Citation Nr: 1804237 Decision Date: 01/23/18 Archive Date: 01/31/18 DOCKET NO. 14-21 937 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to service connection for left knee disorder. 2. Entitlement to service connection for an acquired psychiatric disorder, to include depression, anxiety and post-traumatic stress disorder (PTSD). REPRESENTATION The Veteran represented by: J. Michael Woods, Attorney at Law ATTORNEY FOR THE BOARD P. Franke, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Army from October 1959 to August 1968. These matters initially came before the Board of Veterans' Appeals (Board) from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. In December 2013, the Veteran testified at a hearing before a Decision Review Officer (DRO). The transcript has been associated with the Veteran's electronic claims file. On his May 2014 VA Appeals Form 9, the Veteran initially requested a Travel Board hearing. However, in a November 2015 written statement, the Veteran subsequently withdrew the hearing request and the hearing request was considered withdrawn. 38 C.F.R. § 20.704 (2017). In its August 2016 decision, the Board reopened the Veteran's claim of entitlement to service connection for residuals of a left knee injury and remanded for further development the claims for right knee disorder, to include as secondary to a left knee disorder and depression. The Board has re-characterized the Veteran's claim for depression more broadly in order to clarify the nature of the benefit sought and ensure complete consideration of the claim. Clemons v. Shinseki, 23 Vet. App. 1, 5-6, 8 (2009). In the Board's August 2016 remand, it directed that a Statement of the Case (SOC) addressing the Veteran's claim for service connection for a right knee disorder, to include as secondary to a left knee disorder, be issued and sent to the Veteran, as required under Manlincon v. West, 12 Vet. App. 238 (1999). Additionally, the directive stated that the Veteran be informed how and within what time period the Veteran is to complete the appeal, specifically with the submission of a VA Appeals Form 9. In compliance with that directive, a July 2017 SOC denying the claim for service connection for right knee osteoarthritis was issued and sent with appropriate information pertaining to completing an appeal. The record does not indicate that the Veteran filed a VA Appeals Form 9 within the 60 days from the date of the letter providing the above information or within the remainder, if any, of the one-year period from the date of the letter notifying him of the action that he has appealed; nor was a request submitted for more time to file the appeal. 38 C.F.R. § 20.202. See also Myers v. Derwinski, 1 Vet. App. 127, 129 (1991). Therefore, the Board does not have jurisdiction of that issue. 38 C.F.R. §§ 3.160(d), 20.202. This appeal was processed using the Veterans Benefits Management System (VBMS) and the Legacy Content Manager Documents (LCMD) (formerly Virtual VA) electronic claims files. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (West 2014). The issue of entitlement to service connection for an acquired psychiatric disorder, to include depression, anxiety and PTSD, is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDING OF FACT The most probative (competent and credible) medical evidence of record indicates the Veteran's current left knee disorder is less likely than not etiologically related to his military service. Arthritis was first demonstrated more than 1 year after service separation. CONCLUSION OF LAW The left knee disorder was not incurred in or related to active duty service and arthritis may not be presumed to have been. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107 (2012); 38 C.F.R. §§ 3.303 , 3.304, 3.307, 3.309 (2014). REASONS AND BASES FOR FINDING AND CONCLUSION Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) provides that VA will notify the Veteran of the need of necessary information and evidence and assist him or her in obtaining evidence necessary to substantiate a claim, as well as obtaining a medical examination or opinion of the Veteran's disability when necessary. 38 U.S.C. § 5103 (a); 38 C.F.R. § 3.159 (b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). VA has assisted the Veteran in obtaining evidence to the extent possible, in collecting service treatment records, arranging examinations and obtaining opinions. In addition, the Board is satisfied that VA has substantially complied with the directives of the Board's previous remand. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). The Veteran was afforded a Compensation and Pension examination in May 2017, which produced findings pertinent to deciding the claim for entitlement to service connection. Nieves-Rodriguez v. Peake, 22 Vet. App 295 (2008); see Barr v. Nicholson, 21 Vet. App. 303 (2007). The Board finds the examination adequate for its purpose. Moreover, neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to duty to assist argument). Service Connection Generally, service connection may be granted for disability arising from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection for a disability requires evidence of: (1) The existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). See also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). Certain chronic diseases, including arthritis, may be service connected on a presumptive basis if manifested to a compensable degree in a specified period of time post-service. 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. That period of time is usually one year. 38 C.F.R. § 3.307 (a)(3). For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303 (b). Under 38 C.F.R. § 3.303 (b), an alternative method of establishing an in-service disease or injury and a nexus for chronic diseases is through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Savage v. Gober, 10 Vet. App. 488, 495-97 (1997); see also Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage, 10 Vet. App. at 495-96; see Hickson, 12 Vet. App. at 253 (lay evidence of in-service incurrence sufficient in some circumstances for purposes of establishing service connection); 38 C.F.R. § 3.303 (b). Lay Evidence Lay assertions may serve to support a claim for service connection by establishing the occurrence of observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C. § 1154(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F. 3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). Lay evidence can be competent and sufficient to establish a diagnosis or etiology when (1) a lay person is competent to identify a medical condition; (2) the lay person is reporting a contemporaneous medical diagnosis or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The Veteran's Assertions The Veteran contends in his December 2013 RO Formal hearing testimony, his April and August 2011 Statements in Support of Claim and his October 2013 correspondence that he injured his left knee in in-service basic training in 1959 and has experienced worsening pain ever since. The Veteran testified that since his separation from service, there has been a continuity of treatment for this service-connected injury. He further contends that over-compensation for the functional limitation of the left knee has resulted in degenerative joint disease of the right knee. The Veteran asserts in the statement accompanying his September 1990 VA Appeals Form 9 and his October 1991 correspondence that his left knee disorder not only creates difficulties in standing and walking, but in using the clutch while driving a truck for his job, thereby ultimately causing unemployability. Left knee Disorder The Veteran's October 1959 induction examination shows "NO" checked next to trick" or locked knee. The examiner did note that the Veteran previously had worn a back brace to correct a kyphosis (excessive curvature) deformity and the examination further revealed a minimal lumbodorsal scoliosis. His August 1962 separation and reenlistment examination similarly reflected a "NO" to a "trick" or locked knee and noted the Veteran's use of a back brace in 1955. In February 1963 and July 1965 periodic examinations, the Veteran's lower extremities were noted as "NORMAL. In a July 1965 annual examination, the box for "trick" or locked knee was checked "NO." His 1959 swollen left knee and thigh were noted as "healed." In an August 1966 period physical examination, the Veteran's lower extremities were noted as "NORMAL." The Veteran's June 1968 separation examination recorded "YES" next to the boxes concerning whether he now had or had ever had a "trick" or locked knee and swollen or painful joints. Once again, the Veteran swollen knee from basic training was noted as treated. No clinical abnormalities were described. In November 1989, the Veteran presented to High Point Orthopaedic Associates, complaining of knee pain and problems walking, standing and driving. X-rays revealed minimal degenerative changes, good joints spacing and indications "reminiscent" of previous Osgood-Schlatter disease. Additionally, the orthopedic physician noted a tibial fracture, apparently unknown to the Veteran, but which appeared to be only 9 to 12 months old A December 1989 VA examination noted the Veteran's complaints of left knee swelling, pain, occasional inability to bend the knee due to pain, and difficulty standing and driving. However, upon examination, the VA examiner's found that there was "full and free" range of motion, the ability to squat and rise and no atrophy of thigh musculature. X-rays revealed possible residuals of old Osgood-Schlatter pathology, a spur formation on the left patella and, once again, indications of a healed fracture of the left tibia. Between September 2004 and December 2006, examinations at Salisbury VA provided an assessment of degenerative joint disease of the Veteran's knees. The Veteran complained of worsening pain, for which medication no longer appeared to be effective. The Veteran began to receive knee injections. October 2004 and December 2006 MRI reports at Salisbury VA identified thinning articular cartilage in the medial compartment and the medial patellar femoral compartment and some degenerative change in the posterior horn of the medial meniscus. However, no meniscal tear or displaced meniscal fragment was detected and cruciate and collateral ligaments were intact. Additionally, older evidence of Osgood-Schlatter disease was revealed. In September 2010, the Veteran's reports of the in-service basic training accident which injured his knee were noted and mentioned intermittent steroid injections knee braces have helped and the Veteran is diligent in his home exercise program. By November 2010, the Veteran returned for another injection and the doctor assessed the Veteran with bilateral degenerative joint disease, noting that the left is worse due to the initial injury and the right knee developed issues due to compensating for the left. Radiological findings showed joint space narrowing with mild osteoarthritis. A November 2010 MRI revealed severe left knee tri-compartmental osteoarthritis and a torn medial meniscus. In January 2011, the assessed the Veteran with bilateral knee degenerative joint disease with severe osteoarthritis on the left, and a torn medial left meniscus, with displaced meniscal fragments. She opined that these issues are more likely than not to have been sustained while on military duty in 1960 [sic] when the Veteran fell over tree roots while on a basic training march. She added that given the fact that the left knee has been catching and locking since 1960, it is more likely than not that the left medial meniscus tore at that time. In April 2011 visits to an orthopedic surgeon, the Veteran underwent more corticosteroid injections. The examiner noted full flexion in both knees, but extension reduced by five degrees. Injections continued through July 2017, including right knee injections and the Veteran continued to wear knee braces and use a cane. Assessments included osteoarthritis, but no swelling, effusion or inflammation erythema was noted during this period and the knee's range of motion remained good. In May 2017, the Veteran underwent a VA examination, in which the May 2017 VA examiner noted an April 2011 diagnosis of degenerative arthritis in both knees. She further noted limited ability to flex either knee due to degenerative changes in the knee; increased weakness of the quadriceps that also affects his overall knee tracking; unable to stand or sit for long periods of time, climb stairs without discomfort and assistance of his upper extremities to pull him up the stairs; unable to kneel or squat; use of knee braces on both knees and a cane for added stability, aiding in ambulation, and for safety to prevent falls; and a November 2010 MRI of the left knee shows severe tri-compartmental DJD. She added that there was objective evidence of pain on passive range of motion testing of the left knee; and objective evidence of pain on non-weight bearing testing of the left knee. The May 2017 VA examiner opined that the Veteran's disorder was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event or illness. She explained that, although the Veteran reported that he injured his knee in boot camp in 1959, there was no noted diagnosis of any left knee condition. However, she stated that there is mention of left knee swelling during service and previous Osgood-Schlatter disease, which occurs before the growth plate completely closes in young adulthood. She further stated that Osgood-Schlatter disease is caused by an injury and does not occur on its own. The May 2017 the VA examiner added that, although this is the only objective evidence that could be found, there is no evidence of continuity of care for the left knee during service, the left knee is not mentioned again until 1990, 22 years after discharge and, therefore, the current left knee diagnosis is less likely directly related to military service. The Veteran's Arguments At the outset, the Board notes that, as indicated above, the Veteran has received diagnoses of osteoarthritis, associated with his left knee disorder. Arthritis is classified as a chronic disease under 38 C.F.R. § 3.309 (a) and, as stated earlier in this decision, as a chronic disease it will be presumed service connected if manifest to a compensable degree within one year of separation from service. 38 C.F.R. § 3.307 (a)(3). See also Walker v. Shinseki, 708 F.3d 1331, 1337 (Fed. Cir. 2013). Moreover, as stated earlier in this decision, an alternative method of establishing an in-service disease or injury and a nexus for chronic diseases is through a demonstration of continuity of symptomatology. 38 C.F.R. § 3.303 (b); Barr v. Nicholson, 21 Vet. App. 303 (2007); see Savage v. Gober, 10 Vet. App. 488, 495-97 (1997); see also Clyburn v. West, 12 Vet. App. 296, 302 (1999). Although the Veteran's left knee injury was noted in service, after separation from service in August 1968 the record contains no history of treatment following upon separation until November 1989, over 21 years after separation from service, when the Veteran sought treatment at High Point Orthopaedic Associates. Prior to that, the record presents no evidence of a chronic knee condition from which service connection can be presumed or a continuity of symptomatology by which a nexus between the Veteran's current left knee disorder and an event, injury or illness in service can be established. The Board further notes that, although one examiner stated in her January 2011 opinion that the Veteran's severe left knee osteoarthritis and torn meniscus are more likely than not to have been sustained in an in-service fall and that the catching and locking of the knee since that time makes it more likely than not that the left medial meniscus tore at that time, she provided no rationale for this statement. Whether familiar with the Veteran's treatment record or not, the examiner did not refer to any clinical findings in the record of "catching" and "locking" of the Veteran's knee after the injury. The STRs contain nothing to this effect and there are no records of treatment for 21 years separation from service. The Board cannot determine how or on what basis she arrived at her conclusion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). For these reasons, Dr. S.J.'s opinion is assigned limited probative weight. Significantly, it is noted that while the service treatment records, particularly some examination reports, contain the history of an injury in 1959, they also note that it healed. There are no clinical abnormalities set out on the various examinations and service treatment records reveal that the Veteran was seen for various complaints during service, but never again for complaints of left knee pathology. He is not shown to have had any difficulty doing any duties or assignments in service due to any left knee complaints. When first seen in 1989, records seem to reveal a recent injury to the knee, this is years post service. In contrast, the May 2017 VA examiner opined that the Veteran left knee disorder was less likely than not service-connected because there had been no diagnosis at the time and no treatment until, by her reckoning, 22 years after separation from service. Yet, she referred to the only "objective evidence" being indications of previous Osgood-Schlatter disease due to an injury (an inflammation of the patellar ligament in the form of a painful lump on the tibia just below the knee, associated with young adolescents). The May 2017 VA examiner provided a rationale for her opinion and her findings and diagnosis are based on accurate characterizations of the evidence. For these reasons, her findings and opinion receive significant probative weight. Moreover, they align with the medical evidence on file as set out above. The Board cannot render its own independent medical judgments; it does not have the expertise. Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). Therefore, the Board cannot make a finding as to what injury or disease might have caused or is associated with the Veteran's left knee disorder. However, the Board must make findings of fact and assess and weigh the evidence accordingly. See Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001); Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001). See also 38 U.S.C. § 7104 (a). What is factually certain from the record is in the very first examination the record provides from November 1989 is that indications "reminiscent" of Osgood-Schlatter disease were detected, as were otherwise mild degenerative changes and good joint spacing. Osgood-Schlatter disease is subsequently identified in the December 1989 VA examination, in MRI reports from October 2004 and December 2006 and in the May 2017 VA examination. Moreover, as addressed above, what the November 1989 orthopedist had found "quite interesting" was evidence of a possible stress fracture of the Veteran's left tibia, the Veteran's report that he had never received an assessment or diagnosis of this and that this fracture was as recent as from the previous 9 to 12 months. The December 1989 VA examiner also detected indications of a healed fracture of the left tibia. From this evidence, the record provides no diagnosis which is contemporary with the Veteran's service or afterward for over 21 years, but subsequent examinations and treatment reveal disease and trauma associated with the Veteran's left knee and gradual worsening degenerative changes as the Veteran grew older. Conclusion The Board has carefully reviewed and considered the Veteran's December 2013 RO Formal hearing testimony, as well as his numerous statements, to include his statement accompanying his September 1990 VA Appeals Form 9, his March 2007, April 2011 and August 2011 Statements in Support of Claim, his October 1991 and October 2013 correspondence, and his reports during examinations, as they appear throughout the record. Additionally, the Board has reviewed and considered the August 2007 statement of the Veteran's sister, S.W. and the September 2007 statement of the Veteran's supervisor. All of these have assisted the Board in understanding better the nature and development of the Veteran's disability. As stated earlier in this decision, lay people are competent to report on matters observed or within their personal knowledge. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). Therefore, the Veteran, his sister and his supervisor are competent to provide statements of symptoms which are observable to their senses and there is no reason to doubt their credibility. However, the Board must emphasize that they are not competent to diagnose or interpret accurately findings pertaining to the Veteran's left knee disorder or its relation to service, as this requires highly specialized knowledge and training. 38 C.F.R. § 3.159 (a)(1). See also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). As already stated, the Board cannot substitute its own judgment for those of medical professionals. Rather, the Board must look to the clinical evidence when there are contradictory findings or statements inconsistent with the record. In the absence of explicit indications in the contemporaneous evidence of a nexus to service, it must rely on medical findings and opinions to establish service connection with a current disability. Rucker v. Brown, 10 Vet. App. 67, 74 (1997). For the reasons stated and based on findings, diagnosis and opinion of the May 2017 VA examiner, the Board finds the record does not contain competent medical findings, an adequate opinion or a supporting rationale which establish a nexus between the Veteran's current left knee disability and in-service event, injury or illness and, therefore, service connection cannot be established. The Board has considered the benefit-of-the-doubt doctrine; however, the Board does not perceive an approximate balance of positive and negative evidence. The preponderance of the evidence is against the claim, the doctrine is not applicable and the claim must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. ORDER Entitlement to service connection for left knee disorder is denied. REMAND VA must provide a VA medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the Secretary to make a decision on the claim. See McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also 38 U.S.C. § 5103A (d)(2), 38 C.F.R. § 3.159 (c)(4)(i). The March 2016 psychiatric assessment of the Veteran included unspecified anxiety disorder and states that the Veteran's depressive disorder began in military service, continues uninterrupted to the present and is aggravated by his bilateral hearing loss, left thumb injury and knee conditions. Some of her findings were recorded on an out of date December 2010 VA examination form. By way of explanation, she summarizes several articles which generally assert correlations between military service and symptoms of psychiatric disturbances. The record further indicates that between June 2012 and February 2017, depression screening of the Veteran, with one exception, resulted in negative scores. From this sparse record, the Board cannot make any determination of the etiology of the Veteran's acquired psychiatric disorder, to include depression, anxiety and PTSD, without further findings and an opinion which provides a rationale for its conclusions. Moreover, the Board notes that in the Veteran's June 2014 Statement in Support of Claim, he requests "an exam at the VAMC to evaluate his depression." In view of the record as it now stands, a psychiatric examination is indicated. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Contact the Veteran and/or his representative for information pertaining to any current treatment for his acquired psychiatric disorder, to include depression, anxiety PTSD at any VA facility and by any private treatment provider. Obtain any records pertaining to that treatment not yet associated with the claims file and associate them with the claims file. The Veteran's assistance should be requested in obtaining any records of recent treatment as indicated. All attempts to obtain records should be documented in the claims file. 2. After all additional records have been obtained and associated with the claims file, but whether or not records are obtained, schedule the Veteran for a VA psychiatric examination. The examination should provide findings and diagnoses as to the nature, extent and etiology of any psychiatric disorder found, to include a review of the entire electronic claims file. The complete electronic claims file must be made available to the examiners in conjunction with the examination. The examiner should detail all psychiatric findings. All indicated tests should be accomplished and all findings reported in detail. The examiner is further requested to render an opinion, addressing whether is at least as likely as not (probability of at least 50 percent) that any psychiatric disorder found had its onset or is otherwise etiologically related to the Veteran's period of active service. The examiner should comment on the findings and opinions of other examiners, which appear in the record. In addition, the opinion should acknowledge, address, consider, and discuss all lay evidence in the record pertaining to the Veteran's acquired psychiatric disorder, to include depression, anxiety and PTSD, to include the Veteran's RO hearing testimony, his lay statements, any lay statements of his wife, family members, friends, co-workers, or others, as well as the Veteran's reports to providers, as they appear throughout the record. Findings should be reconciled with other records on file to the extent possible. If an opinion cannot be made without resort to speculation, that examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. 3. After completing the above development and any other indicated development, readjudicate the claim. If the benefits sought are not granted, provide the Veteran and his representative with a supplemental statement of the case and allow an appropriate opportunity to respond before returning the case to the Board. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ MICHAEL D. LYON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs