Citation Nr: 1805030 Decision Date: 01/25/18 Archive Date: 02/05/18 DOCKET NO. 11-09 408 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for a lumbar spine disability. 2. Entitlement to service connection for hypertension (HTN) to include as secondary to service-connected posttraumatic stress disorder (PTSD). 3. Entitlement to service connection for sleep apnea. 4. Entitlement to service connection for a left ear hearing loss disability. 5. Entitlement to service connection for erectile dysfunction to include as secondary to service-connected PTSD. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and his spouse ATTORNEY FOR THE BOARD N. Rippel, Counsel INTRODUCTION The Veteran served on active duty from October 2004 to December 2005 and active duty for training (ACDUTRA) service from January 1997 to April 1997 and February 2002 to August 2002. These matters come to the Board of Veterans' Appeals (Board) on appeal from an August 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. The Veteran provided testimony at a May 2016 videoconference hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. In November 2016, the Board issued a decision remanding these matters, along with claims of entitlement to service connection for PTSD and a total disability rating based on individual unemployability due to service connected disability (TDIU), to the Agency of Original Jurisdiction (AOJ). In August 2017, the RO granted service connection for PTSD and also granted TDIU, and as such those claims are no longer before the Board. For issues, 1, 3-5, as the requested medical examinations and opinions were obtained, the Board finds the directives have been substantially complied with, and the matters again are before the Board. Stegall v. West, 11 Vet. App. 268, 271 (1998). The issue of service connection for hypertension to include as secondary to service-connected PTSD is addressed in the REMAND portion of the decision below and is REMANDED to the AOJ. FINDINGS OF FACT 1. A chronic lumbar spine disability was not manifested in service; neither arthritis nor degenerative disc disease (DDD) of the lumbar spine was manifested in the first post service year; and a back disorder is not attributable to service. 2. Erectile dysfunction is related to the Veteran's service-connected PTSD. 3. A left ear hearing loss disability has not been shown to have had its onset in service or within one year of service, nor is such disability shown to have been caused or aggravated by disease or injury in active military service. 4. Sleep apnea was not manifest in service and is not attributable to service. CONCLUSIONS OF LAW 1. Lumbar spine disability was not incurred in or aggravated during service, and neither arthritis nor DDD may be presumed to have been incurred therein. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2017). 2. Erectile dysfunction is proximately due to or the result of his service-connected PTSD. 38 C.F.R. §§ 3.303, 3.310 (2017). 3. A left ear hearing loss disability was not incurred in or aggravated during service, and an organic disease of the nervous system, left ear sensorineural hearing loss may not be presumed to have been incurred therein. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2017). 4. Sleep apnea was not incurred in or aggravated by service. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist Upon receipt of a complete or substantially complete application, VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5103 (a), 5103A (2012); 38 C.F.R. § 3.159 (2017). Issue 5 is being granted and thus no duty to notify or assist analysis is needed. Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist as to claims 1 through 3, and the appeals may be considered on the merits. As to claim 4, a May 2010 letter satisfied the duty to notify. The duty to assist includes assisting the claimant in the procurement of relevant records. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159 (c). The RO associated the Veteran's VA treatment records, service treatment records, identified private records and SSA records with the claims file. No other relevant records have been identified and are outstanding. The Board finds VA has satisfied its duty to assist with the procurement of relevant records. The duty to assist also includes providing a medical examination or obtaining a medical opinion when necessary to make a decision on a claim, as defined by law. See 38 C.F.R. § 3.159 (c)(4). The representative argues in November 2017 that the June 2017 VA audiological examination is inadequate and an independent medical opinion (IMO) should be obtained. 38 C.F.R. §§ 3.328 and 20.901(d) provide for an IMO when the issue under consideration poses a medical problem of such obscurity or complexity, or has generated such controversy in the medical community at large, as to justify solicitation of an independent medical opinion. The Board denies this request. Specifically, while the representative argues the examiner was unable to confirm the testing was reliable, the examiner actually found that the Veteran's behavioral responses to testing were considered unreliable, not reflective of current hearing status, and not appropriate for use in disability determination. She noted his responses did not improve with reinstruction and retesting. Considering that the Veteran's responses and behavior were unreliable, the Board cannot identify any an obscure, complex, or controversial medical questions as contemplated by 38 C.F.R. §§ 3.328 and 20.901(d), or any reason to order further medical inquiry. The VA record is replete with reference to the fact that there are no noted barriers to learning or treatment for this Veteran. Additional remand for this reason is not necessary. Since VA has obtained all relevant identified records and provided adequate medical examination where necessary, the duty to assist in this case is satisfied. II. Service Connection A. Law Generally, to establish service connection a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service." Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). For veterans who served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including arthritis and 'other organic diseases of the nervous system' such as a sensorineural hearing loss and DDD, are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 38 C.F.R. §§ 3.307 (a), 3.309(a). 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. If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. § 3.303 (b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (the theory of continuity of symptomatology can be used only in cases involving those disabilities specified as chronic under 38 C.F.R. § 3.309 (a)). Service connection may also be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). Service connection is also warranted for a disability which is proximately due to, aggravated by or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (a). Such secondary service connection is warranted for any increase in severity of a nonservice-connected disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310 (b). VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154(a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Lay evidence cannot be determined to be not credible merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). However, the lack of contemporaneous medical evidence can be considered and weighed against a Veteran's lay statements. Id. Further, a negative inference may be drawn from the absence of complaints or treatment for an extended period. Maxson v. West, 12 Vet. App. 453, 459 (1999), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). With respect to periods of ACDUTRA service, there must be some evidence that the appellant became disabled as a result of a disease or injury incurred or aggravated in the line of duty during the period of ACDUTRA. Smith, 24 Vet. App. at 47. In the absence of such evidence, the period of ACDUTRA would not qualify as "active military, naval, or air service," and the appellant would not qualify as a "veteran" by virtue of ACDUTRA service alone. Id. With respect to a claim for aggravation of a preexisting condition during ACDUTRA, the claimant must provide direct evidence both that a worsening of the condition occurred during the period of ACDUTRA and that the worsening was caused by the period of ACDUTRA. Smith, 24 Vet. App. at 48. The presumption of soundness under 38 U.S.C. § 1111 does not apply when a claimant, veteran or otherwise, has not been examined contemporaneous to entering a period of ACDUTRA. Smith, 24 Vet. App. at 45. The presumption pertaining to chronic diseases under 38 U.S.C. § 1112 and the presumption of aggravation under 38 U.S.C. § 1153 also do not apply to ACDUTRA or INACDUTRA service. Id. See also Acciola v. Peake, 22 Vet. App. 320 (2008); Mercado-Martinez v. West, 11 Vet. App. 415, 419 (1998); Paulson v. Brown, 7 Vet. App. 466, 470 (1995). Only service department records can establish if and when a person was serving on active duty, ACDUTRA, or INACDUTRA. Cahall v. Brown, 7 Vet. App. 232, 237 (1994). Service department records are binding on VA for purposes of establishing service in the U.S. Armed Forces. Duro v. Derwinski, 2 Vet. App. 530, 532 (1992); see also 38 C.F.R. § 3.203, limiting the type of evidence accepted to verify service dates. A service department finding that an injury occurred in the line of duty will be binding on the VA unless it is patently inconsistent with the requirements of laws administered by the VA. 38 C.F.R. § 3.1 (m); see Kinnaman v. Principi, 4 Vet. App. 20, 28 (1993). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. VA shall consider all information and lay and medical evidence of record in a case and when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show. The Veteran should not assume that the Board has overlooked pieces of evidence that are not specifically discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000). The law requires only that the Board provide reasons for rejecting evidence favorable to the Veteran. B. Lumbar Spine Disability It is uncontroverted that the Veteran has current lumbar spine disability and that he believes it is due to his service in Iraq where he worked as a supply person and had to carry 30 and 45 pound sacks. The DD-214's of record confirm that his MOS was unit supply specialist. The critical question is whether the current disability is due to service as asserted. A review of the claim file shows that in October 1993, the Veteran was involved in a motor vehicle accident at which time he was diagnosed with back strain. He was not on active duty at the time. An October 1996 pre-service screening shows that a prior back strain was noted. In November 2005, he complained of intermittent backache without injury. Imaging studies showed normal vertebral alignment, bodies and space intact, no fractures or dislocations, no compression deformity, no spondylosis and no spondylolisthesis. Sacro-iliac joints were normal and the diagnosis was backache. A March 2006 post-deployment assessment form notes that the Veteran complained of back problems. In an April 2006 extensive VA examination, the Veteran complained of back problems dating to 2001 which worsened during his duty in Iraq because he had to carry heavy gear. He described treatment with Goody powder and no radiation to legs, numbness or other neurological symptoms. A March 2007 VA X-ray of the low back noted chronic mechanical low back pain with no radiculopathy. The findings included no evidence of acute injury or destructive process, disc spaces were well preserved with normal alignment, pedicles intact, SI joints and soft tissue unremarkable. An August 2007 primary care note indicates the Veteran now had radiation into the right leg with his back pain, with an onset of four days prior. MRI in May 2008 reflected degenerative changes at L4-5 without acute abnormality. At the hearing before the undersigned, he testified he has had back problems since service. Consistent with the 2016 remand directives, the Veteran was afforded a VA examination to determine the etiology of any current lumbar spine disability. The examiner reviewed the claims folder. In a June 2017 Disability Benefits Questionnaire, the examiner opined that the Veteran's present low back disability, lumbar degenerative arthritis of the spine and intervertebral disc syndrome "DDD", was not related to service because it first manifested following service, in May 2008. The examiner noted that this initial diagnosis was based on the May 2008 MRI. He cited to the November 2005 treatment note showing normal findings including X-ray, as well as normal X-ray in March 2007 as evidence that the current lumbar spine disability was not present at least prior to March 2007. The examiner also cited review the April 2006 VA examination of the Veteran during which he complained of low back pain dating to 2001 worsened by wearing heavy gear in Iraq. However, it was the examiner's ultimate conclusion that the current lumbar spine disability began following service and was thus not related to service or any incident in service. Here, the Board accepts the opinion of the VA examiner that the lumbar spine disability did not pre-exist active service. The opinion is based on the evidence of record, and is explained; the Board finds it to be of significant probative value in this matter. See Bloom v. West, 12 Vet. App. 185, 187 (1999) (the value of a physician's statement is dependent, in part, upon the extent to which it reflects clinical data or other rationale to support the opinion). The Veteran's lumbar spine disorder was not incurred in service and did not develop within one year of the December 2005 separation from active service and is not otherwise related to service. Indeed, the earliest post-service complaints of radiating back pain is in August 2007, over a year after separation. Also, the medical opinion evidence is wholly against the claim. While there are ongoing complaints of low back pain throughout the record, the examiner in 2017 clarifies that the current lumbar spine disability is distinct, not due to service and not actually documented until May 2008. In essence, the denials of radiating pain prior to August 2007 support the conclusion that the current lumbar spine disability was not present prior to that time. The Board has considered and weighed the lay assertions and in fact ordered examination based in part on these assertions. However, on the issue of whether there was evidence of chronic disease, arthritis or DDD, in service or within the initial post service year, or whether the current lumbar spine disability is otherwise related to service, the medical opinion evidence is more probative because it is rendered by a neutral medical professional who considered the reported history. And this evidence preponderates against the notion that a lumbar spine disability was incurred in service, or developed within one year of separation from service or is otherwise related to service to include wearing heavy gear in Iraq. Indeed, the medical evidence demonstrates an absence of the current back disability for over a year following service and medical opinion evidence is wholly against the claim. As this evidence is more credible than the lay assertions, it is of more probative value. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). It is also clear that the complaints in service, and in fact prior to August 2017, are not representative of a lumbar spine disability. The Veteran's lay theory is of significantly less probative weight when compared with the objective record, and the findings by the neutral 2017 VA examiner. The medical evidence and the lack of competent support for the Veteran's theory, preponderate against the claim. See Gilbert, supra. While the service records certainly support the theory that he wore heavy gear, neither arthritis nor DDD was "noted" during service and he did not have characteristic manifestations sufficient to identify the disease entity. 38 C.F.R. § 3.303 (b). In fact, radiating back symptoms were actually denied prior to August 2007. To the extent that there is an argument of continuity, these findings along with the 2017 VA opinion establish that he did not have a medically chronic or regulatory chronic lumbar spine disability and did not have continuity of symptoms of any of the post service pathology. As the preponderance of the evidence is against the claim of service connection for a low back disorder, the benefit-of-the-doubt doctrine does not apply, and the claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. C. Left Ear Hearing Loss Disability The determination of whether a veteran has a disability based on hearing loss is governed by 38 C.F.R. § 3.385. For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz (Hz) is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. See 38 C.F.R. § 3.385. There is no dispute that the Veteran was exposed to excessive noise during service. The Veteran testified in 2016 that his hearing in his left ear had deteriorated and he now needed hearing aids. His most recent VA audiological examination was in October 2010 at which time no hearing loss disability of the left ear per VA regulation was noted. Audiograms of record dated in October 2007 and August 2008 also fail to show hearing loss disability by VA standards. Given his testimony and the remoteness of the most recent VA examination, the Board ordered a new VA examination to determine if he now has a left ear hearing loss disability. The report of June 2017 VA audiological evaluation reflects that the examiner reviewed the claims file and noted the following: Veteran's behavioral responses to testing today were considered unreliable, not reflective of current hearing status, and not appropriate for use in disability determination. There was poor test-retest reliability with veteran's behavioral responses to testing and poor correlation between behavioral responses and other results from non-behavioral testing. The veteran's behavioral responses to testing did not improve with reinstruction and retesting, and are not considered reliable measures of the current hearing status. Speech reception thresholds were obtained at 10dB for both ears. The right ear pure tone average was 45dB and the left ear pure tone average was 90dB. The large differences in these results suggest poor pure tone test reliability. An OAE screen was passed in both ears at 1000, 1500, 2000, 3000, 4000 and 6000Hz. The pure tone thresholds obtained did not correspond with the passing OAE results suggesting poor pure tone test reliability. This report could not be entered in a DBQ Audio Hearing Loss and Tinnitus template due to the restrictions of that template. A February 2017 VA treatment note reflects that the Veteran denied decreased hearing in the right or left ear. He denied problems with hearing in treatment records dated in 2016, but hearing loss was listed as one of his multiple medical problems in a January 2016 primary care note. Sensorineural hearing loss was listed as a problem in an October 2010 treatment note. However, there is no audiogram of record demonstrating that he has hearing loss disability as defined at 38 C.F.R. § 3.385. The preponderance of the evidence is against this claim. The Veteran has been found to have unreliable and inconsistent test results on the most recent VA examination, and no other medical records demonstrate that the Veteran has a current hearing loss disability. Although the Veteran has testified that he has a current left ear hearing loss disability, he lacks the requisite expertise to say that the hearing loss is the specific thresholds required for a showing of current disability for VA purposes. The question of whether the Veteran has a hearing loss disability related to service is a medical question that is not subject to lay observation alone. Hence, the opinions of the Veteran in this regard are not competent in this case. Additionally, even though hearing loss is considered a chronic disease; the Veteran's reports of left ear hearing loss since service are less probative than the test results that show no hearing loss as defined by VA. This is especially true, because the showing of a current disability would require specific test results. The most probative evidence is provided by the multiple VA medical examinations. The most probative evidence is against finding a current left ear hearing loss disability. The preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine does not apply, and the claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. D. OSA The Veteran has current sleep apnea. He reports that his sleep problems started while in Iraq. At the hearing, he testified that his shipmates would make fun of him for noises he made while sleeping. The March 2006 post deployment assessment notes that the Veteran reported having sleeping problems. VA outpatient treatment records show the Veteran has been issued a CPAP machine. Accordingly, this matter was remanded in 2016 for VA examination to determine the etiology of any current sleep disability. VA examination for sleep apnea was performed in April 2017 by an examiner who reviewed the claims folder. It was noted that obstructive sleep apnea was diagnosed in May 2007. The Veteran reported that he had trouble sleeping in Iraq. He was also scared due to RPG attack. His wife stated he snores loudly and stops breathing and chokes and wakes up several times. He feels tired during day time. He was given CPAP machine in 2007. The examiner found that the OSA was not related to service and explained as follows: STR are silent for specific symptoms or documentation of either sleep apnea or RLS conditions. Post deployment questionnaire dated 3-26-2006 Veteran reported "problems sleeping/feeling tired after sleeping," which are non-specific symptoms that could be due to a number of medical problems including his currently diagnosed PTSD. Due to the lack of objective medical evidence, the conditions of Obstructive Sleep Apnea and Period Limb Movement Syndrome/Restless Leg Disorder were less likely than not incurred in or aggravated by service or any incident in service. Records did not report condition of Obstructive Sleep Apnea until 2007. The preponderance of the evidence indicates that sleep apnea was not incurred during or aggravated by service and is not otherwise related to service. Indeed, as explained by the VA examiner, while non-specific sleep problems have been reported prior to diagnosis of sleep apnea, obstructive sleep apnea was not reported in the record until 2007, following active service. The Board accepts the examiner's opinion that the non-specific sleep symptoms noted in March 2006 could be due to a number of medical problems including his PTSD. The VA medical opinion evidence, which considered the Veteran's contentions and the service and post-service record, is wholly against the claim. As the VA opinion is based on the evidence of record, and is explained, the Board finds the report and opinion of probative value in this matter. The Board finds it highly significant that the VA examiner did not consider the reported non-specific sleep problems to be indicative of sleep apnea prior to May 2007. This well-supported opinion by a neutral examiner is highly probative of the lack of relationship between sleep apnea and service. Indeed, the medical evidence demonstrates (1) an absence of documented disability until over a year following service as well as medical opinion evidence that preponderates against the claim. The Veteran's lay theory is of significantly less probative weight when compared with the objective record, and the findings by the neutral VA examiner. In weighing the evidence, the Board finds that the medical evidence of record, and the lack of competent support for the Veteran's theory, preponderates against the claim. See Gilbert, supra. As the preponderance of the evidence is against the claim of service connection for sleep apnea, the benefit-of-the-doubt doctrine does not apply, and the claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. E. Erectile dysfunction The Veteran contends his erectile dysfunction is caused by now service-connected PTSD. His representative argued in a November 2017 presentation that the Veteran's erectile dysfunction is caused by medications used to treat his PTSD. At the May 2016 hearing before the undersigned, the Veteran argued that he had been told by health care providers that his erectile dysfunction was related to medication for hypertension and as-yet-nonservice-connected PTSD. See hearing transcript, pp.28-29. Since then, service connection has been established for PTSD. Review of the VA treatment records reveals a primary care note with the impression of erectile dysfunction not helped by taking testosterone, and referral to a urologist. A May 2016 Urology Consultation note indicates the Veteran was referred for erectile dysfunction evaluation because Viagra was of no help. It was noted that he was on many PTSD medications. The genitourinary findings were normal. The clinical impression was erectile dysfunction secondary to medication for PTSD. He was referred to see a psychiatrist. His medication list from this period forward reflects medication for erectile dysfunction. This matter was deferred in the Board remand because of the potential impact of the PTSD claim. Under the circumstances, the Board now concludes that the current erectile dysfunction is proximately due to service-connected PTSD. Accordingly, service connection is warranted for erectile dysfunction secondary to PTSD. ORDER Service connection for a lumbar spine disability is denied. Service connection for a left ear hearing loss disability is denied. Service connection for sleep apnea is denied. Service connection for erectile dysfunction secondary to PTSD is granted. REMAND In regards to HTN, the Veteran has argued not only that it pre-existed service and was aggravated by service, but also that it is proximately due to PTSD. See July 2007 Veteran's statement. Now that service connection has recently been awarded for PTSD, an addendum opinion should be obtained addressing this theory advanced by the Veteran. Accordingly, the case is REMANDED for the following action: 1. Obtain an addendum medical opinion by an appropriate examiner to provide a medical opinion addressing the Veteran's hypertension. Upon review of the Veteran's claims file, and after performing any necessary testing, the examiner should provide response to the following question: Is it at least as likely as not that any hypertension was caused or aggravated beyond its natural progression by his service-connected PTSD or medication for the same? If aggravation is found, the examiner should also identify the baseline level of severity of the nonservice-connected disability to the extent possible. Clear rationale for all opinions must be provided, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. The examiner's attention is invited to the Veteran's testimony and July 2007 statement presented in support of his claim. The Veteran is considered credible to the extent that his statements are not directly contradicted by any established fact. 2. After the completion of any action deemed appropriate in addition to that requested above, the Veteran's claim should be readjudicated. If any benefit sought remains denied, the Veteran should be provided a SSOC and given the opportunity to respond. 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 (2012). ____________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs