Citation Nr: 1756447 Decision Date: 12/07/17 Archive Date: 12/15/17 DOCKET NO. 14-17 527 ) DATE Advanced on the Docket ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Whether new and material evidence has been received to reopen a claim of service connection for a back disability. 2. Entitlement to service connection for a back disability. 3. Entitlement to service connection for thyroid cancer, to include as due to herbicide exposure. 4. Entitlement to benefits under 38 U.S.C.A. § 1151 for additional disability of the vocal cords, claimed as a result of VA surgical procedures following the diagnosis of thyroid cancer in April 2012. 5. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD). 6. Entitlement to service connection for a left knee disability. 7. Entitlement to service connection for a right knee disability. 8. Entitlement to service connection for a left hip disability. 9. Entitlement to service connection for a right hip disability. ORDER New and material evidence with respect to the claim of service connection for a back disability has been received; that claim is reopened, and to this limited extent, the appeal of that issue is granted. Entitlement to service connection for thyroid cancer, to include as due to herbicide exposure, is denied. Entitlement to benefits under 38 U.S.C.A. § 1151 for additional disability of the vocal cords, claimed as a result of VA surgical procedures following the diagnosis of thyroid cancer in April 2012, is denied. FINDINGS OF FACT 1. The Veteran's claim for service connection for a back disability was denied in a March 2002 rating decision; the Veteran did not perfect an appeal. 2. The evidence submitted since the March 2002 rating decision, pertinent to the claim for service connection a back disability is neither cumulative nor redundant, relates to an unestablished fact necessary to substantiate the claim, and raises a reasonable possibility of substantiating the claim. 3. Thyroid cancer was first demonstrated years after service and is not etiologically related to any incident of service including exposure to an herbicide agent. 4. Right vocal cord paralysis noted after surgical procedures provided by VA following the diagnosis of thyroid cancer in June 2012 is not the result of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA or an event not reasonably foreseeable in furnishing the treatment. CONCLUSIONS OF LAW 1. The March 2002 rating decision that denied the claim of entitlement to service connection for back and neck pain, is final. 38 U.S.C.A. § 7105 (c) (West 2014); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2017). 2. Since the March 2002 rating decision, new and material evidence has been received, and the claim of entitlement to service connection for a back disability, is reopened. 38 U.S.C.A. § 5108 (West 2014); 38 C.F.R. § 3.156 (2017). 3. Thyroid cancer was not incurred in or aggravated by active duty service, nor may its incurrence or aggravation be presumed. 38 U.S.C.A. §§ 1110, 1112, 1116 (West 2014); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2017). 4. The criteria for entitlement to benefits under 38 U.S.C.A. § 1151 for an additional disability of the vocal cords have not been met. 38 U.S.C.A. §§ 1151, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.361 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1960 to September 1968. His awards include the Vietnam Service Medal and the Vietnam Campaign Medal. This matter comes to the Board of Veterans' Appeals (Board) on appeal from April 2012 and July 2013 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. The Veteran testified at a video conference hearing before the undersigned Veterans Law Judge in July 2017. An April 2012 rating decision denied service connection for PTSD, left hip, right hip, left knee, and right knee disabilities. The Veteran filed a timely notice of disagreement regarding the decision, but he has not been issued a statement of the case regarding the issues on appeal. See Manlincon v. West, 12 Vet. App. 238 (1999). I. Claim to Reopen VA may reopen and review a previously denied claim if new and material evidence is submitted by or on behalf of the veteran. 38 U.S.C.A. § 5108 (West 2014). New evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing 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 prior 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 United States Court of Appeals for Veterans Claims held in Shade v. Shinseki that the language of 38 C.F.R. § 3.156 (a) creates a low threshold to reopen, and emphasized that the regulation is designed to be consistent with 38 C.F.R. § 3.159 (c)(4), which "does not require new and material evidence as to each previously unproven element of a claim." 24 Vet. App. 110, 120-21 (2010). The provisions of 38 U.S.C.A. § 5108 require a review of all evidence submitted by or on behalf of a claimant since the last final denial on any basis to determine whether a claim must be reopened. See Evans v. Brown, 9 Vet. App. 273, 282-83 (1996). For purposes of the new and material analysis, the credibility of the evidence is presumed. Justus v. Principi, 3 Vet. App. 510, 512-13 (1992). The Veteran originally filed a claim of service connection for back and neck pain in February 2000. In March 2002, the RO denied the claim based on a finding that in the absence of a diagnosis for the pain, service connection could not be established. The Veteran was notified of the decision by a March 2002 letter. He did not initiate an appeal, nor was new and material evidence received within the appeal period. As a result, the March 2002 rating decision is final. 38 U.S.C.A. § 7105 (c)(West 2014); 38 C.F.R. §§ 3.104, 3.156(b), 20.302, 20.1103 (2017). Prior to the March 2002 denial, the evidence of record included the Veteran's STRs dated from June 1960 to September 1968 showing that the Veteran was seen with complaints of back pain for three months and VA treatment records that showed the Veteran was negative of joint pain and had no loss of range of motion of the back. Structure was normal and without soft tissue or bony abnormalities. The Veteran also denied neck pain, stiffness or decreased range of motion when seen in July 2000. The joints were negative, no swollen lymph nodes or other lesions were shown, and there was no loss of range of motion. Evidence received since the March 2002 denial includes VA treatment records, continuing to reflect complaints of and treatment for back pain, multiple diagnoses of the back, a May 2012 VA examination report of the lumbar spine, and a transcript from the Veteran's hearing before the Board in July 2017. Given these new diagnoses, in conjunction with the Veteran's lay statements and the opinion of the May 2012 VA examiner, the Board finds that new and material evidence has been submitted and that the claim for service connection for a back disability is reopened. The reopened claim will be addressed in the REMAND section of the decision below. II. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303 (a). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service"-the so-called "nexus" requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). See also Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed.Cir.2007). When a chronic disease is shown in service sufficient to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303 (b). For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. Id. For this purpose, a chronic disease is one listed at 38 C.F.R. § 3.309 (a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (holding that the term "chronic disease in 38 C.F.R. § 3.303 (b) is limited to a chronic disease listed at 38 C.F.R. § 3.309 (a)). 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). A. Thyroid Cancer The Veteran contends that service connection is warranted for thyroid cancer and its residual conditions as they were incurred due to herbicide exposure during active service in Vietnam. The record clearly demonstrates a current disability. VA treatment records show that the Veteran was diagnosed with malignant neoplasm of thyroid in April 2012. A thyroidectomy was performed and the Veteran has continued to receive monitored care throughout the claims period. While service records are negative for complaints or treatment related to thyroid cancer, the Veteran contends that service connection is warranted for the disability as due to herbicide exposure. VA regulations provide for a presumption of service connection for certain disabilities associated with herbicide exposure under 38 C.F.R. §§ 3.307 and 3.309. Thyroid cancer is not included on the list of diseases presumptively associated with exposure to certain herbicide agents and service connection on a presumptive basis is not possible. Service connection is also possible for certain chronic diseases presumed to have been incurred in service if manifested to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307 (a), 3.309(a). Malignant tumors are a chronic disease as defined by 38 C.F.R. § 3.309 (a), but the Board cannot conclude that the Veteran's condition was present to a compensable degree in the year following his separation from active duty in September 1968. The August 1968 separation examination does not include any findings or laboratory testing indicative of cancer. There is also no medical or lay evidence indicating that the Veteran's thyroid cancer manifested within a year of his separation. In fact, the earliest evidence of the disability dates from April 2012, approximately 44 years after service, when a thyroid mass was identified during VA treatment. Service connection on a presumptive basis for thyroid cancer as a chronic disease is therefore not warranted. Although service connection is not appropriate for the Veteran's disability on any presumptive bases, the Federal Circuit has determined that a claimant is not precluded from establishing service connection with proof of actual direct causation, i.e. a link between the Veteran's current disability and in-service exposure to herbicides. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). Service and post-service treatment records do not support the claim for service connection as directly due to herbicide agent exposure. The Veteran received treatment during service for multiple conditions, but none of his complaints or medical findings indicate the presence of thyroid cancer or any other thyroid dysfunction. As noted above, the August 1968 separation examination did not contain any findings indicative of cancer. There is also no evidence of the claimed condition until decades after the Veteran's discharge from active duty. The Veteran was diagnosed with thyroid cancer in April 2012 and there is no medical or lay evidence prior to that date. There is also no competent medical evidence in support of the claim. None of the Veteran's treating physicians have documented a link between his thyroid cancer and exposure to herbicide agents. At the July 2017 Board hearing, the Veteran stated that he claimed his thyroid cancer resulted from herbicide exposure, but testified that he "[understood] there [was] no nexus," but asked for 60 days to allow time to try and get medical evidence from his medical providers regarding a relationship between herbicide exposure and the thyroid cancer. To date, the Veteran has not submitted any evidence in the form of treatise evidence, a medical study, or an opinion from a medical professional supporting the claim for service connection. As noted in the discussion above, service connection is possible for certain chronic disabilities under 38 C.F.R. § 3.303 (b) based on a continuity of symptomatology. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Veteran's thyroid cancer is a chronic disease listed in 38 C.F.R. § 3.309 (a). However, the Veteran has not reported a history of continuous symptoms since service or provided any statements specifically describing the onset of his condition. With respect to his general contentions linking his thyroid cancer to herbicide agent exposure during service, he is not competent to opine as to medical etiology or render medical opinions. Grover at 112. The Board acknowledges that the Veteran is competent to report observable symptoms, but finds that his opinion as to the cause of his symptoms simply cannot be accepted as competent evidence in this case. See Jandreau at 1376-1377 (Fed. Cir. 2007). In sum, the post-service medical evidence of record shows that earliest evidence of the Veteran's claimed condition was decades after his separation from active duty service. In addition, the weight of the competent evidence is against a finding that the Veteran's thyroid cancer is related to active duty and herbicide agent exposure. Accordingly, the Board must conclude that the preponderance of the evidence is against the claim and it is denied. 38 U.S.C.A. § 5107 (b) (West 2014). III. Benefits under 38 U.S.C.A. § 1151 Under 38 U.S.C.A. § 1151, compensation shall be awarded for a qualifying additional disability of a Veteran in the same manner as if such additional disability were service connected. A disability is a qualifying additional disability if the disability was not the result of the Veteran's willful misconduct and either: 1) the disability was caused by hospital care, medical or surgical treatment, or examination furnished to the Veteran under any law administered by the Secretary, either by a Department employee or in a Department facility, and the proximate cause of the disability was either A) carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the Department in furnishing the hospital care, medical or surgical treatment, or examination; or B) an event not reasonably foreseeable. See 38 U.S.C.A. § 1151. Claims under § 1151 must show evidence of actual causation, meaning that "the evidence must show that the . . . medical treatment . . . resulted in the Veteran's additional disability." 38 C.F.R. § 3.361 (c)(1). Further, the evidence must show that the medical treatment was the proximate cause of the Veteran's additional disability. 38 U.S.C.A. § 1151 (a)(1). Pursuant to VA regulation, the proximate cause "is the action or event that directly caused the disability or death, as distinguished from a remote contributing cause." 38 C.F.R. § 3.361 (d). To establish the proximate causation element, it must be shown that "VA failed to exercise the degree of care that would be expected of a reasonable health care provider" or that "VA furnished the hospital care, medical or surgical treatment, or examination without the Veteran's or, in appropriate cases, the Veteran's representative's informed consent." Id. Informed consent is the freely given consent that follows a careful explanation by the practitioner to the patient of the proposed diagnostic or therapeutic procedure or course of treatment. The practitioner must explain in language understandable to the patient the nature of a proposed procedure or treatment; the expected benefits; reasonably foreseeable associated risks, complications or side effects; reasonable and available alternatives; and anticipated results if nothing is done. The patient must be given the opportunity to ask questions, to indicate comprehension of the information provided, and to grant permission freely without coercion. The practitioner must advise if the proposed treatment is novel or unorthodox. The patient may withhold or revoke his or her consent at any time. 38 C.F.R. §17.32(c). To determine whether there was informed consent, VA will consider whether the health care providers substantially complied with the requirements of 38 C.F.R. § 17.32. Minor deviations from the requirements of 38 C.F.R. § 17.32 that are immaterial under the circumstances of a case will not defeat a finding of informed consent. Consent may be express (i.e., given orally or in writing) or implied under the circumstances specified in 38 C.F.R. § 17.32 (b), as in emergency situations. In this case, the Veteran seeks benefits under 38 U.S.C.A. § 1151 for additional disability of the vocal cords, claimed as a result of VA surgical procedures following a diagnosis of thyroid cancer in April 2012. Specifically, the record reflects the Veteran underwent surgical procedures at the VA, to include a June 2012 neck exploration with right thyroid lobectomy, frozen section, repair of possible right recurrent laryngeal nerve injury. Informed consent was completed. It was further noted that the risks, benefits, and alternatives to the surgery were discussed with the Veteran who agreed to proceed with planned procedure. The Veteran had the opportunity to review a copy of the printed consent for this procedure. It was noted that the Veteran had a possible right recurrent laryngeal nerve injury with repair. He had an intraoperative consultation with Chief of Surgery, ENT surgeon, and Neurosurgeon. Following the surgery, the Veteran was diagnosed with dysphagia/dysphonia status post thyroidectomy and iatrogenic right vocal cord paralysis. In September 2012, the Veteran underwent a left thyroid lobectomy. Prior to the surgery, it was noted that the Veteran had follicular carcinoma status post right thyroidectomy with paralysis of the right vocal cord. Recommendation for follicular cancer was total thyroidectomy. However, because the Veteran experienced nerve injury on the right, he was at risk for tracheostomy if he experienced a nerve injury on the other side. The physician discussed the risks and benefits of the procedure with the Veteran and his wife at length. Informed consent was completed and it was further noted that the risks, benefits, and alternatives to the surgery were discussed with the Veteran who agreed to proceed with the total thyroidectomy. An October 2012 VA treatment record shows an impression of "right vocal cord paralysis, iatrogenic." Another October 2012 VA treatment record reflects that the Veteran presented for postop follow-up for a left hemi thyroidectomy in September 2012. This was following a right thyroidectomy for follicular carcinoma. "This surgery was complicated with right laryngeal nerve damage. The Veteran [denied] any problems associated with the surgery." It was observed that the Veteran's voice was intact but sounded weak and hoarse "consistent with unilateral recurrent laryngeal nerve injury." A November 2012 VA treatment record reflects the Veteran's vocal quality was hoarse with reduced intensity. The Veteran indicated that he lost his voice by the end of the day on most days and used written language to express his needs. The speech therapist and the Veteran discussed how laryngeal nerve damage and severe signs and symptoms of hypothyroid can impact voice. It was noted that a recurrent laryngeal nerve damage recent follow-up ENT visit indicated persistent paralysis of the right vocal cord. There were no significant changes. The Veteran was educated on possibility of function not [returning] and impact on voice. Hypothyroidism voice signs and symptoms included rough hoarse voice and slow speech. The Veteran communicated that he felt that described his voice. The speech therapist provided the Veteran with and reviewed handouts of relaxation techniques, vocal hygiene, and saving his voice. A January 2013 VA treatment record reflects persistent paralysis of the right vocal cord. An August 2014 VA treatment record reflects a history of thyroidectomy due to CA and iatrogenic right vocal cord paralysis. The Veteran reported significant improvement in vocal quality, which he attributed to the voice therapy he received in 2012. He was happy with his voice and was not concerned about the dysphonia. In July 2013, the VA obtained an opinion regarding this issue. Dr. S. E. noted review of the Veteran's claims file. She stated noted that the Veteran underwent right thyroid lobectomy in June 2012. Dr. S. E. further stated that during this surgery, the Veteran suffered transection and repair of right vocal cord and has had persistent hoarseness. "A vocal cord injury of this type is a known complication of this type of thyroid surgery and thus was, although uncommon, reasonably foreseeable event." As detailed above, the Board finds that the Veteran's right vocal cord paralysis is an additional disability that resulted from his thyroid lobectomy. The medical evidence of record demonstrates that vocal cord paralysis is a known complication of a thyroid lobectomy. Furthermore, the right vocal cord paralysis did not result from the carelessness, negligence, lack of skill, or similar incidence of fault on the part of the attending VA personnel, as the proper care was given to the Veteran before, during, and after the surgery. In this regard, the Board finds the July 2013 VA examiner's opinion on this point to be persuasive and probative. Dr. S. E. explained that the surgical procedure provided by VA, which resulted in right vocal cord paralysis was a known complication of a thyroid lobectomy. The Board further notes that during the surgery, it was noted that the Veteran had a possible right recurrent laryngeal nerve injury with repair. He had an intraoperative consultation with Chief of Surgery, ENT surgeon, and Neurosurgeon. Additionally, with regard to postoperative care, VA treatment records show that the Veteran was treated initially with conservative management and later educated on use of laryngeal elevation exercises. A speech therapist also provided the Veteran with and reviewed handouts of relaxation techniques, vocal hygiene, and saving his voice. Therefore, the Board finds that carelessness, negligence, lack of skill, or similar incidence of fault on the part of the attending VA personnel did not result in the Veteran's right vocal cord paralysis, and the proper postoperative care was afforded to the Veteran to mitigate complications. Indeed, the Veteran testified during his July 2017 Board hearing that it is not his contention that the VA physician was negligent in performing his surgery. Rather, he just "wants [VA] to make it where [he] can eat and swallow things better." Finally, the Board finds that the Veteran was adequately informed about the risks of the procedure. In this regard, the Board notes that the surgery report shows informed consent was completed and the risks, benefits, and alternatives to the surgery were discussed with the Veteran who agreed to proceed with planned procedure. It was also noted that the Veteran had the opportunity to review a copy of the printed consent for this procedure. Indeed, the Veteran testified during the July 2017 Board hearing that he signed a consent form. The Board finds that the opinion of the July 2013 examiner to be highly probative on the matters of fault and foreseeability. Her medical opinion, after reviewing the claims file, is highly persuasive as it reflects consideration of all relevant facts and evidence and a detailed rationale for the conclusions reached. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (holding that it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). These elements of the claim are complex medical questions that were adequately and sufficiently answered. In consideration of this evidence, the Board finds that additional disability was caused by the VA surgery, but a preponderance of the evidence is against a finding that this additional disability was the result of negligence, carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the VA health care providers who provided treatment, or of an event not reasonably foreseeable. As noted, the July 2013 examiner did not find that the Veteran's right vocal cord paralysis was the result of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA. Thus, the examiner's opinion weighs against any negligence or other instances of fault by VA physicians. Further, the Board finds that informed consent for the procedure was obtained, as the risks associated with the procedure were properly explained. The Board sincerely sympathizes with the Veteran and understands his contentions regarding his frustration with his voice and the ability to swallow. The evidence and the law, however, do not support his claim for compensation benefits. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not applicable and compensation under 38 U.S.C.A. § 1151 is not warranted. See 38 U.S.C.A. § 5107 (b); 38 C.F.R. § 3.102. REMAND Back Disability The Veteran claims that he suffered a back disability as a result of service. A September 1963 STR reflects a complaint of and treatment for back pain. Following service, the Veteran was afforded a VA examination of his lumbar spine in May 2012. The Veteran was diagnosed with degenerative disc disease (DDD) of the lumbar-sacral spine. Upon review of the Veteran's claims file and interview of the Veteran, the examiner provided a negative etiology opinion. Since that examination, the record reflects diagnoses of moderate multilevel degenerative disease most notable at C5-6 and C6-7, mild thoracolumbar degenerative spondylosis, mild diffuse degenerative facet disease, mild dextroscoliosis of the cervical spine, and degenerative changes of the thoracic spine. As the examiner did not address the additional diagnoses of record, the Board finds that the examination is inadequate and a new VA examination is required. Thus, the Board concludes that the examination report is inadequate. See Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). Acquired Psychiatric Disorder, Left Knee, Right Knee, Left Hip, and Right Hip As noted above, the Veteran filed a timely notice of disagreement regarding the April 2012 rating decision that denied service connection for PTSD, left hip, right hip, left knee, and right knee disabilities, which puts the issues in appellate status. He has not been issued a statement of the case after the submission of his notice of disagreement. The Board is required to remand these issues for the issuance of a statement of the case. See Manlincon, supra; 38 C.F.R. § 19.9 (c). Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Obtain any outstanding VA treatment records. 2. Issue a statement of the case regarding the issues of entitlement to service connection for an acquired psychiatric disorder, to include PTSD, left hip, right hip, left knee, and right knee disabilities. 3. Schedule the Veteran for an appropriate VA examination with a qualified physician to determine whether any current back disability is related to military service. The physician should clearly identify all current disability(ies) affecting the cervical spine, lumbar spine, and thoracic spine, to include DDD of the lumbar-sacral spine, moderate multilevel degenerative disease most notable at C5-6 and C6-7, mild thoracolumbar degenerative spondylosis, mild diffuse degenerative facet disease, mild dextroscoliosis of the cervical spine, and degenerative changes of the thoracic spine. Then, for each identified disability, the physician should provide an opinion as to whether it is at least as likely as not (50 percent probability or more) that any current back disability is related to the Veteran's military service, to include the Veteran's complaint of back pain in September 1963. 4. Finally, readjudicate the appeal. If any benefit sought remains denied, issue a supplemental statement of the case and return the case to the Board. The Veteran 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.A. §§ 5109B, 7112 (West 2014). ______________________________________________ M. HYLAND Veterans Law Judge, Board of Veterans' Appeals ATTORNEY FOR THE BOARD S. Gordon, Associate Counsel Copy mailed to: Tennessee Department of Veterans' Affairs Department of Veterans Affairs