Citation Nr: 1756462 Decision Date: 12/07/17 Archive Date: 12/15/17 DOCKET NO. 14-06 142 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Boston, Massachusetts THE ISSUES 1. Entitlement to an initial, compensable rating for bilateral hearing loss. 2. Entitlement to rating in excess of 30 percent for posttraumatic stress disorder (PTSD) prior to March, 1, 2016 and to a rating in excess of 50 percent thereafter. 3. Entitlement to an initial rating in excess of 30 percent for squamous cell carcinoma of larynx. REPRESENTATION Veteran represented by: Vietnam Veterans of America WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD S. M. Stedman, Associate Counsel INTRODUCTION The Veteran served on active duty from February 1966 to February 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2012 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Boston, Massachusetts. The April 2012 rating decision, in pertinent part, increased the evaluation of the Veteran's service-connected PTSD to 30 percent, effective November 9, 2011. A subsequent rating decision increased his PTSD rating to 50 percent, effective March 1, 2016. The April 2012 rating also granted service connection for bilateral hearing loss and squamous cell carcinoma of the larynx, each disability being evaluated as noncompensable. During the pendency of this appeal, the rating for squamous cell carcinoma of the larynx was raised to 30 percent. In May 2017, the Veteran testified at a hearing before the undersigned Veterans Law Judge (VLJ). A transcript of that hearing has been associated with the claims file. The issue of entitlement to an initial rating in excess of 30 percent for squamous cell carcinoma of the larynx is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. Throughout the appellate period, the Veteran's bilateral hearing loss was manifested by puretone threshold averages no higher than 48 decibels in the right ear and 48 decibels in the left ear, and speech recognition scores no lower than 96 in the right ear and 92 in the left ear. 2. Prior to March 1, 2016, the Veteran's PTSD more closely approximates occupational and social impairment with occasional decreases in work efficiency and intermittent periods of inability to perform occupational tasks. 3. From March 1, 2016, forward, the Veteran's PTSD more closely approximates occupational and social impairment with reduced reliability and productivity. CONCLUSIONS OF LAW 1. The criteria for a compensable rating for bilateral hearing loss have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.3, 4.85, 4.86, Diagnostic Code 6100 (2017). 2. The criteria for a rating in excess of 30 percent for PTSD have not been met prior to March 1, 2016. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.1, 4.7, 4.10, 4.126, 4.130, Diagnostic Code 9411 (2017). 3. The criteria for a rating in excess of 50 percent for PTSD have not been met from March 1, 2016, forward. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.1, 4.7, 4.10, 4.126, 4.130, Diagnostic Code 9411 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has considered the Veteran's claims and decided entitlement based on the evidence. 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 claims. 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). I. Increased Ratings Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. The percentage ratings are based on the average impairment of earning capacity and individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2017). Any reasonable doubt regarding a degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2017). Thus, if two ratings are potentially applicable, the higher rating is to be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2017). The schedule recognizes that disability from distinct injuries or diseases may overlap. See 38 C.F.R. § 4.14 (2017). Separate disability ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition was not "duplicative of or overlapping with the symptomatology" of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 262 (1994). However, the evaluation of the same disability or its manifestations under various diagnoses, which is known as pyramiding, is to be avoided. 38 C.F.R. § 4.14 (2017). Because the level of disability may have varied over the course of the claim, the rating may be "staged" higher or lower for segments of time during the period under review in accordance with such variations, to the extent they are sufficient to warrant changes in the evaluations assignable under the applicable rating criteria. See Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007); Fenderson v. West, 12 Vet. App. 119, 126 (1999). For increased-rating claims, where a claimant seeks a higher evaluation for a previously service-connected disability, it is the present level of disability that is of primary concern, and VA considers the level of disability for the period beginning one year prior to the claim for a higher rating. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994); see also 38 C.F.R. § 3.400 (o)(2) (2017). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence on any issue material to the claim. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. When the evidence supports the claim or is in relative equipoise, the claim will be granted. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). If the preponderance of the evidence weighs against the claim, it must be denied. See id.; Alemany v. Brown, 9 Vet. App. 518, 519 (1996). A. Hearing Loss Hearing loss is evaluated under 38 C.F.R. § 4.85, Diagnostic Code (DC) 6100. In evaluating hearing loss, disability ratings are derived from a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are performed. See Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). Hearing loss disability evaluations range from noncompensable to 100 percent based on organic impairment of hearing acuity, as measured by controlled speech discrimination tests using the Maryland CNC word list, in conjunction with the average hearing threshold, measured by puretone audiometric tests in the frequencies 1000, 2000, 3000, and 4000 cycles per second. 38 C.F.R. § 4.85, DC 6100. The rating schedule establishes eleven auditory acuity levels designated from Level I, for essentially normal hearing acuity, through Level XI for profound deafness. See id. VA audiometric examinations are generally conducted using a controlled speech discrimination test together with the results of a puretone audiometry test. Id. Table VI in 38 C.F.R. § 4.85 is then used to determine the numeric designation of hearing impairment based on the puretone threshold average derived from the audiometry test, and from the results of the speech discrimination test. The horizontal rows in Table VI represent nine categories of the percentage of discrimination based on the controlled speech discrimination test. See id. The vertical columns in Table VI represent nine categories of decibel loss based on the puretone audiometry test. Id. The numeric designation of impaired hearing (Levels I through XI) is determined for each ear by intersecting the horizontal row corresponding to the percentage of discrimination and the vertical column corresponding to the puretone decibel loss. Id. The percentage evaluation is derived from Table VII in 38 C.F.R. § 4.85 by intersecting the vertical column corresponding to the numeric designation for the ear having the better hearing acuity (as determined by Table VI) and the horizontal row corresponding to the numeric designation level for the ear having the poorer hearing acuity (as determined by Table VI). For example, if the better ear has a numeric designation Level of "V" and the poorer ear has a numeric designation Level of "VII," the percentage evaluation is 30 percent. See id. There are alternative criteria for certain exceptional patterns of hearing loss. Specifically, if puretone thresholds in each of the specified frequencies of 1000, 2000, 3000, and 4000 Hertz are 55 decibels or more, an evaluation will be based on either Table VI or Table VIa in 38 C.F.R. § 4.85, whichever results in a higher evaluation. 38 C.F.R. § 4.86(a) (2017). Each ear will be evaluated separately. Id. When the puretone threshold is 30 decibels or less at 1000 Hertz and 70 decibels or more at 2000 Hertz, the Roman numeral designation for hearing impairment will be chosen from either Table VI or Table VIa in 38 C.F.R. § 4.85, whichever results in the higher Roman numeral, and that numeral will then be elevated to the next higher numeral. 38 C.F.R. § 4.86(b). The Board notes that the Veteran's hearing loss is not manifested by the exceptional patterns set forth in 38 C.F.R. § 4.85(a), (b). Accordingly, the alternative criteria do not apply. See 38 C.F.R. § 4.86. In the present case, the Veteran asserts that he is entitled to a compensable disability rating for his bilateral hearing loss. The preponderance of the evidence shows that the criteria for increased ratings are not satisfied at any time during the appellate period. A January 2011 VA examination report reflects a puretone threshold average of 48 decibels (dB) in the right ear, and 41 dB in the left ear. Speech recognition scores were 96 percent bilaterally. A March 2015 VA examination report reflects a puretone threshold average of 48 dB bilaterally. Speech recognition scores were 96 percent in the right ear, and 92 percent in the left ear. Throughout the appellate period, the applicable examination reports show that the highest puretone threshold average for the right ear was 48 dB. The lowest speech recognition score was 96 percent. Applying these values to Table VI results in a numeric designation of I for the right ear. The highest puretone average for the left ear was 48 dB. The lowest speech recognition score was 92 percent. Applying these values to Table VI results in a designation of I for the left ear. The point where designations IV and VIII intersect on Table VII yields a 0 percent, or noncompensable, rating. The Board has considered the Veteran's statements and testimony regarding his difficulties with hearing and communicating due to his hearing loss, as well as wearing hearing aids. The Board does not doubt that his hearing loss causes considerable challenges. The Board sincerely empathizes with the Veteran, but is bound to apply the applicable rating criteria. For the reasons explained above, the criteria for higher evaluations are not satisfied. The functional effects of the Veteran's difficulty hearing and understanding speech in various contexts are contemplated by the rating schedule. See Doucette, 28 Vet. App. at 369, 371. Accordingly, a compensable rating for bilateral hearing loss is not warranted. B. PTSD Under 38 C.F.R. § 4.130, Diagnostic Code 9411, the Veteran's service-connected PTSD is evaluated as 30 percent disabling prior to March 1, 2016, and 50 percent disabling thereafter, according to VA's General Rating Formula for Mental Disorders. See 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1. Under the General Rating Formula, as pertinent to the present appeal, a 30 percent rating is warranted where the disorder is manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, Diagnostic Code 9411. A 50 percent rating is warranted where the disorder is manifested by 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; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating requires 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); and inability to establish and maintain effective relationships. Id. The maximum 100 percent rating requires 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; and memory loss for names of close relatives, own occupation, or own name. Id. The symptoms associated with each evaluation under the General Rating Formula do not constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Thus, the evidence considered in determining the appropriate evaluation of a psychiatric disorder is not restricted to the symptoms set forth in the General Rating Formula. See id. VA must consider all symptoms of a claimant's condition that affect his or her occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders (DSM-V). 38 C.F.R. §§ 4.125, 4.126. The Federal Circuit clarified that the General Rating Formula for Mental Disorders requires (1) sufficient symptoms of the kind listed in the percentage requirements, or others of similar severity, frequency or duration; and (2) that those symptoms cause the level of occupational and social impairment specified in the regulation. See Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013). If the evidence demonstrates that the claimant's psychiatric disorder produces symptoms and resulting occupational and social impairment equivalent to that set forth in the criteria for a given rating in the General Rating Formula, then the appropriate, equivalent rating will be assigned. Mauerhan, 16 Vet. App. at 443. In this regard, the Board must consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126 (2016); Vazquez-Claudio, 713 F.3d at 117 (noting that the "frequency, severity, and duration" of a veteran's symptoms "play an important role" in determining the disability level). While VA considers the level of social impairment, it shall not assign an evaluation based solely on social impairment. Id. In evaluating psychiatric disorders, VA also considers a claimant's Global Assessment Functioning (GAF) scores, which are based on a scale set forth in the DSM-IV reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996); DSM-IV. According to DSM-IV, a score of 61-70 indicates "[s]ome 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 generally functioning pretty well, has some meaningful interpersonal relationships." A score of 51-60 indicates "[m]oderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning, (e.g., few friends, conflicts with peers or co-workers)." Id. A score of 41-50 indicates "[s]erious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job)." Id. A score of 31-40 indicates "[s]ome impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) OR major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work)." Id. A GAF score thus may demonstrate a specific level of impairment. See Richard, 8 Vet. App. at 267 (observing that a GAF score of 50 indicates serious impairment); accord Bowling v. Principi, 15 Vet. App. 1, 14-15 (2001). While an examiner's classification of the level of psychiatric impairment reflected in the GAF score assigned can be probative evidence, such a score is by no means determinative of the rating assigned by VA in evaluating a psychiatric disorder under the rating criteria. See 38 C.F.R. §§ 4.2, 4.126 (2017); VAOPGCPREC 10-95 (March 31, 1995). Rather, VA must take into account all of the Veteran's symptoms and resulting functional impairment as shown by the evidence of record in assigning the appropriate rating, and will not rely solely on the examiner's assessment of the level of disability at the time of examination. See 38 C.F.R. § 4.126. i. Rating prior to March 1, 2016 At a January 2012 VA examination, the Veteran reported experiencing hypervigilance, weekly nightmares, frequent waking, and a restricted range of affect. He had been married to his wife for 41 years and described their relationship as good. He also got along with his two sons and his grandchildren. He was involved with the American Legion and did some volunteering at the VA, but did not socialize outside of that. He had some acquaintances through work, but no close friends. He had been employed as a manager full time at M.R.C. since the 1980s. He said that he was a reliable worker and got along fine with coworkers, but there were some opportunities that he did not pursue because they would require going out of his comfort zone and more interpersonal interactions. The Veteran's symptoms included anxiety, suspiciousness, irritability, chronic sleep impairment, and mild memory loss. On mental status examination, the Veteran was alert, responsive, and oriented in all spheres. He was well groomed and neatly dressed, with good eye contact. Speech was normal in all realms, and his presentation was pleasant and cooperative. His mood appeared generally euthymic; his affect was appropriate and congruent to mood. Thought process was logical and linear, and he denied audio and visual hallucinations, a history of depressive/manic or hypomanic episodes, symptoms of obsessive compulsive disorder, and panic attacks. His energy and interest levels were intact, and his motivation was generally intact though he noted some difficulty initiating projects at times. Insight and judgment were good, and the Veteran denied suicidal and homicidal ideation, as well as any history of suicide attempts. The examiner confirmed the Veteran's diagnosis of PTSD and assigned a GAF score of 62. The examiner opined that he had occupational and social impairment with occasional decrease in work efficiency. In a January 2012 letter, the Veteran stated he rarely sleeps through the night and frequently experiences bizarre or upsetting dreams. He further endorsed hypervigilance when in public and avoiding certain activities indoors, including movies, concerts, and sporting events. See January 2012 Statement in Support. The preponderance of the evidence shows that the criteria for a rating in excess of 30 percent were not satisfied or more nearly approximated prior to March 1, 2016. The Veteran has not manifested the symptoms listed in the criteria for a 50 percent rating, and the symptoms he does have are not equivalent in severity, frequency, and duration so as to result in occupational and social impairment with reduced reliability and productivity. The frequency, severity, and duration of the Veteran's reported PTSD symptomatology (i.e., anxiety, suspiciousness, irritability, chronic sleep impairment, and mild memory loss) are captured by the criteria for a 30 percent rating. Further, the clinical findings showed that his speech was normal, his thought process was logical and linear, he denied having panic attacks, and his insight and judgment were good. Alternatively, with respect to occupational and social impairment, the Veteran maintained good relationships with his family members and was employed full time. Accordingly, the criteria for a 50 percent rating were not satisfied or approximated prior to March 1, 2016; thus, a rating in excess of 30 percent is not warranted prior to March 1, 2016. ii. Rating from March 1, 2016, forward At a March 2016 VA examination, the Veteran reported that he and his wife go to casino on a regular basis. He was still an active member of American Legion and attended events at the VAMC. He also went to a prison monthly to meet with Veteran inmates. He denied having any close friends. He still worked full time at M.R.C. as a director. In the past, he gave presentations and did program development, but these duties were reassigned to someone else. He did not know the reason. Consequently, he had less job satisfaction. The Veteran's symptoms included feeling emotionally detached, intrusive memories, sounds and smells triggering flashbacks, frequent awakenings at night, hypervigilance, difficulty remembering names, and problems focusing his attention. His affect was slightly flat; and his abstract thinking was intact. He denied any delusions and homicidal or suicidal ideations. His insight and judgment were fair. The examiner opined that he had occupational and social impairment with reduced reliability and productivity due to symptoms including suspiciousness, chronic sleep impairment, mild memory loss, and an inability to establish and maintain effective relationships. The examiner noted the Veteran appeared to be emotionally detached, and had difficulty focusing and remembering names. At the May 2017 Board hearing, the Veteran testified that he stays isolated from others including co-workers and family members, and experiences flashbacks and hypervigilance. The Veteran further testified that he did not do well in group sessions, and has not been treated for his PTSD since about 2007. He was still employed full time and helping veterans in prison. See May 2017 Hearing Transcript. The preponderance of the evidence shows that the criteria for a rating in excess of 50 percent were not satisfied or more nearly approximated from March 1, 2016, forward. The Veteran's symptoms reported above (i.e., flashbacks, chronic sleep impairment, difficulty establishing and maintaining effective relationships, etc.) are captured by the 50 percent criteria which include symptoms such as suspiciousness, chronic sleep impairment, difficulty in understanding complex commands, impaired judgment, impaired abstract thinking, and disturbances of motivation and mood. He has not manifested the symptoms listed in the criteria for a 70 percent rating, and the symptoms he does have are not equivalent in severity, frequency, and duration so as to result in occupational and social impairment with deficiencies in most areas. To the contrary, with respect to occupational and social impairment, the Veteran is married and he and his wife go to a casino on a regular basis. He is also employed full time and involved in some volunteer activities. Accordingly, the criteria for a 70 percent rating were not satisfied or approximated from March 1, 2016, forward; thus, a rating in excess of 50 percent is not warranted for this time period. ORDER Entitlement to a compensable rating for bilateral hearing loss is denied. Entitlement to a rating in excess of 30 percent for PTSD prior to March 1, 2016 is denied. Entitlement to a rating in excess of 50 percent for PTSD from March 1, 2016, forward, is denied. REMAND Unfortunately, the Veteran's remaining claim must be remanded for further development. Although the Board sincerely regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide his claim so he is afforded every possible consideration. 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159(c), (d) (2017). The Veteran's squamous cell carcinoma of the larynx has been rated as 30 percent disabling pursuant to 38 C.F.R. § 4.97, Diagnostic Code 6819-6516. See March 2016 Rating Codesheet; see also 38 C.F.R. § 4.27 (hyphenated diagnostic codes are used when a rating under one diagnostic code requires the use of an additional diagnostic code to identify the basis for the evaluation assigned. The additional code is shown after the hyphen). Diagnostic Code 6819 relates to malignant neoplasms of any part of the respiratory system, and directs that if there are no recurrences or metastasis, then the residuals of the malignant neoplasms will be the basis of the rating. Under Diagnostic Code 6516, chronic laryngitis manifested by hoarseness with inflammation of cords or mucous membrane is rated as 10 percent disabling and chronic laryngitis manifested by hoarseness, with thickening or nodules of cords, polyps, submucous infiltration or pre-malignant changes on biopsy is rated as 30 percent disabling. The 30 percent rating is the maximum rating. Another potentially applicable rating criteria for the residuals of squamous cell carcinoma of the larynx includes Diagnostic Code 6518. Under Diagnostic Code 6518, following a partial laryngectomy, the residuals are to be rated under Diagnostic Code 6516 (laryngitis), Diagnostic Code 6519 (aphonia), or Diagnostic Code 6520 (stenosis of the larynx). 38 C.F.R. § 4.97, DC 6518. The Board finds a new examination is required to address the severity of the Veteran's squamous cell carcinoma of the larynx. He was last afforded a VA examination in June 2012. Since that time, additional medical evidence, including a December 2013 sinusitis/rhinitis and other conditions of the nose, throat, larynx and pharynx disability benefits questionnaire (DBQ) completed by his private doctor, has been obtained. The December 2013 DBQ indicated that the Veteran has laryngeal stenosis and dysphagia from radiation therapy, suggesting a worsening of his condition. See December 2013 DBQ, Section IV, Parts C3 and F2. The Veteran also testified in May 2017 that he was having trouble swallowing. Thus, a remand is required in order to schedule the Veteran for an additional VA examination. Finally, as this matter is being remanded, efforts should be made to obtain the Veteran's updated private treatment records. Accordingly, the case is REMANDED for the following action: 1. Make arrangements to obtain the Veteran's complete treatment records from Massachusetts General Hospital and/or Massachusetts Eye and Ear, to include from Peter Friedensohn, M.D., dated from February 2014 forward. 2. Thereafter, schedule the Veteran for an appropriate VA examination to determine the severity of his squamous cell carcinoma of the larynx residuals. The entire claims file, to include a copy of this REMAND, must be provided to the VA examiner, who must note its review. The examiner should use the appropriate Disability Benefits Questionnaire(s) (DBQ) to assess the severity of all residuals attributable to the Veteran's service-connected squamous cell carcinoma of the larynx residuals. All symptoms and clinical findings associated with this condition must be reported in detail. The examiner should specifically consider and address whether the Veteran has dysphagia from his radiation therapy and/or laryngeal stenosis. All examination findings, along with a complete rationale for all opinions expressed, must be set forth in the examination report. 3. Finally, after completing any other development that may be indicated, readjudicate the claim on appeal. If the benefits sought are not granted, the Veteran and his representative must be furnished a supplemental statement of the case (SSOC) and 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 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). ______________________________________________ P. M. DILORENZO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs