Citation Nr: 1801581 Decision Date: 01/10/18 Archive Date: 01/23/18 DOCKET NO. 13-27 981 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Diego, California THE ISSUES 1. Entitlement to service connection for acquired psychiatric disability to include depression, anxiety, and posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for a disorder manifested by rectal bleeding, to include hemorrhoids and anal fissure. 3. Entitlement to service connection for a disorder manifested by chronic constipation, claimed as ileus. 4. Entitlement to an initial compensable disability rating for migraine headaches. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD K. J. Kunz, Counsel INTRODUCTION The Veteran served on active duty from January 2004 to February 2008. She had service in Iraq. She also had National Guard service. These matters come before the Board of Veterans' Appeals (Board) from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California. In a March 2012 rating decision, the RO denied service connection for a PTSD for compensation purposes but granted such for treatment purposes. In an August 2014 rating decision, the RO denied service connection for hemorrhoids and ileus. The RO granted service connection for migraine headaches, and assigned a 0 percent, noncompensable disability rating. In February 2017, the Veteran had a Board videoconference hearing before the undersigned Veterans Law Judge (VLJ). A transcript of that hearing is of record. In a September 2013 claim the Veteran sought service connection for hemorrhoids and for ileus. In the February 2017 Board hearing she explained that her hemorrhoids were manifested by rectal bleeding, and that an anal fissure had been noted in service. She explained that her ileus was manifested by chronic constipation, diagnosed during service as due to ileus. In light of the Veteran's explanations, the Board is restating the hemorrhoids issue as service connection for a disorder manifested by rectal bleeding, to include hemorrhoids and anal fissure, and is restating the ileus issue as service connection for a disorder manifested by chronic constipation, claimed as ileus. The issues of service connection for disorders manifested by rectal bleeding and chronic constipation, and of the rating for migraine headaches, are addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction, in this case the RO. FINDING OF FACT Psychiatric problems described as sleep disturbance, anxiety, depression, and PTSD are attributable to service. CONCLUSION OF LAW Psychiatric disability, to include anxiety disorder, depressive disorder, and PTSD, was incurred in service. 38 U.S.C. §§ 1110, 1111, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION Duties to Notify and Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5100, 5102, 5103A, 5107, 5126 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.326(a) (2017). Under the notice requirements, VA is to notify the claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, VA will attempt to obtain. 38 C.F.R. § 3.159(b) (2017). In Bryant v. Shinseki, 23 Vet. App. 488, 493-94 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) requires that the VLJ who conducts a Board hearing fulfill duties to (1) fully explain the issues and (2) suggest the submission of evidence that may have been overlooked. The RO provided the Veteran notice in letters issued in 2011 through 2014. In those letters, the RO notified her what information was needed to substantiate claims for service connection. The letters also addressed how VA assigns disability ratings and effective dates. In the February 2017 Board hearing, the undersigned VLJ fully explained the issues and suggested the submission of evidence that may have been overlooked. The Veteran has not asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), and has not identified any prejudice in the conduct of the hearing. The Board therefore finds that the VLJ who conducted the hearing complied with the duties set forth in 38 C.F.R. § 3.103(c)(2), and that any error in providing further notice during the hearing constitutes harmless error. The claims file contains service medical records, post-service medical records, and reports of VA medical examinations. The examination reports and other assembled records are adequate and sufficient to reach decisions on the issue that the Board is deciding at this time. The Board finds that the Veteran was notified and aware of the evidence needed to substantiate the claim, and the avenues through which she might obtain such evidence, and the allocation of responsibilities between the Veteran and VA in obtaining evidence. The Veteran actively participated in the claims process by providing evidence and argument. Thus, she was provided with a meaningful opportunity to participate in the claims process, and she has done so. (CONTINUED ON NEXT PAGE) Psychiatric Disability including PTSD The Veteran contends that she has depression, anxiety, and PTSD that began or worsened during her service, following traumatic experiences including a mortar attack and sexual assaults. Service connection may be established on a direct basis for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Service connection may also be granted for any disease diagnosed after service when all the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). The Court has explained that, in general, service connection requires (1) evidence of a current disability; (2) medical evidence, or in certain circumstances lay evidence, of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the current disability. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection for certain chronic diseases, including psychoses, may be established based upon a legal presumption by showing that the disease manifested itself to a degree of 10 percent disabling or more within one year from the date of discharge from service. 38 U.S.C. § 1112 (2012); 38 C.F.R. §§ 3.307, 3.309 (2017). A veteran will be considered to have been in sound condition when examined and accepted for service, except as to disorders noted on entrance into service, or when clear and unmistakable (obvious or manifest) evidence demonstrates that the disability existed prior to service and was not aggravated by service. Only such conditions as are recorded in examination reports are to be considered as noted. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). If the claimant was not examined at entrance, the presumption of soundness does not attach. When there is a preexisting injury or disease, it will be considered to have been aggravated by service when there is an increase in disability during service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C. § 1153 (2012); 38 C.F.R. § 3.306(a) (2017). In Horn v. Shinseki, 25 Vet. App. 231, 234 (2012), the Court explained that, when no preexisting condition is noted upon entry into service, the burden falls on VA to rebut the presumption of soundness, which requires both clear and unmistakable evidence that an injury or disease existed before service and clear and unmistakable evidence that an injury or disease was not aggravated by service. The Court went on to state that "even when there is clear and unmistakable evidence of preexistence, the claimant need not produce any evidence of aggravation in order to prevail under the aggravation prong of the presumption of soundness." Horn at 235. In such cases, the Court explained, the burden is on VA to establish by clear and unmistakable evidence that the disability did not increase in severity during service, or to establish by clear and unmistakable evidence that any increase in severity during service was due to the natural progress of the disease. See Horn at 235. PTSD is a mental disorder that develops as a result of traumatic experience. It is possible for service connection to be established for PTSD that becomes manifest after separation from service. Service connection for PTSD requires: (1) medical evidence diagnosing the condition in accordance with VA regulations; (2) a link, established by medical evidence, between current symptoms and an in-service stressor; and (3) credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). The evidence necessary to establish the occurrence of a recognizable stressor during service varies depending on the circumstances of the veteran's service and of the claimed stressor. If the veteran engaged in combat with the enemy, the claimed stressor is related to that combat, and the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran's service, then, in the absence of clear and convincing evidence to the contrary, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f)(2). Similarly, if a stressor claimed by a veteran is related to the veteran's fear of hostile military or terrorist activity, a VA or VA-contracted psychiatrist or psychologist confirms that the claimed stressor is adequate to support a diagnosis of PTSD, and the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran's service, then, in the absence of clear and convincing evidence to the contrary, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f)(3). In general, if a veteran's service and claimed stressors were not under circumstances that provide for his or her lay testimony alone to establish the occurrence of the stressor, the record must contain service records that corroborate the veteran's testimony as to the occurrence of the claimed stressor. See Zarycki v. Brown, 6 Vet. App. 91, 98 (1993). If a PTSD claim is based on in-service personal assault, evidence from sources other than the veteran's service records may corroborate the veteran's account of the stressor. 38 C.F.R. § 3.304(f)(5). The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a claim, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107. To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. The Veteran's claims file does not include a report of medical examination at her January 2004 entrance into service. In a December 2013 memorandum a VA official described the unsuccessful efforts to obtain the report of her entrance examination, and concluded that further efforts would be futile. Given the lack of an entrance examination, the Board will not presume the Veteran was sound at entrance. In a March 2014 letter the Veteran wrote that, when she was transferred in 2004 from a fort in Kentucky to one in New York, drill instructors in Kentucky told her that her service medical records were lost. She related that she went to New York without medical records, and next had an examination in New York in 2005. The Veteran's available service medical records include records from as early as May 2004. Records from 2004 are silent as to mental health symptoms or issues. In January 2005 screening for depression was negative. In treatment in March 2005 she reported difficulty sleeping. In April 2005 screening for depression was negative. In a September 2005 medical history, she reported trouble sleeping. On examination in September 2005, the examiner marked normal for her psychiatric condition. In treatment in January 2006, the Veteran had follow-up for depression. She reported having felt down for years, since childhood. She stated that she was raped as a child, and that she had counseling before she entered service. In the 2006 service treatment a clinician diagnosed major depression and prescribed antidepressant medication. In March 2006 the Veteran endorsed recent feelings of depression. In May 2006 she reported depression. The Veteran's service records document that she served in Iraq from November 2006 through October 2007, and that she served in a designated imminent danger pay area. In treatment in December 2006 she requested a refill of antidepressant medication. In treatment in January 2007 she reported a history of panic attacks beginning at a young age. She stated that in January 2006 she was started on medication for depression and anxiety. In January 2007 she reported that recently a friend had been killed. She related insomnia, isolation, depression, and anxiety. In April 2007 the Veteran had follow up for depression. She related that she first had depression after her brother raped her when she was seven years old and for years thereafter. She stated that as a child she had therapy for that depression. A clinician noted a history of sexual abuse and job stress, and listed a diagnosis of recurrent major depression. In treatment in May 2007 the Veteran reported tiredness and ongoing depression. In a post-deployment assessment in October 2007 she related current mental health treatment, including by the combat stress team. She reported that treatment included medications for depression and anxiety. She indicated that during the deployment she still felt tired after sleeping. She related lacking interest or pleasure in doing things, and feeling numb and detached. In treatment of the Veteran in November 2007, a list of problems included major depression, anxiety disorder, and dysthymic disorder. In a December 2007 history, she reported treatment in service for anxiety, memory impairment, and sleep disturbance. On examination of the Veteran in December 2007, the examiner noted her reports of anxiety, nervousness, and difficulty sleeping, and her treatment with psychiatric medications. The examiner found that presently she had no suicidal or homicidal thoughts. On the examination report the examiner marked normal for her psychiatric condition. After separation from active duty, in an August 2008 National Guard medical report, the Veteran stated that in 2006 and after her service in Iraq she was treated for depression. In May 2009, it was noted that she was in treatment, including medication, for PTSD. In VA treatment in June 2009, it was noted that she had a history of depression, PTSD, and military sexual trauma. In June 2009, a VA clinician reported that she was in treatment for PTSD and depression. The Veteran's claims file contains records of VA mental health treatment in 2010 and 2011. In July 2010 she reported that as a child she was molested by a brother, and she had some counseling. She stated that during service, beginning in 2006, she was diagnosed with and treated for depression and PTSD. She related that after separation from service her anxiety continued. She indicated that she had VA mental health treatment beginning in 2009. She stated that presently she was on medication for her psychiatric problems. She reported had difficulty sleeping and episodes of depression, but no recent panic attacks. A clinician adjusted psychiatric medications. In August 2010 the Veteran reported ongoing anxiety but some improvement in sleep. A clinician listed diagnoses of PTSD and depression, and noted history of military sexual trauma and childhood sexual abuse. Clinicians continued the diagnoses and medications through 2010 and 2011. In September 2010 and November 2010 the Veteran related ongoing anxiety. In November 2010 she stated that psychiatric medication decreased her symptoms. In February 2011 she reported stress, anxiety, and occasional nightmares. In June 2011 statements, the Veteran wrote that during service, at her first duty station, she was subjected to an incident of sexual harassment. She stated that afterward that she had trouble sleeping. She reported that during her deployment in Iraq, while on a supply run, she saw a mortar hit a distance away, and then a mortar almost struck the vehicle she was driving, striking less than 50 meters away. She related that she turned around and returned to her unit. She stated that soon afterward she began to have nightmares. On VA examination in December 2011 the Veteran reported that during childhood she was sexually assaulted and began seeing a therapist. She related two events during service that were difficult for her. The examiner did not provide any description or identification as to which two events during service the Veteran discussed at the examination. The examiner reported having reviewed the claims file. The examiner expressed the opinion that events during the Veteran's service did not meet the criteria for stressors causing PTSD, and would not have caused her depression. The examiner expressed the opinions that the Veteran's childhood sexual trauma caused her depression, and that it is less likely than not that events during her service caused her depression or caused PTSD. In an April 2012 statement, the Veteran asserted that she has PTSD due to combat stress. She stated that her ongoing nightmares and flashbacks were about war stressors, not sexual assault. In an October 2012 statement, the Veteran again described the mortar attack she experienced during service. She stated that when a mortar hit near her vehicle events seemed to go in slow motion. She reported that she felt panic stricken, and she quickly turned her vehicle around and drove back to her unit. She related that since that attack she had nightmares about it. She also reported that during service in Iraq, during outpatient treatment visits at a hospital, she saw victims of IED explosions, including a small child who had been burned, a civilian whose leg had been blown off, and distraught, blood-covered soldiers who had brought in a team member. She stated that these sights were very traumatizing to her. In an April 2013 statement, the Veteran wrote that on the two occasions when she saw wounded persons during her Iraq service she was very upset. She stated that she was traumatized by the mortar attack, in which her vehicle was almost hit, and the driver of another vehicle was hit by shrapnel. She reported that at the time she was extremely frightened, she felt powerless, and she froze. In a September 2013 statement, the Veteran contended that psychological issues during childhood were resolved during childhood. She stated that during service she was treated for depression. She asserted that stressors she experienced during service that caused her current psychiatric problems, whether described as PTSD, anxiety, or depression. She contended that but for the traumatic experiences during service she would not have her current issues. In the February 2017 Board hearing, the Veteran stated that when she entered service she was in good psychological condition. She related that she felt excited, and had plans and goals. She reported that during service she began to have mental health problems with effects including sleep disturbance. She indicated that during service she was subjected to sexual trauma on two occasions. She recounted the mortar attack she experienced in Iraq. She stated that one of the mortars exploded near her vehicle and actually hit another vehicle. She recalled that during the attack she felt panicked. She related that during service she also was frightened by being awakened at night by the test firing of weapons. She stated that in mental health treatment during service for anxiety a doctor described her symptoms as PTSD symptoms. She reported that mental treatment during service included medications. She indicated that she started on medication after the first in-service sexual trauma, and resumed treatment during her deployment in Iraq. She reported that after service she continued to have psychiatric issues including sleep disturbance, anxiety, paranoia, and difficulty being out in public. She related an episode in which she had physical symptoms in response to noise. She indicated that after service she started VA mental health treatment in November 2008. She reported that presently she continued on medications to address her anxiety and PTSD. She expressed disagreement with the assumptions and conclusions of the VA clinician who examined her in 2011, that her problems were due to events before her service and were not affected by events during service. In February 2017, the Veteran's mother wrote that the Veteran told her by telephone, soon after it happened, of a sexual assault on her during service. The mother stated that the Veteran became withdrawn after that. The mother related that the Veteran also told her of a second sexual assault on her that occurred later in service. The mother stated that after service the Veteran told her about a mortar attack that she experienced in Iraq. The mother reported that after those experiences in service, and continuing after service, through the present, the Veteran was depressed, anxious, and easily startled. The mother wrote that the Veteran had trouble sleeping, had crying spells, and sometimes isolated herself. The Veteran reports that her childhood sexual abuse was followed by counseling in childhood. She states that she was in normal psychological condition when she entered service. As the report of her service entrance examination is unavailable, there is no evidence that any active psychiatric disorder was noted on that examination. She has indicated that her psychiatric problems had resolved at the time of service entrance. This is corroborated by the lack of any pertinent psychiatric complaints, treatment or diagnoses in the first few years of service. During service, the Veteran had mental health treatment, including medication, for issues described as depression, anxiety, and sleep disturbance. Records from soon after service reflect continuation of the symptoms. Thus, information from the Veteran and clinicians supports the continuation after service of the problems treated in service. It is acknowledged that the Veteran had preservice psychiatric problems; however, it appears that such problems resolved by the time the Veteran entered service. Based on the existence of psychiatric problems during service and the continuation of such problems after service, the Board grants service connection for psychiatric disability, including depressive and anxiety disorders. Resolving reasonable doubt in the Veteran's favor, any current PTSD is included in her service-connected psychiatric disability. The Board finds the Veteran's testimony regarding sexual assault in service to be credible. Statements from family members corroborate that the Veteran had confided in them shortly after the inservice incidents occurred. Further, there is a diagnosis of PTSD and numerous references to military sexual trauma in the VA medical records. ORDER Entitlement to service connection for psychiatric disability, to include anxiety disorder, depressive disorder, and PTSD, is granted. REMAND The Board is remanding to the RO, for additional action, the issues of service connection for disorders manifested by rectal bleeding and chronic constipation, and the issue of the rating for migraine headaches. The Veteran contends that she was treated for hemorrhoids, manifested by rectal bleeding, during service, and that she continued to have hemorrhoids and rectal bleeding after service and through the present. She reports that during service she was treated for constipation and diagnosed with ileus. She contends that ileus, manifested by chronic constipation, continued after service and through the present. The Veteran's service treatment records reflect reports of constipation from January 2007 forward. In July 2007 she reported abdominal cramping, constipation, and bleeding after bowel movements. A clinician assessed that the bleeding was from the rectum, and was secondary to complications of constipation, either hemorrhoids or fissure. In October 2007 the Veteran was seen for abdominal pain. The treating clinician found distention of her abdomen was distended and decreased bowel sounds. The clinician's assessment was ileus. Problem lists in treatment reports from November 2007 forward problems include abdominal pain, ileus, anal fissure, and blood with bowel movements. In a December 2007 medical history, the Veteran marked yes for history of frequent indigestion or heartburn. On examination in December 2007, the examiner indicated that the anus and rectum were not examined. After service, in VA treatment in June 2009, the Veteran reported rectal burning and bleeding. The treating clinician saw no external hemorrhoids. Examination was limited due to patient discomfort. The clinician's recommendations included a high fiber diet. In a September 2013 claim the Veteran sought service connection for hemorrhoids and for ileus. In August 2015 the Veteran had a VA examination that addressed ileus. The examiner noted that ileus typically is a short term condition, and opined that the Veteran's ileus likely resolved in service. The examiner stated that, considering the Veteran's psychiatric history and her digestive symptoms, irritable bowel syndrome was a more likely etiology for her current chronic constipation. In the February 2017 Board hearing, the Veteran noted that in service in 2007 she was evaluated for constipation and was diagnosed with ileus. She stated that presently she continued to have chronic constipation, with bowel movements occurring only once or twice a week. She reported that she had hemorrhoids that were manifested by rectal bleeding, and that an anal fissure had been noted in service. She stated that while she was being treated in service for abnormal vaginal bleeding, clinicians determined that she also had rectal bleeding and a fissure. She reported that her rectal bleeding continued after service and was noted in VA treatment. She related that presently she had bleeding with all or most bowel movements. The Veteran has not had a VA examination addressing her rectal bleeding. The possibility of a relationship between the Veteran's (now service-connected) psychiatric disability and her chronic constipation has been raised. The Board is remanding the bleeding and constipation issues for a VA examination with file review and opinions as to the nature and likely etiology of current digestive system disorders manifested by rectal bleeding and chronic constipation. Effective September 24, 2013, the RO granted service connection for the Veteran's migraine headaches and assigned a disability rating of 0 percent. The Veteran contends that the frequency and severity of her migraine headaches warrant a higher rating. Under the VA rating schedule, migraine headaches are rated based on the frequency, severity, duration of the attacks. See 38 C.F.R. § 4.124a, Diagnostic Code 8100 (2017). Under that code, a compensable 10 percent rating is warranted if there are characteristic prostrating attacks averaging one in two months over the last several months. Higher ratings, up to 50 percent, are warranted if there are more frequent prostrating attacks. Id. On VA examination in April 2014, the Veteran reported having migraines two to three times per week. She stated that she had not missed school because of the migraines. In the February 2017 Board hearing, she reported that she had seven to ten migraines per month, and that she was incapacitated during the attacks. As there is evidence that the severity of the Veteran's migraines has increased, the Board is remanding the rating issue for a new VA examination to obtain current findings. Records reflect that the Veteran receives treatment for her migraines in the VA San Diego Healthcare System. The claims file contains records of treatment as recently as 2015. On remand any more recent treatment records should be obtained. Accordingly, the case is REMANDED for the following action: 1. Obtain from the VA San Diego Healthcare System all records of outpatient and inpatient treatment of the Veteran from January 2015 through the present. Associate those records with her electronic (VBMS) claims file. (CONTINUED ON NEXT PAGE) 2. Schedule the Veteran for a VA examination to address the nature and likely etiology of any current digestive system disorders with manifestations including rectal bleeding and chronic constipation. Provide the examiner access to the Veteran's claims file. Ask the examiner to review the claims file, obtain history from the Veteran, and examine the Veteran. Ask the examiner to clearly and thoroughly explain his or her findings and opinions. Ask the examiner to state diagnoses for all current digestive system disorders, with particular attention to any disorders manifested by rectal bleeding or chronic constipation. Ask the Veteran to specifically state whether or not the Veteran has hemorrhoids, anal fissure, or irritable bowel syndrome. Ask the examiner to provide, for each current digestive system disorder, opinion as to whether it is at least as likely as not (at least a 50 percent likelihood) that the disorder is: (a) Related to any digestive system disorder or symptoms that were present during service; (b) Proximately due to or the result of anxiety, depression, or PTSD; or (c) aggravated by anxiety, depression, or PTSD. (CONTINUED ON NEXT PAGE) 3. Schedule the Veteran for a VA examination to obtain information as to the current manifestations and effects of her migraine headaches. Provide the examiner access to the Veteran's claims file. Ask the examiner to review the claims file, obtain history from the Veteran, and examine the Veteran. Ask the examiner to note the frequency of her migraine attacks, and whether those attacks are completely prostrating, prostrating, or not prostrating. Ask the examiner to provide opinion as to the extent to which her migraines affect her capacity for employment. 4. Then review the expanded claims file and readjudicate the remanded claims. If any of those claims is not granted to the Veteran's satisfaction, provide her and her representative a supplemental statement of the case, and afford them an opportunity to respond. The Board intimates no opinion as to the ultimate outcome of the remanded matters. The Veteran has the right to submit additional evidence and argument on those matters. 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). ______________________________________________ K. PARAKKAL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs