impairment. CONCLUSIONS OF LAW 1. The March 2006 rating decision denying service connection for tinnitus and hypertension is final. 38 U.S.C.A. § 7105 (c) (West 2014); 38 C.F.R. §§ 3.104, 3.156, 20.200, 20.201, 20.302, 20.1103 (2016). 2. New and material evidence has been received sufficient to reopen the claims for service connection of tinnitus and hypertension . 38 U.S.C.A. § 5108 (West 2014); 38 C.F.R. § 3.156 (a) (2016). 3. Resolving reasonable doubt in favor of the Veteran, the criteria for entitlement to service connection for tinnitus have been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1154(b); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 4. The criteria for an evaluation of 70 percent, but no higher, for PTSD have been approximated. 38 U.S.C.A. § 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.130, Diagnostic Code 9411 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. New and material evidence for tinnitus and hypertension VA may reopen and review a claim that has been previously denied if new and material evidence is submitted by or on behalf of the veteran. New evidence is evidence not previously submitted to agency decision makers and material evidence is evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156 (a). 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, for purposes of the "new and material" analysis, the credibility of the evidence is presumed. Justus v. Principi, 3 Vet. App. 510, 512-513 (1992). In this case, the Cleveland RO initially denied service connection for tinnitus and hypertension in March 2006. The RO determined that the Veteran's hypertension did not manifest in service or to a compensable degree within one year of separation. In addition, based on an October 2005 VA medical opinion, the RO concluded that the Veteran's tinnitus was not incurred or caused by his military service in large part because he had reported that his tinnitus symptoms began many years after service. The Veteran did not appeal the March 2006 rating decision and the decision is final. The evidence received since the March 2006 rating decision includes evidence that is new and material to the claims. With respect to the claim for tinnitus, the evidence includes private medical records, the Veteran's lay statements, and his hearing testimony which reflect that his tinnitus had its onset during service and has been persistent thereafter. In addition, the Veteran has asserted a new theory of entitlement to service connection for hypertension. Specifically, he has claimed that his hypertension was proximately caused by his service-connected PTSD; in support of his claim, he submitted medical literature suggesting a link between hypertension and PTSD. As this new evidence could reasonably substantiate the claims were they to be reopened, either by triggering VA's duty to assist the Veteran by providing a VA examination or through consideration of an alternative, secondary theory of entitlement, the evidence is new and material. Reopening of the claims for entitlement to service connection for tinnitus and hypertension is therefore warranted. II. Service Connection for Tinnitus Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). In cases where a Veteran asserts service connection for injuries or disease incurred in combat, lay or other evidence of service incurrence will be considered sufficient proof of service connection if consistent with the circumstances, conditions, or hardships of such service, notwithstanding the fact that there is no official record of such incurrence during service, and, to that end, VA shall resolve every reasonable doubt in favor of the Veteran. See § 3.304 (d) (2016). The United States Court of Appeals for the Federal Circuit has further held that the presumption found in § 1154(b) applies not only to the potential cause of a disability, but also to whether a disability itself was incurred while in service. See Reeves v. Shinseki, 682 F.3d 988, 999 (Fed. Cir. 2012). The Veteran asserts that he developed tinnitus as a result of excessive noise exposure from firefights, grenades, and mortars while engaged in combat during his tour in Vietnam. See May 2006 NOD. The Veteran testified that the symptoms worsened shortly after discharge from service and he also denied any significant post-service noise exposure. See Board hearing transcript at 11-13. The Veteran's DD Form 214 shows that his military occupational specialty (MOS) was an infantryman and he was awarded the Combat Infantryman Badge. Private audiological records from Dr. J.T. from July 2012 to August 2013 show that the Veteran is currently diagnosed with tinnitus with a reported onset in the early 1970s. Furthermore, the Veteran reported a history of exposure to loud noises during service from guns and artillery. See Charles v. Principi, 16 Vet. App. 370, 374 (2002) (noting that lay testimony may establish the presence of tinnitus because ringing in the ears is capable of lay observation). The Veteran is also competent to report that his symptoms of tinnitus began in service and have continued thereafter. See 38 C.F.R. § 3.159 (a) (2) (2016); Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cr. 2007). The Board notes that during the appeal period, the record does not contain any medical or lay evidence that is against the claim or that rebuts the combat presumption. Given the Veteran's competent and credible statements and testimony, the private medical evidence which supports his assertions, and the application of the combat presumption, the Board concludes that a grant of service connection for tinnitus is warranted. III. Increased Evaluation for PTSD The Board has considered the Veteran's claim and decided entitlement to a higher evaluation for PTSD based on the evidence of record. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record, with respect to his claim. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Moreover, during the March 2016 Board hearing, the undersigned Veterans Law Judge explained the issues on appeal and asked questions designed to elicit the submission of evidence that may have been overlooked. These actions provided an opportunity for the Veteran and his representative to introduce material evidence and pertinent arguments, in compliance with 38 C.F.R. § 3.103 (c)(2) and consistent with the duty to assist. See Bryant v. Shinseki, 23 Vet. App. 488, 492 (2010). 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. 38 C.F.R. § 4.7. In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). While the regulations require review of the recorded history of a disability by the adjudicator to ensure a more accurate evaluation, the regulations do not give past medical reports precedence over the current medical findings. Where the question for consideration is a higher initial rating since the grant of service connection, evaluation of the medical evidence since the grant of service connection to consider the appropriateness of "staged rating" (assignment of different ratings for distinct periods of time, based on the facts found) is required. Fenderson v. West, 12 Vet. App. 119, 126 (1999); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). In this case, the Veteran's PTSD is assigned a 50 percent disability rating pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411. Under Diagnostic Code 9411, a 50 percent rating is warranted when the psychiatric disorder results in occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted when the psychiatric disorder results in occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. A 100 percent rating is warranted when the psychiatric disorder results in total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. The use of the term "such as" in the general rating formula for mental disorders in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). It is not required to find the presence of all, most, or even some, of the enumerated symptoms recited for particular ratings. The use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each veteran and disorder, and the effect of those symptoms on the claimant's social and work situation. In Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013), the U.S. Court of Appeals for the Federal Circuit stated that "a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." "Although the veteran's symptomatology is the primary consideration, the regulation also requires an ultimate factual conclusion as to the veteran's level of [occupational and social] impairment." Id. Psychiatric examinations frequently include assignment of a Global Assessment of Functioning (GAF) score. According to the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV),GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health illness." The GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue; rather, the GAF score must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126 (a). The Board notes that the use of GAF scores has been abandoned in the DSM-5 because of, among other reasons, "its conceptual lack of clarity" and "questionable psychometrics in routine practice." See Diagnostic and Statistical Manual for Mental Disorders, Fifth edition, p. 16 (2013). In this case, however, DSM-IV was in use at the time the medical entries of record were made. Thus, the GAF scores assigned remain relevant for consideration in this appeal. Id. The Board finds that the Veteran's disability picture, to include the severity, frequency, and duration of his symptoms, as well as the resulting impairment of social and occupational functioning, is consistent with a 70 percent rating during the entire period on appeal. The Board has considered the Veteran's lay statements, VA treatment records, and June 2009 VA PTSD examination. Throughout the entire period on appeal, the Veteran has maintained a history of symptoms that predominantly includes continuous depression, severe social isolation, nightmares, an inability to establish and maintain effective relationships, exaggerated startle response, hypervigilance, and suicidal ideation. See e.g. June 2009 VA examination; November 2009 VA treatment record; Board hearing transcript at 4-8. He has also reported avoiding crowds and attending any sorts of activities since he arrived in Topeka, distrust of others, emotional detachment, and intense anger. See PTSD evaluation from Veteran's psychologist received April 2016. The Board finds that these symptoms and the social and occupational effects related thereto support a 70 percent evaluation for the period on appeal. See Vazquez-Claudio, 713 F.3d at 118. Although the Veteran does not endorse all of the symptoms listed in the criteria for a 70 percent rating, such as spatial disorientation, under Mauerhan, the lack of such symptomatology is not fatal to the Veteran's claim for a higher rating. The frequency, severity, and duration of the Veteran's PTSD symptoms such as continuous depression, severe social impairment, and suicidal ideation more closely approximate the criteria for a 70 percent evaluation and result in occupational and social impairment with deficiencies in most areas. Finally, the Board acknowledges the Veteran has been assigned a GAF score of 65 during his VA examination. A GAF score ranging between 61 and 70 is assigned when there are some mild symptoms (e.g., depressed mood and mild insomnia), or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but when the individual is functioning pretty well and has some meaningful interpersonal relationships. However, in this case, the GAF score assigned is but one factor for consideration in a rating. While considering the GAF scores as part of the overall social and occupational functioning picture, the Board finds the Veteran's lay statements, hearing testimony, and narratives contained in the VA examination and VA treatment records are the most probative evidence of the Veteran's psychological symptomatology. The evidence of record does not show that the Veteran has total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. The Board emphasizes that a 100 percent disability evaluation requires both total social and occupational impairment. See Melson v. Derwinski, 1 Vet. App. 334 (1991) (use of the conjunctive "and" in a statutory provision meant that all of the conditions listed in the provision must be met); cf. Johnson v. Brown, 7 Vet. App. 95 (1994) (only one disjunctive "or" requirement must be met in order for an increased rating to be assigned). In this regard, the Board acknowledges the Veteran's lay statements regarding the severity of his symptoms and that he is currently unemployed. However, throughout the appeal period, the Veteran has not been shown to have total occupational or social impairment due to PTSD. Thus, the criteria for a total evaluation have not been met or approximated at any time during the appeal period. See 38 C.F.R. § 4.130, Diagnostic Code 9411. Thus, the Board concludes that the weight of the evidence is against a rating in excess of 70 percent for PTSD. As such, the benefit-of-the-doubt rule does not apply. Gilbert, 1 Vet. App. at 53. ORDER New and material evidence having been submitted, the claim of service connection for tinnitus is reopened. New and material evidence having been submitted, the claim of service connection for hypertension is reopened. Entitlement to service connection for tinnitus is granted. Entitlement to a 70 percent evaluation for PTSD, but no higher, is granted. REMAND A remand is necessary to ensure that there is a complete record upon which to decide the Veteran's claims so that the Veteran is afforded every possible consideration. The Veteran contends that his hypertension, thoracic aneurysm, and aortic valve disorder were caused by his service-connected PTSD. Private treatment records show that in December 1991, the Veteran was assessed with aortic insufficiency with an aneurysm of the ascending aorta and underwent surgery for aortic valve replacement. The Veteran was afforded a VA examination in February 2010 at which time he was diagnosed as having status post aortic valve replacement, aortic aneurysm, and coronary artery disease. She opined that the Veteran's diagnoses were not at least as likely as not due to his service-connected PTSD. In so finding, the examiner stated that aortic aneurysms are most often caused by damage to the artery's wall due to atherosclerosis and other conditions but she did not include PTSD as one of the causes of aortic insufficiency. Notably, since the February 2010 examination, service connection has been granted for coronary artery disease. Thus, the Board finds that a clarifying medical opinion is warranted to ascertain whether the Veteran's aortic aneurysm and aortic valve replacement are proximately caused by his service-connected coronary artery disease which the examiner noted was one of the conditions which causes aortic aneurysms. An April 2015 VA examiner reviewed the Veteran's claim file and opined that the Veteran's valvular heart disease and heart valve replacement are most likely congenital in nature. However, the examiner did not address whether there was a superimposed disease or injury that occurred during service. Furthermore, the examiner stated that the Veteran's hypertension was less likely than not aggravated beyond its natural progression by service-connected PTSD. In so finding, the examiner reported that there was no objective correlation between the severity of the Veteran's hypertension and his PTSD. However, since the April 2015 opinion, the Veteran has submitted articles suggesting a relationship between PTSD and cardiovascular diseases. In addition, the Veteran and his representative have raised a claim for a TDIU during the Board hearing. The Veteran was previously denied entitlement to TDIU in March 2006 and July 2009 rating decisions but he did not appeal the decisions. However, during the hearing, the Veteran alleged that his PTSD is the cause of his inability to secure employment. The record indicates that there is some evidence that the Veteran's PTSD has rendered him unemployable and other evidence that it has not. If a claimant or the record reasonably raises the question of whether the veteran is unemployable due to the disability for which an increased evaluation is sought, then part and parcel to that claim for an increased evaluation is whether a TDIU as a result of that disability is warranted. Rice v. Shinseki, 22 Vet. App. 447 (2009). Thus, the AOJ should develop a claim for TDIU in accordance with Rice. Accordingly, the case is REMANDED for the following action: 1. The Veteran should be provided with a VA examination and opinion by a qualified medical specialist to determine the nature and etiology of the Veteran's aortic insufficiency, aortic valve replacement, and hypertension. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, the February 2010 and April 2015 VA examination reports, the medical articles submitted by the Veteran in March 2016 regarding the relationship between PTSD and cardiovascular diseases, and the Veteran's lay statements. The Veteran contends that his aortic aneurysm, aortic valve replacement, and hypertension are secondary to his service-connected PTSD. A) The examiner should opine whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran's hypertension, aortic aneurysm, and aortic valve replacement were proximately caused or aggravated by the Veteran's service-connected PTSD and/or coronary artery disease. It should be noted that two separate opinions are required, one for proximate causation and another for aggravation. "Aggravation" means a permanent worsening of a disease or disability beyond its natural progression. If aggravation is found, the examiner must, to the extent possible, attempt to establish a baseline level of severity of the hypertension, aortic aneurysm, and aortic valve replacement, prior to aggravation. In rendering the opinion, the examiner should address the February 2010 VA examiner's statement that aortic aneurysms are most often caused by damage to the artery's wall due to atherosclerosis. In this regard, the examiner should note that the Veteran is service-connected for coronary artery disease. The examiner should also discuss the medical literature submitted by the Veteran which suggests a link between PTSD and cardiovascular disease. B) The examiner should indicate whether the Veteran's aortic aneurysm and aortic valve replacement is a congenital "defect" or "disease." Generally, a "disease" is a condition considered capable of improving or deteriorating, whereas a "defect" is a condition not considered capable of improving or deteriorating. (i) If the examiner concludes that the Veteran has a congenital defect, the examiner should opine as to whether it at least as likely as not (a 50 percent or greater probability) that there was a superimposed disease or injury during military service that resulted in additional disability. A complete rationale should be given for this conclusion. (ii) If the examiner determines that the Veteran's aortic aneurysm and aortic valve replacement, is not a congenital defect, but is a disease, is there clear and unmistakable evidence that it preexisted active service? (iii) If there is clear and unmistakable evidence that the disability preexisted service, the examiner is asked to opine as to whether there is clear and unmistakable evidence that the preexisting disability was not permanently worsened during service beyond the natural progression of the disorder. (iv) If there was an increase during active service in the severity of the Veteran's aortic aneurysm and aortic valve replacement, the examiner should opine as to whether such an increase was clearly and unmistakably due to the natural progress of the disease. The examiner should note that "clear and unmistakable evidence" means that the evidence cannot be misinterpreted and misunderstood, i.e. is undebatable. A complete rationale should be given for all opinions and conclusions expressed. 2. The AOJ should consider whether the Veteran is entitled to TDIU under the provisions of 38 C.F.R. § 4.16, based on impairment attributable to his service-connected disorders, in accordance with Rice v. Shinseki, 22 Vet. App. 447 (2009). In so doing, the AOJ may decide to pursue further development such as securing additional medical evidence or medical opinions, as is deemed necessary. 3.. After completing the above actions, the case should be reviewed by the AOJ on the basis of additional evidence. If the benefits sought are not granted, the Veteran and his representative should be furnished a supplemental statement of the case and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The Veteran has 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 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). ______________________________________________ ROBERT C. SCHARNBERGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs