Citation Nr: 1800219 Decision Date: 01/04/18 Archive Date: 01/19/18 DOCKET NO. 14-09 000 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Phoenix, Arizona THE ISSUES 1. Entitlement to service connection for upper extremity peripheral neuropathy secondary to diabetes mellitus II (DMII) (claimed as neuropathy of hands). 2. Entitlement to service connection for lower extremity peripheral neuropathy secondary to DMII (claimed as neuropathy of feet). 3. Entitlement to a rating in excess of 30 percent for service-connected posttraumatic stress disorder (PTSD). 4. Entitlement to a total disability rating based upon individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Veteran represented by: Stephen Vaughn, Agent ATTORNEY FOR THE BOARD G. Johnson, Associate Counsel INTRODUCTION The Veteran had honorable active service in the United States Army from December 1968 to December 1970. The Veteran received multiple awards and medals including the Purple Heart. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Denver, Colorado, which denied service connection for upper and lower peripheral neuropathy, secondary to DMII, and a May 2014 rating decision which continued a 30 percent rating for PTSD. The Board notes that the November 2017 notice of certification to the Board was returned as undeliverable. However, as the Veteran's representative was copied on the correspondence, the Board finds that the defect in the notice of certification is not prejudicial. The issues of entitlement to service connection for neuropathy of the hands and neuropathy of the feet are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDING OF FACT For the entire period on appeal, the Veteran's service-connected PTSD symptoms have more nearly approximated occupational and social impairment, with deficiencies in most areas. Symptoms of total occupational and social impairment have not been demonstrated. CONCLUSION OF LAW Resolving all reasonable doubt in favor of the Veteran, the criteria for an initial rating of 70 percent, and not higher, for PTSD, for the period on appeal, have been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.1, 4.7, 4.126, 4.130, Diagnostic Code 9411 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.326(a). In light of the favorable disposition of the claim for an increased rating for service-connected PTSD, the Board finds that any deficiencies with regard to the duty to notify or assist is non prejudicial, and thus, no further discussion of VA's duties to notify and assist is necessary. II. Increased Rating for Service-Connected PTSD The Veteran seeks a rating in excess of 30 percent for his service connected PTSD. In a July 2014 notice of disagreement, the Veteran's representative asserted that the Veteran's symptoms warranted a higher rating. The representative stated that the Veteran was inpatient in September 2013 for three days for suicidal ideation and in March 2014 for one week for psychotic episodes. The representative asserted that the Veteran had difficulty establishing and maintaining effective work and social relationships, experienced anxiety attacks every other day, had severe short term memory, extreme impaired judgment, severe mood swings, and was hypervigilant. The representative noted that the Veteran had been married and divorced three times and had one friend, a male roommate. The representative also noted that the Veteran was last employed in 1998 as a school bus driver for approximately 8 to 9 months, but he could not tolerate the children, and could not remember the scheduled stops. Disability ratings are based on the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that rating. 38 C.F.R. § 4.7. Otherwise, the lower rating will be assigned. Id. Although the Veteran's entire history is reviewed when assigning a disability evaluation, where service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994), see also 38 C.F.R. § 4.1. The United States Court of Appeals for Veterans Claims (Court) has held that in determining the present level of a disability for any increased evaluation claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505, 510 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. When rating a mental disorder, VA must consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the claimant's capacity for adjustment during periods of remission. VA shall assign a rating based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). When rating the level of disability from a mental disorder, VA will consider the extent of social impairment, but shall not assign a rating solely on the basis of social impairment. 38 C.F.R. § 4.126(b). Service connection for PTSD with an evaluation of 30 percent was granted in a March 2010 rating decision. The Veteran filed a claim for increased rating in February 2014. A rating decision issued in May 2014 continued the 30 percent rating for PTSD. The Veteran is currently assigned a 30 percent rating for his service connected PTSD, effective October 30, 2009, pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411 and the General Rating Formula for Mental Disorders. A 30 percent evaluation is warranted where there is 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). Id. A 50 percent evaluation is warranted where there is 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; impaired judgment; impaired abstract thinking; disturbance of motivation and mood; and difficultly in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation is warranted where there is 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 worklike setting); and inability to establish and maintain effective relationships. Id. A 100 percent evaluation 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. When rating a mental disorder, VA must consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the claimant's capacity for adjustment during periods of remission. VA shall assign a rating based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). When rating the level of disability from a mental disorder, VA will consider the extent of social impairment, but shall not assign a rating solely on the basis of social impairment. 38 C.F.R. § 4.126(b). A Veteran may only qualify for a given disability rating under 38 C.F.R. § 4.130 by demonstrating the presence of the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117-118 (Fed. Cir. 2013). In addition to requiring the presence of the enumerated symptoms, 38 C.F.R. § 4.130 also requires that those symptoms have caused the specified level of occupational and social impairment. Vazquez-Claudio, supra. However, the factors listed in the rating schedule are simply examples of the type and degree of symptoms, or their effects, that would justify a particular rating, so the determination should not be limited solely to whether a Veteran exhibited the symptoms listed in the rating scheme, but should also be based on all of a Veteran's symptoms affecting his level of occupational and social impairment. See Mauerhan v. Principi, 16 Vet. App. 436, 442-443 (2002); Amberman v. Shinseki, 570 F.3d 1377, 1380 (Fed. Cir. 2009); see also 38 C.F.R. § 4.126(a); compare Massey v. Brown, 7 Vet. App. 204, 208 (1994). It is error where the Board fails to assess adequately evidence of a sign or symptom experienced by the Veteran, misrepresents the meaning of a symptom, or fails to consider the impact of the Veteran's symptoms as a whole. However, the presence or lack of evidence of a specific sign or symptom listed in the evaluation criteria, including suicidal ideation, is not necessarily dispositive of any particular disability level. Bankhead v. Shulkin, 29 Vet. App. 10, 25 (2017). For instance, the scores assigned under the Global Assessment of Functioning (GAF) scale may be a relevant consideration. See e.g., Bowling v. Principi, 15 Vet. App. 1, 14 (2001). However, the American Psychiatric Association has since determined that the GAF score has limited usefulness in the assessment of the level of disability. Noted problems include lack of conceptual clarity and doubtful value of GAF psychometrics in clinical practice. 79 Fed. Reg. 45093 (Aug. 4, 2014). The Board notes that effective August 4, 2014, the regulations governing the rating of mental disorders were updated to replace all references to the DSM-IV with references to the DSM-V, which no longer utilizes the GAF score system. 80 Fed. Reg. 14308 (Mar. 19, 2015). However, this change does not apply to claims that were certified for appeal to the Board prior to August 4, 2014 even if such claims were subsequently remanded. Id. As the Veteran's claim had been certified to the Board in November 2017, the DSM-IV is no longer applicable to his claim. The evidence reflects that the Veteran has been diagnosed with other nonservice-connected psychiatric disorders. The use of manifestations not resulting from service-connected disease or injury is to be avoided when establishing the service-connected disability evaluation. 38 C.F.R. § 4.14. However, where it is not possible to distinguish the effects of a nonservice-connected condition from those of a service-connected condition, the reasonable doubt doctrine dictates that all symptoms be attributed to the Veteran's service-connected disability. See Mittleider v. West, 11 Vet. App. 181 (1998). Post service treatment records from November 2012 reflect a diagnosis of PTSD; major depression, recurrent without psychosis; insomnia associated with mental illness; and narcissistic personality disorder (NPD). The Veteran had been hospitalized in September 2013 for three day for anger problems and suicidal ideation, and had been hospitalized for a week in March 2014 with depressive symptoms and hallucinations. VA treatment records in November 2012 reflect a diagnosis of PTSD; major depression, recurrent without psychosis; insomnia associated with mental illness; and NPD. The Veteran had been having a fantasy of getting a sniper rifle and targeting the Department of Education due to student loans for his stepdaughter. The treatment provider opined that the Veteran's fantasy did not rise to the level of homicidal ideation. The Veteran stated that he did not want to harm anyone; he just wanted to draw attention to his problem, and to the problem of other veterans like him. The Veteran's biggest trigger was frustration and perceived slights against him. The treatment provider opined that the Veteran was narcissistic and quite entitled. The treatment provider noted that there were some passive aggressive tendencies to him as well; he had a lot of suspiciousness, bordering on paranoia. The Veteran denied outright delusional beliefs, auditory hallucinations, or visual hallucinations. The treatment provider noted that the Veteran also had symptoms of PTSD, and had issues with hypervigilance, hyperarousal, and intrusive thoughts, mostly surrounding the incident that got him his Purple Heart. The treatment provider noted that although the Veteran denied any current suicidal ideation, his fantasy about the sniper rifle included the thought that "they would have to take me out then." The treatment provider also noted that the Veteran had problems with long-term relationships, had been married three times, and was currently divorced. The Veteran had four stepchildren, and only had a good relationship with one of them. The Veteran's parents and his sister were deceased. VA treatment records reflect that the Veteran was hospitalized in September 2013 for three days for anger problems and suicidal ideation. The Veteran was diagnosed with major depressive disorder (MDD), recurrent, moderate severity; anxiety disorder, not otherwise specified; and PTSD. The Veteran was also diagnosed with cluster B traits, because he was exhibiting NPD. The Veteran threatened to go on hunger strike and douse himself with gas and light himself on fire to draw attention to the problem he had been having with the Department of Education over his stepdaughter's student loans. The treatment provider noted that the when the Veteran was initially assessed he did not endorse any suicidal or homicidal ideation, or any delusions or paranoia. The Veteran's medications were adjusted, and the Veteran was released the next day after reporting improvements in his mood, anger and outlook. VA treatment records reflect that the Veteran was hospitalized for a week in March 2014 with depressive symptoms and hallucinations. The Veteran reported that he was seeing a deceased friend from Vietnam, as well as his mother and sister, who were both deceased. At discharge, the treatment provider noted no suicidal or homicidal ideation. The Veteran reported worsening of symptoms of PTSD, anxiety and depression. The treatment provider noted that the Veteran would not be prescribed antipsychotic medications at that time, because the Veteran had not had any psychotic symptoms there. The Veteran was afforded a VA examination in May 2014, which reflected a diagnosis of MDD, recurrent, unspecified; PTSD; and NPD. The examiner noted that MDD was a separate and distinct condition diagnosed by the Veteran's treating psychiatrist, and it was not a progression of PTSD. NPD was a condition, which the Veteran's treating psychiatrist diagnosed in 2012, and was separate and distinct from the previously diagnosed PTSD; the personality disorder was not a progression of PTSD. The May 2014 examiner opined that it was possible to differentiate the symptoms, which were attributable to each diagnosis. NPD was characterized by repetitive maladaptive patterns of behavior, which develop during childhood and adolescence. Behaviors included difficulty adapting after stressful situations, persistent difficulty in social relationships, impulsivity and poor regulation of emotions. Symptoms include disturbance of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work, inability to establish and maintain effective relationships, impaired impulse control, impaired judgment, suicidal gestures, and ideation. PTSD symptoms included avoidance of thoughts, feelings related to combat memories, hypervigilance, and nightmares. Symptoms of depression included decreased mood, fatigue, recurrent passive thoughts of death, insomnia, irritability, crying, and social withdrawal. The examiner noted that there was no suicidal or homicidal ideation. The overlap of symptoms that were attributed to PTSD and depression included irritability and outbursts of anger, difficulty concentrating, restricted range of affect, diminished interest or participation in significant activities. The May 2014 examiner noted that the conditions had different times of onset and different etiologies. PTSD was the only condition associated with the Veteran's combat experiences. The other two conditions could be mutually aggravating and were not related to his combat experiences. The examiner opined that it was possible to differentiate what portion of the Veteran's occupational and social impairment was caused by each mental disorder. The major depression and personality disorder were the conditions to which the majority (80 percent) of psychosocial impairment is attributable. Specifically, both of the Veteran's recent hospitalizations (September 2013 and March 2014) were due to his suicidal ideation related to the five-year battle regarding his debt to the Department of Education. According to the Veteran, he was voluntarily hospitalized in 2014 after disclosing to a social worker that he intended to light himself on fire with gasoline at the Capitol building in Washington, DC with his Purple Heart in one hand and a letter about the Department of Education in the other hand. The May 2014 examiner noted that the Veteran had been married three times and divorced his third wife in 2011. The Veteran reported a significant drop in social life since his divorce. However, he remained in contact with his godchild and his four stepchildren from his third marriage; and he traveled once a year with his stepdaughter. He had a good relationship with his roommates, went out to breakfast regularly, got along well with other Veterans, and attended regular social meetings with Veteran's organizations. VA treatment records in May 2014 reflect that the Veteran had been prescribed an antipsychotic medication, because the Veteran had psychotic symptoms. VA treatment records in June 2014 reflect the Veteran called to increase his psychiatric medications. The Veteran reported that he was having visual hallucinations of dead people three to four nights per week. He denied suicidal ideation, and reported that he had a friend staying with him, who was available to talk with him during the night. The Veteran was afforded a VA examination in December 2016, which reflected a diagnosis of PTSD, MDD, recurrent, unspecified, and NPD. The examiner noted that it was not possible to differentiate what portion of each symptom was attributable to each diagnosis because each condition likely contributed in various ways to the Veteran's symptoms. The Veteran's symptoms included depressed mood, anxiety, chronic sleep impairment, and disturbances of mood and motivation. The examiner noted that the Veteran also had homicidal ideation. The Veteran reported that there were times when anger could not be totally controlled, and he felt like hurting someone. The Veteran did not have an identified target for his anger. The Veteran also reported that he had been having hallucinations related to speaking to a person who was not present. The person he would see was the one who took his place in Vietnam. He reported that currently the hallucinations would rarely occur. The Veteran also reported problems with restlessness, attention issues, short-term memory issues, panic attacks, and irritability. He still had nightmares three or four nights per month. He still had some social isolation but he felt more functional. He denied feeling hopeless, helpless, or powerless. He reported that things had been going well for him for the past three months. The December 2016 examiner noted that the Veteran had been married three times, and his last marriage was five years prior. The Veteran reported that he had problems in his marriage due to control issues and anger. He did not have any biological children, but had four stepchildren; and would go on a road trip with his stepdaughter once a year. His sister had been killed in a motor vehicle accident, and he tried to communicate with his niece. The Veteran lived with his only friend and another individual. The Veteran regularly went to a restaurant for breakfast, and used to play golf when he had a partner, currently he would watch television all day. The examiner noted that the Veteran was last employed seven to eight years prior, as a school bus driver for nine months. Prior to that, he owned a software company for 40 years and previously worked for IBM for 10 years. He reported that he completed a BS degree in "engineering mechanic" in 1968 prior to service. Resolving all reasonable doubt in favor of the Veteran, the Board finds that the symptoms of PTSD have more nearly approximated the criteria for a 70 percent rating, but not higher, for the entire period on appeal. As the December 2016 examiner has stated it is not possible to differentiate what portion of the Veteran's level of occupational and social impairment was attributable to PTSD versus his other diagnosed psychiatric disorders; VA has resolved any doubt in his favor and attributed the impairments from these disorders to his service-connected PTSD. See Mittleider, supra. Throughout the period on appeal, the Veteran's PTSD symptoms were manifested primarily by ongoing symptoms of irritability, anxiety, depressed mood, hypervigilance, social isolation, sleep disturbance, and hallucinations. The Board finds that the Veteran's symptomatology throughout the period on appeal has been consistent with and more nearly approximated occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking, or mood, the criteria for a 70 percent rating. Although the medical evidence does not show symptomatology such as 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, the symptoms noted in the rating schedule are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular disability rating. Mauerhan, supra. Thus, even though not all the listed symptoms compatible with a 70 percent rating are shown, the Board concludes that the type and degrees of symptomatology contemplated for a 70 percent rating appear to be demonstrated throughout the period on appeal. However, the Board finds that the symptoms associated with the Veteran's PTSD do not meet the criteria for a 100 percent rating at any period of this appeal. A 100 percent rating requires total occupational and social impairment due to certain symptoms. The Board finds that neither the delineated symptoms nor comparable symptoms are shown to be characteristic of the Veteran's PTSD. The evidence of record does not indicate that the Veteran has exhibited persistent delusions; grossly inappropriate behavior; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation, or own name. Throughout the record, the Veteran was consistently found to be oriented. He was able to maintain a relationship with his stepdaughter, and his roommates. He socialized with his family and friends to some extent, though, the Board acknowledges, that the Veteran reported that he had become increasingly withdrawn. Although the Board acknowledges that the Veteran has had hallucinations, he has never displayed grossly inappropriate behavior, any sort of delusions, or had the intermittent inability to perform activities of daily living. Therefore, the Board finds that total social and occupational impairment has not been shown. In sum, the Board finds psychiatric symptoms shown do not support the assignment of the maximum 100 percent schedular rating. ORDER Entitlement to a 70 percent rating for PTSD, but no higher, is granted, for the entire period on appeal, subject to the laws and regulations governing the payment of monetary benefits. REMAND I. Upper and Lower Peripheral Neuropathy The Veteran asserts that neuropathy of the hands and neuropathy of the feet is related to exposure to Agent Orange or to service-connected DMII. In a May 2011 notice of disagreement, the Veteran stated that, exposure to Agent Orange caused his bilateral peripheral neuropathy of the lower extremities. The Veteran stated that he had complained about peripheral neuropathy of the lower extremities beginning in 1970. The Veteran was afforded a VA examination in February 2010, which reflected a diagnosis of bilateral lower extremity peripheral neuropathy. The examiner noted that there was insufficient clinical evidence for a current diagnosis related to neuropathy of the upper extremities. The examiner opined that the Veteran's symptoms were more consistent with carpal tunnel syndrome for which the Veteran had been treated surgically. The Veteran reported onset of numbness in both feet in 1970, and onset of numbness in both hands in 2005. He reported repetitive use of his hand caused pain. He had been treated surgically for carpal tunnel syndrome with no benefit, and he had been treated with physical therapy. The Veteran reported constant numbness. The examiner opined that bilateral lower extremity peripheral neuropathy was not caused by or a result of diabetes mellitus. The examiner noted that onset of numbness in feet was in 1970 (30 years prior to reported onset of diabetes). Peripheral neuropathy has not progressed significantly since then. Further, the examiner noted that the Veteran had not been diagnosed with DMII during the February 2010 examination. The examiner did not offer a sufficient etiological opinion as to whether the Veteran's neuropathy of the hands and feet was related to exposure to Agent Orange, which rendered the examination inadequate. The Board notes that the November 2010 rating decision indicates that there is an August 2010 VA examination from the Cheyenne VA Medical Center. The opinion is not part of the claims file, and should be obtained and added to the record on remand. On remand, the AOJ should ensure that all outstanding VA and private records are obtained and associated with the record on appeal. II. TDIU The Veteran's request for entitlement to a TDIU is inextricably intertwined with his claims for service connection for neuropathy of the hands and feet. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Because a favorable determination on the service connection claims for neuropathy of the hands and feet could affect the outcome of the claim for TDIU, the service connection claim is inextricably intertwined with the TDIU issue and must be adjudicated by the AOJ prior to the Board's adjudication of the TDIU claim. See Grantham v. Brown, 114 F.3d 1156, 1158-1159 (Fed. Cir. 1997). Therefore, action on the claim for TDIU is deferred pending additional development. Accordingly, the case is REMANDED for the following action: 1. The AOJ should obtain all outstanding private and VA records relating to treatment of the Veteran's neuropathy of the hands and feet. The AOJ should ensure that the Veteran's August 2010 VA examination is obtained and associated with the record on appeal. 2. The AOJ must determine whether the August 2010 VA examination provides a sufficient etiological opinion as to whether the Veteran's neuropathy of the hands and feet is related to exposure to Agent Orange. If the AOJ determines that the August 2010 VA examination does not provide a sufficient etiological opinion as to whether the Veteran's neuropathy of the hands and feet is related to exposure to Agent Orange, the AOJ should schedule the Veteran for a VA examination to ascertain the etiology of the Veteran's neuropathy of the hands and feet. All necessary tests should be conducted. The claims file should be made available to and be reviewed by the examiner in conjunction with the examination. The examiner should address the following: a. whether the Veteran has neuropathy of the hands and/or feet; b. whether it is at least as likely as not (50 percent or greater likelihood) that any current neuropathy of the hands or feet manifested during, is otherwise causally or etiologically related to, or aggravated by, a period of active duty service, to include exposure to Agent Orange; c. whether it is at least as likely as not (50 percent or greater likelihood) that any current neuropathy of the hands or feet is proximately due to a service-connected disability to include DMII; d. whether it is at least as likely as not (50 percent or greater likelihood) that any current neuropathy of the hands or feet is aggravated (increased in severity) by a service-connected disability to include DMII. The examiner should consider and discuss the Veteran's reported symptoms of numbness of both feet in 1970. In rendering the opinion, the examiner should consider the Veteran's statements that he had numbness of both feet in 1970 to be competent. The examiner should provide a complete rationale for all opinions expressed and conclusions reached. 3. Readjudicate the issues on appeal in light of all of the evidence of record. If the issues remain denied, the Veteran and his representative should be provided with a supplemental statement of the case as to the issues on appeal, and afforded a reasonable period within which to respond thereto. 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. §§ 5109B, 7112. ______________________________________________ BRADLEY W. HENNINGS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs