Citation Nr: 1804672 Decision Date: 01/24/18 Archive Date: 02/05/18 DOCKET NO. 09-32 154A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for myelogenous leukemia, to include as secondary to herbicide exposure. 3. Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD) prior to July 14, 2016 and in excess of 50 percent thereafter. 4. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL The Veteran and spouse ATTORNEY FOR THE BOARD Amanda Christensen, Counsel INTRODUCTION The Veteran, who is the appellant, served on active duty from April 1967 to January 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from July 2008 and September 2009 rating decisions of a Regional Office (RO) of the Department of Veterans Affairs (VA) in St. Petersburg, Florida. This appeal was previously before the Board in July 2015, at which time it was remanded for additional development. In October 2016 the Board reopened the Veteran's claim for service connection for myelogenous leukemia, and remanded the remaining issues listed above for further development. In July 2016, the Veteran and his spouse testified via videoconference before the undersigned Veterans Law Judge. A transcript of this hearing is of record. The issue of entitlement to TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran has been diagnosed with myelogenous leukemia, which is not among the conditions that the VA has presumptively associated with herbicide exposure. 2. The Veteran's myelogenous leukemia did not onset in service and is not related to service. 3. The Veteran's PTSD manifests with symptoms including sleep disturbance, depression, anxiety, intrusive thoughts, irritability, and exaggerated startle response, causing occupational and social impairment with deficiencies in most areas. CONCLUSIONS OF LAW 1. The criteria for service connection for myelogenous leukemia have not been met. 38 U.S.C. §§ 1110, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.303, 3.304, 3.307, 3.309 (2017). 2. The criteria for a rating of 70 percent, but no greater, for PTSD have been met. 38 U.S.C. § 1155, 5107 (2012); 38 C.F.R. §§ 3.321, 4.1, 4.130, Diagnostic Code 9411 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service Connection for Myelogenous Leukemia The Veteran contends his myelogenous leukemia, diagnosed in 1996, is related to his service, to include his exposure to Agent Orange in Vietnam. Service connection will be granted if it is shown that the veteran suffers from a disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty, during active military service. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303 (2017). Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); see also Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). To establish service connection, there must be a competent diagnosis of a current disability; medical or, in certain cases, lay evidence of in-service occurrence or aggravation of a disease or injury; and competent evidence of a nexus between an in-service injury or disease and the current disability. Hickson v. West, 12 Vet. App. 247, 252 (1999); see Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Certain diseases associated with exposure to certain herbicide agents used in support of military operations in the Republic of Vietnam (Vietnam) during the Vietnam War will also be presumptively considered to have been incurred in service. 38 U.S.C. § 1116(a)(1) (2012). The presumption requires exposure to an herbicide agent and manifestation of the disease to a degree of 10 percent or more within the time period specified for each disease. 38 C.F.R. § 3.307(a)(6)(ii) (2017). The diseases presumptively associated with herbicide exposure are: AL amyloidosis, chloracne or other acneform disease consistent with chloracne, type 2 diabetes, Hodgkin's disease, ischemic heart disease, all chronic B-cell leukemias, multiple myeloma, non-Hodgkin's lymphoma, Parkinson's disease, early-onset peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers, and soft-tissue sarcoma. 38 C.F.R. § 3.309(e) (2017). In November 2010 a VA medical opinion was obtained as to the type of leukemia the Veteran was diagnosed with. The doctor reviewed the Veteran's file and explained that the Veteran's myelogenous leukemia is not considered to be a B-cell or hairy cell leukemia. Thus, as the evidence shows that the type of leukemia the Veteran was diagnosed with is not among the conditions listed to be eligible for presumptive service connection based on Vietnam service, presumptive service connection is not warranted. However, service connection would still be warranted on a direct basis if the evidence showed that the condition was at least as likely as not caused by the Veteran's exposure to Agent Orange in Vietnam or another aspect of his service. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). In support of his claim, the Veteran submitted several medical articles from the internet regarding myelogenous leukemia. One of these articles, entitled "Acute Monocytic Leukemia" from the Orphanet Encyclopedia (May 2004), discussed "predisposing factors" for the possible etiology of myelogenous leukemia and related disorders. Among these factors was listed herbicides, although Agent Orange was not specifically cited. An information page from the American Cancer Society states that the risk of acute myeloid leukemia is increased of exposure to certain chemicals, include long-term exposure to high levels of benzene, which is found in gasoline and some cleaning products. In August 2017, a VA physician reviewed the Veteran's record and opined that it is less likely than not that the Veteran's acute myelogenous leukemia, diagnosed in 1996 and in remission for many years, was incurred in or is related to his Vietnam herbicide exposure or naval vessel engine room exposure. The physician cited to the American Cancer Society's position that a specific cause for acute myelogenous leukemia is not known, and even when a person has one or more risk factors, there is no way to tell if it actually caused the cancer. The physician noted that the Veteran smokes and is an older male, which are risk factors for the condition. He further noted that exposure to herbicides or pesticides, workplace exposure to gasoline and diesel, and exposure to electromagnetic fields are all unproven, uncertain, and controversial risk factors according to the American Cancer Society. The physician acknowledged the Veteran's service in Vietnam, for which he is presumed to have been exposed to Agent Orange, and his work in a ship engine room, which may have exposed him to gasoline or diesel. However, he concluded that it is not possible to connect those military exposures to the Veteran's subsequent development of acute myelogenous leukemia. The Board acknowledges the Veteran's own opinion that his acute myelogenous leukemia is related to his service, to include his exposure to Agent Orange in Vietnam or chemical exposures working in a ship's engine room. However, as a lay person, the Veteran himself does not have the education, training, or experience to opine as to the etiology of such a complicated, internal, unseen condition. See 38 C.F.R. § 3.159(a)(1); see also Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011). Accordingly, the Veteran's lay statements in this regard are not competent or probative evidence supporting his claim. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). The Board has also considered the medical literature submitted by the Veteran. That evidence was also considered by the VA physician who provided the August 2017 nexus opinion. While the medical literature evidence does generally suggest that herbicide and some chemical exposures may be a predisposing factor or risk factor for developing acute myelogenous leukemia, it does not specifically discuss Agent Orange, nor the Veteran's particular medical history. The evidence is both generic and stops far short of affirming any specific exposures claimed by the Veteran are in fact causes of acute myelogenous leukemia based on current medical research. The Board finds the most probative opinion is that of the VA examiner, a medical professional, who reviewed the Veteran's specific circumstances as well as medical literature on the topic. The examiner concluded that it is less likely than not that the Veteran's exposures in service caused his subsequent development of acute myelogenous leukemia. The Board acknowledges the Veteran's contention that a medical link may be made in the future and notes that he may refile his claim for service connection if new evidence develops. However, the Board finds that a preponderance of the evidence currently associated with the Veteran's claims file is against finding service connection for his acute myelogenous leukemia. Therefore, the benefit of the doubt doctrine does not apply and his claim must be denied. Increased Rating for PTSD Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Veteran's PTSD is currently evaluated as 30 percent disabling prior to July 14, 2016 and 50 percent disabling thereafter under the criteria of Diagnostic Code 9411. See 38 C.F.R. § 4.130. A 30 percent rating is assigned 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 rating contemplates 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 difficulty 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; intermittently illogical obscure, or irrelevant speech; 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 is warranted where there is 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. Symptoms listed in VA's general rating formula for mental disorders 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 rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The nomenclature employed in the portion of VA's Rating Schedule that addresses service-connected psychiatric disabilities is based upon the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association. 38 C.F.R. § 4.130. The fourth edition of the manual (DSM-IV) contains a Global Assessment of Functioning (GAF) scale, with scores ranging between zero and 100 percent, representing the psychological, social, and occupational functioning of an individual on a hypothetical continuum of mental health illness. Higher scores correspond to better functioning of the individual. Under DSM-IV, GAF scores ranging between 61 and 70 are assigned when there are some mild symptoms (e.g., depressed mood and mild insomnia), or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but when the individual is functioning pretty well and has some meaningful interpersonal relationships. GAF scores ranging between 51 and 60 are assigned when there are moderate symptoms (like flat affect and circumstantial speech, and occasional panic attacks), or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). GAF scores ranging between 41 and 50 are assigned when there are serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting), or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). GAF scores ranging between 31 and 40 are assigned when there is some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family and is unable to work). According to the applicable rating criteria, when evaluating a mental disorder, the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission must be considered. 38 C.F.R. § 4.126(a). In addition, the evaluation must be 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. Id. Further, when evaluating the level of disability from a mental disorder, the extent of social impairment is considered, but the rating cannot be assigned solely the basis of social impairment. 38 C.F.R. § 4.126(b). The Board finds that the evidence supports that the Veteran is entitled to a 70 percent rating, but no greater, for the entire period on appeal. A 70 percent rating contemplates occupational and social impairment with deficiencies in most areas. For a higher, 100 percent rating, total occupational and social impairment must be shown. Here, the Board finds that the Veteran's overall functioning, with consideration of all of his PTSD symptoms, is most closely approximated by the criteria for a 70 percent rating. A June 2008 VA treatment note states that the Veteran's severe PTSD symptoms interfere with his relationships. A June 2012 VA treatment note states that the Veteran has "major difficulty" in establishing and maintaining effective work and social relationships. Throughout the period on appeal the Veteran has reported a good relationship with his wife of more than three decades. He has also reported a good relationship with his adult child and minor grandchildren. Although he has consistently denied having friends, VA treatment records do reflect he regularly attended group counseling sessions beginning in 2008. A January 2014 VA treatment note relates that the Veteran continues to isolate at home, but does look forward to weekly breakfasts with his prior group therapy members. At his July 2016 Board hearing the Veteran's wife reported that they rarely go out and only sometimes have family come to their home to visit them. The Veteran testified he only goes out only when necessary. At his July 2016 VA examination he further explained that he avoids crowds as they make him anxious. He reported having a few Vietnam friends with whom he speaks about once a week on the phone. Thus, while the evidence certainly suggests that the Veteran self-isolates, the evidence does not reflect that he has a complete inability to establish and maintain effective relationships. He has maintained a many-decades relationship with his wife, as well as maintaining a relationship with his adult child and minor grandchildren. He further has maintained a relationship with his PTSD therapy group members beyond the established therapy sessions to the extent of meeting with them weekly for breakfast. While the Veteran's social contacts may be extremely limited, the Board finds that his ability to maintain some, limited relationships does not support a 100 percent disability rating. Throughout the period on appeal the Veteran has reported he keeps busy doing household chores and yardwork, watching television, doing puzzles, and building toys in his workshop to donate to children, although he reported taking a break from this activity for a period due to headaches. He reported he has not worked since 1991. A June 2012 treatment note reflects that the Veteran reported he is unable to work due to his low frustration tolerance and propensity for a violent reaction. At his 2016 Board hearing the Veteran stated that he can't put up with people and rather than have a confrontation he took himself out of the workforce. Although the Veteran has consistently reported problems with irritability and anger, the evidence does not reflect any episodes of violence against others. At his August 2009 VA examination he reported he used to punch holes in walls prior to going on medication. He has consistently denied suicidal or homicidal ideation, reporting only passive suicidal thoughts in the past at his July 2008 VA examination. At his July 2016 Board hearing he reported he tries to walk away from confrontation rather than become violent. He reported verbal outbursts, although not directed at his wife, at his July 2016 VA examination. Thus, the evidence reflects that the Veteran's irritability affects his ability to work with others but suggests that he is able to exercise control such that he is not a danger of hurting himself or others. Thus, the Board finds the severity of this symptom also supports a 70 percent rating, but not a 100 percent rating. The Veteran has reported a number of other PTSD symptoms that also affect his functioning, including sleep disturbance, depression, anxiety, intrusive thoughts, irritability, and exaggerated startle response. Treatment records from 2008 and 2009 reflect the Veteran reported nightmares once a week. At his April 2010 VA examination he reported nightmares once a month. An August 2013 VA treatment record reflects he reported nightmares once or twice a week. At his July 2016 VA examination he reported nightmares several times per week. The Veteran has reported his sleep impairment has negatively affected him throughout the period on appeal. An April 2014 VA treatment note reflects that the Veteran reported he ruminates about his nightmares the next day and feels depressed and anxious as a result. The Veteran has also reported experiencing chronic depression throughout the period on appeal. At his July 2008 VA examination he reported depression every day nearly all day. In May 2008 he rated his depression a 6 out of 10. In July 2009 he indicated it had reduced to a 5 out of 10. At his August 2009 VA examination he described it as daily moderate chronic depression. He reported an increase in depression in August 2011 and June 2012, with an August 2012 treatment note indicating and decrease in depression with increased medication and an April 2013 VA treatment note indicating an increase in depression with lowered medication. In August 2013 he rated his depression a 4 out of 10. A January 2016 VA treatment note indicates mild depression. At his July 2016 Board hearing he reported depression all the time. The Veteran has also reported problems with anxiety throughout the period on appeal. VA treatment records reflect that the Veteran rated his anxiety as a 5 out of 10 in May 2008 and July 2009. His August 2009 VA examination notes moderate chronic anxiety. An August 2012 VA treatment record notes that the Veteran reported becoming anxious when his routine is changes or something is amiss. He reported his anxiety as a 4 out of 10 in August 2013. In June 2014 he reported an increase in anxiety. The Veteran has also reported problems with intrusive memories throughout the period on appeal. VA treatment notes from May 2008 and July 2009 note daily intrusive thoughts. A June 2008 VA treatment note indicates that the Veteran reported that his intrusive thoughts interfere with his concentration. At his August 2009 VA examination he reported daily intrusive recollections, with intrusive thoughts that are more distressing once a week. At his April 2010 VA examination he reported distressing memories multiple times a week, but was not noted to have panic attacks. According to VA treatment records, he continued to report intrusive thoughts throughout 2011, and in June 2012 he was noted to have severe intrusive thoughts that interfere with his concentration and short-term memory. An August 2012 VA treatment record reflects that he reported intrusive thoughts two to three times per month. At his July 2016 VA examination he reported intrusive thoughts several times per week and panic attacks more than once per week. The August 2009 VA examiner indicated that the Veteran's increased anxiety and depression reduces his ability to cope with daily stressors and lowers his self-confidence and self-esteem. The examiner also stated that the Veteran's hyperarousal avoidance and intrusive memories increase his anxiety and depression as well as irritability and his major mood swings interfere with his social and occupational functioning. Although the July 2008, August 2009, and July 2017 VA examiners all opined that the Veteran's PTSD symptoms cause occupational and social impairment with reduced reliability and productivity, and the April 2010 VA examiner opined that the Veteran's PTSD symptoms are transient or mild and decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, the Board finds that giving the Veteran the benefit of the doubt the evidence as a whole suggests that the Veteran experiences occupational and social impairment with deficiencies in most areas due to his PTSD. The Veteran's GAF scores over this period support that the Veteran has serious symptoms supportive of a 70 percent rating but not a 100 percent rating. A July 2008 VA treatment record lists a GAF of 52. October 2009, January 2010, January 2011, and April 2011 VA treatment records list a GAF of 48. VA treatment records further reflect these GAF scores: 47 in August 2011, 59 in March 2012, 52 in December 2012, 50 in April and July 2013, 55 in August and October 2013, 51 in January 2014, 50 in April 2014, 55 in December 2014 and June 2015, and 53 in January 2016. GAF scores ranging between 41 and 50 are assigned when there are serious symptoms or impairment. GAF scores ranging between 51 and 60 are assigned when there are moderate symptoms or difficulties. The Board notes that the August 2009 and April 2010 VA examiners assigned higher GAF scores than are shown the Veteran's treatment records (a GAF of 65 and 68 respectively). The Veteran has no GAF scores of 40 or less, which would represent some impairment in reality testing or communication or major impairment in several areas. The Board finds that a preponderance of the evidence is against finding that the Veteran has total occupational and social impairment. Despite his PTSD symptoms, the Veteran has several close family relationships and engages in solitary activities and hobbies. VA treatment records and VA examinations consistently note the Veteran to be alert and oriented. He is generally noted to have coherent, goal-directed speech and unremarkable thought process and content. He has never reported persistent delusions or hallucinations nor is there evidence of grossly inappropriate behavior. While he has reported concerns over his irritability with others, the evidence does not reflect he is a persistent danger to himself or others. He has reported some problems with concentration and short-term memory, but only mild in nature. VA treatment records and VA examinations consistently note the Veteran to be appropriately attired and groomed, although the Board acknowledges that at the Veteran's July 2016 Board hearing the Veteran's spouse testified that the Veteran sometimes goes four days or more without a shower before she tells him to go take one. Overall the Board finds that the Veteran's functioning is greater than that represented by a 100 percent rating and that the nature and severity of his symptoms are adequately represented by a 70 percent rating. Duties to Notify and Assist The appellant has not referred to any deficiencies in either the duties to notify or 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 [appellant] fails to raise them before the Board"); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Thus, the Board need not discuss any potential issues in this regard. ORDER Service connection for myelogenous leukemia is denied. A rating of 70 percent, but no greater, for PTSD is granted, subject to the laws and regulations controlling the disbursement of monetary benefits. REMAND VA regulations allow for the assignment of a total disability rating based on individual unemployability (TDIU) when a veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, and the veteran has certain combinations of ratings for service-connected disabilities. If there is only one such disability, that disability must be ratable at 60 percent or more. If there are two or more disabilities, there must be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). The Veteran, who is service-connected for PTSD, residuals of left femur fracture, bilateral hearing loss, tinnitus, left lower extremity peripheral neuropathy, scar on the left anterior superior iliac crest, and erectile dysfunction, meets the schedular criteria with respect to his combined disability rating. In a 2017 application for TDIU the Veteran reported he last worked full-time in 1991 and he became too disabled to work in January 2008 due to PTSD, peripheral neuropathy, and hip pain. He reported full-time employment from 1985 to 1986 as a mail carrier and from 1990 to 1991 as a lab tech. He also reported varying hours as a painter in 1994. At his 2016 Board hearing the Veteran stated he was retired from the postal service due to a back injury. He testified that he had a lot of conflict in his job as a lab tech, noting he was drinking a lot at the time. He stated that he can't put up with people and rather than have a confrontation he took himself out of the workforce and relied on his wife. A January 2010 VA treatment note by the Veteran's treating psychiatrist contains an opinion that the Veteran is "permanently and totally disabled and unemployable," but does not explain on what basis. The Veteran last underwent a VA bones and peripheral nerves examination in August 2007. The Board finds that an examination is needed to determine the functional effect of all of the Veteran's disabilities, both physical and metal, on the Veteran's ability to obtain or maintain substantially gainful employment. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a vocational evaluation to assist in determining the current functional effect of the service-connected disabilities on the Veteran's ability to obtain and maintain substantially gainful employment. The entire claims file should be made available to the examiner. The VA examiner should comment on the functional effect of each the Veteran's service-connected disabilities on his ability to work (disregarding the effects of any disabilities that are not service connected), indicating what functions or types of employment would be inconsistent with or would be precluded by the service-connected disabilities, and what types of employment, if any, would remain feasible despite the service-connected disabilities. The examiner is reminded the Veteran has been awarded service connection for PTSD, residuals of left femur fracture, bilateral hearing loss, tinnitus, left lower extremity peripheral neuropathy, scar on the left anterior superior iliac crest, and erectile dysfunction. The VA examiner should set forth a rationale underlying any conclusions drawn or opinions expressed. 2. Thereafter, readjudicate the Veteran's pending claim in light of any additional evidence added to the record. If the benefit sought on appeal remains denied, the Veteran and his representative should be furnished a supplemental statement of the case and given the opportunity to respond thereto. Thereafter, the case should be returned to the Board for appellate review. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (West 2012). ______________________________________________ H. SEESEL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs