Citation Nr: 1807661 Decision Date: 02/06/18 Archive Date: 02/14/18 DOCKET NO. 14-13 804 ) DATE ) ) On appeal from the Department of Veterans Affairs Medical and Regional Office Center in Wichita, Kansas THE ISSUES 1. Entitlement to service connection for a nose disability, claimed as nasal laceration and blockage. 2. Entitlement to service connection for a disability manifested by shortness of breath. 3. Entitlement to service connection for chronic sinusitis. 4. Entitlement to service connection for residuals of a head injury, claimed as concussion, dizziness, and fainting spells. 5. Entitlement to service connection for cervical spinal stenosis. 6. Entitlement to service connection for cervical radiculopathy of the right upper extremity, claimed as right arm numbness and tingling, to include on a secondary basis. 7. Entitlement to service connection for a right wrist disability. 8. Entitlement to service connection for a left wrist disability. 9. Entitlement to service connection for residuals of left finger fracture. 10. Entitlement to service connection for a disability of the fourth finger of the right hand. 11. Entitlement to service connection for a right and left hand disability, including degenerative joint disease. 12. Entitlement to service connection for a lumbar spine disability, claimed as right back pain. 13. Entitlement to service connection for right leg numbness, to include on a secondary basis. 14. Entitlement to service connection for left leg numbness, to include on a secondary basis. 15. Entitlement to service connection for depression, to include on a secondary basis. 16. Entitlement to a total disability rating based on individual unemployability due to service connected disability (TDIU). ATTORNEY FOR THE BOARD K. R. Fletcher INTRODUCTION The Veteran served on active duty from July 1979 to July 1982. This matter is before the Board of Veterans' Appeals (Board) on appeal from a May 2012 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Wichita, Kansas. This case was before the Board in January 2016 when it was remanded for additional development. The issues of entitlement to service connection for lumbar spine disability, right radiculopathy, left radiculopathy, depression, sinusitis, cervical spine disability, and cervical radiculopathy, and entitlement to TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action on his part is required. FINDINGS OF FACT 1. No right wrist disability, left wrist disability, right fourth finger disability, or disability manifested by shortness of breath was present during the appeal period. 2. Service treatment records (STRs) dated November 1981 reveal that the Veteran sustained a head injury, nasal laceration and left finger fracture when the car he was driving hit a pole at a very high rate of speed; the Veteran's blood alcohol content just after the accident was 0.21% mg. alcohol per 100 ml blood. 3. The weight of the competent evidence shows that the Veteran's in-service head injury, nasal laceration and left finger fracture were not incurred in the line of duty but were incurred as a direct result of an act of willful misconduct. 4. The most probative evidence of record demonstrates that a hand disability did not have onset during service, is not otherwise related to service, and arthritis was not diagnosed within one year of service separation. CONCLUSIONS OF LAW 1. A right wrist disability was not incurred in or aggravated by service. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 2. A left wrist disability was not incurred in or aggravated by service. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 3. A disability of the right fourth finger was not incurred in or aggravated by service. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 4. A disability manifested by shortness of breath was not incurred in or aggravated by service. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 5. A nose disability, claimed as nasal laceration and blockage, was not incurred in the line of duty. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.1, 3.102, 3.301, 3.303 (2017). 6. Residuals of a head injury were not incurred in the line of duty. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.1, 3.102, 3.301, 3.303 (2017). 7. Residuals of left finger fracture were not incurred in the line of duty. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.1, 3.102, 3.301, 3.303 (2017). 8. A right and left hand disability was not incurred in or aggravated by service, and may not be presumed to have been incurred in service. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist The requirements of the Veterans Claims Assistance Act have been met in this case. See 38 U.S.C. §§ 5103, 5103A. The required notice was provided to the Veteran via letter in March 2011. The Veteran has not identified any defect in this notice or claimed any prejudice as a result. VA has also fulfilled its duty to assist the Veteran in developing his claims. The Veteran's service treatment records (STRs) and post-service VA, Social Security Administration (SSA), and private medical records have been obtained and associated with the claims file. The Veteran has not identified any other outstanding evidence that could be obtained to substantiate the claims; the Board is also unaware of any such evidence. VA also assisted the Veteran by providing him with a VA hand examination in 2012 and obtaining an addendum opinion in 2016. Thus, the Board finds that VA has satisfied its duties to notify and assist the Veteran in apprising him as to the evidence needed, and in obtaining evidence pertinent to his claims. II. Service Connection Service connection may be established for a disease or injury incurred in or aggravated during service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303. To prevail on the issue of service connection, there must be (1) evidence of a current disability; (2) evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the present disability. Hickson v. West, 12 Vet. App. 247 (1999). Certain chronic diseases, such as organic diseases of the nervous system and arthritis, are subject to presumptive service connection if they manifest to a compensable degree within one year from separation from service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). For the showing of a chronic disease in service, there must be a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time of service. If chronicity in service is not established, evidence of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. § 3.303(b). However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a) and does not apply to other disabilities which might be considered chronic from a medical standpoint. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Regulations also provide that service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury which was incurred in or aggravated by service. 38 C.F.R. § 3.303(d). Service connection may be established on a secondary basis for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). In the absence of proof of a present disability, there can be no valid claim for service connection. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The requirement for service connection that a current disability be present is satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim even though the disability resolves prior to the adjudication of the claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); Romanowsky v. Shinseki, 26 Vet. App. 289 (2013) (noting that when the record contains a recent diagnosis of disability prior to a veteran filing a claim for benefits based on that disability, the report of diagnosis is relevant evidence that the Board must address in determining whether a current disability existed at the time the claim was filed or during its pendency). After considering all information including the lay and medical evidence of record in a case with respect to benefits under laws administered by the Secretary, when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt will be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The benefit of the doubt rule is inapplicable when the evidence preponderates against the claim. Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. A. Right Wrist, Left Wrist, Right Fourth Finger, Shortness of Breath The Veteran claims that he currently has disabilities of the right wrist, left wrist and right fourth finger related to his military service. See December 2010 and March 2013 statements from the Veteran and December 2011 VA Form 21-526. He has never submitted a claim seeking service connection for a disability manifested by shortness of breath; however, the RO developed this claim in conjunction with the other claims on appeal. See April 2014 Statement of the Case. The Veteran's STRs note that he was seen, including in March and April 1980, with complaints of right fourth finger problems for two month after catching his finger between two seats in January 1980. A right hand X-ray study was within normal limits. The injury was assessed as a sprain and treated with a splint as well as ice and heat treatments. A May 1982 (separation) Report of Medical History notes the Veteran's history of shortness of breath due to smoking. May 1982 (separation) Report of Medical Examination notes no right fourth finger disability was diagnosed. There was a normal clinical evaluation of the upper extremities. STRs are silent for complaints or findings related to a wrist disability. Following service, August 2010 VA X-ray studies revealed no deformities of the left wrist or right wrist. A January 2012 VA Hand and Finger Conditions Examination revealed the Veteran's general complaints of hand pain in cold weather, but no complaints specific to the wrists or right fourth finger. Examination of the right fourth finger showed full range of motion and was otherwise within normal limits. Post-service VA, private, and SSA medical records are silent for findings related to a right wrist disability, left wrist disability, right fourth finger disability, or a disability manifested by shortness of breath. As noted above, there is no support in the record of a right wrist disability, left wrist disability, right fourth finger disability, or disability manifested by shortness of breath. Regarding the orthopedic disabilities, the Board points out that complaints of pain alone, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a disability for which service connection may be granted. Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999). With respect to whether the Veteran's own statements and other lay statements can establish a current disability, 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 (noting that sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer), (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 (Fed. Cir. 2007). Here, the criteria under Jandreau have not been met. There is no medical diagnosis of record to rely on, either contemporaneously or at a later time. Indeed, while the Veteran and other lay persons are competent to report experiencing pain, they lack the requisite medical training, expertise, or credentials needed to render a diagnosis. Such a question is complex, and requires knowledge of the muscular, skeletal and other systems, as well as training in conducting and understanding tests that demonstrate the presence of a disability or injury. The Veteran does not have this training, education or skillset, so he is not competent to diagnose a wrist or finger disability. Moreover, despite his past history of experiencing injury and pain, physical examination has disclosed no disability to account for any current complaints of pain. He has made no allegations regarding shortness of breath. A current disability has not been established either through the clinical record or the lay evidence. In sum, the record does not show the Veteran has had diagnosed right wrist disability, left wrist disability, right fourth finger disability, or disability manifested by shortness of breath at any time during the period under review. See McClain, 21 Vet. App. at 321. Therefore, these claims must be denied. B. Nose Disability, Head Injury, Left Finger Fracture In order for a veteran to be entitled to disability compensation, the injury or disease from which the veteran's disability results must have been incurred in or aggravated by active military, naval, or air service "in line of duty." 38 U.S.C. §§ 101(16), 105(a), 310, 331; see also 38 C.F.R. §§ 3.1(k), 3.1(m), 3.301(a). The term "in line of duty" means "an injury or disease incurred or aggravated during a period of active military, naval, or air service unless such injury or disease was the result of the veteran's own willful misconduct." 38 C.F.R. § 3.1(m); see also 38 U.S.C. § 105(a); 38 C.F.R. § 3.301(a). In line of duty means an injury or disease incurred or aggravated during a period of active military, naval, or air service unless such injury or disease was the result of the veteran's own willful misconduct or, for claims filed after October 31, 1990, was a result of his or her abuse of alcohol or drugs. 38 C.F.R. § 3.1(m). The simple drinking of alcoholic beverage is not of itself willful misconduct. If, in the drinking of a beverage to enjoy its intoxicating effects, intoxication results proximately and immediately in disability or death, the disability or death will be considered the result of the person's willful misconduct. 38 C.F.R. § 3.301(c)(2). Alcohol abuse means the use of alcoholic beverages over time, or such excessive use at any one time, sufficient to cause disability to or death of the user. 38 C.F.R. § 3.301(d). When the service department has made a finding that the injury, disease, or death was incurred in line of duty, or a finding that the injury, disease, or death was not due to misconduct, the finding "will be binding on the Department of Veterans Affairs unless it is patently inconsistent with the requirements of laws administered by the Department of Veterans Affairs." 38 C.F.R. §§ 3.1(m) and 3.1(n). The VA Adjudication Procedure Manual, M21-1, provides further guidance with regard to willful misconduct determinations and alcohol consumption. A person is held responsible for disabling injuries or death that resulted directly and immediately from indulgence in alcohol on an individual occasion. Willful misconduct in cases involving alcohol consumption is the willingness to achieve a drunken state and, while in this condition, to undertake tasks for which the person is unqualified, physically and mentally, because of the resulting intoxication. Determinations of willful misconduct in such instances depend on the facts found. Exercise care to guard against findings of willful misconduct on the basis of inconclusive evidence. An adverse determination requires that there must be excessive indulgence as the proximate cause of the disability or death in question. See VA Adjudication Procedure Manual, M21-1, Part III, Subpart v, Chapter 1, Section D, Topic 2, Blocks a and b. In determining willful misconduct, the M21-1 also indicates that laboratory tests bearing on the issue of alcoholic intoxication together with all other facts and circumstances should be considered. A table was developed by the National Safety Council (NSC) in 1938. In 1960, Blood Alcohol Concentration (BAC) for "under the influence" was reduced from .15 to .10, and then reduced again to .08 in 2004. Under 23 U.S.C. § 163, BAC of .08 is a per se violation of driving while intoxicated. By July of 2005, all states, Washington D.C., and Puerto Rico had adapted BAC of .08 as the legal level intoxication. If an individual's BAC is .08 or more, a presumption is established that the person was under the influence of intoxicating liquor. See VA Adjudication Procedure Manual, M21-1, Part III, Subpart v, Chapter 1, Section D, Topic 2, Block c. 38 U.S.C. § 105(a) establishes a presumption in favor of a finding of line of duty. If it is determined that an exception to the line of duty does apply (such as willful misconduct), and the claim is denied solely on the basis of such exception, it must be established that the denial of the claim was justified by a preponderance of the evidence. Thomas v. Nicholson, 423 F.3d 1279, 1284-85 (Fed. Cir. 2005); Daniel v. Brown, 9 Vet. App. 348, 351 (1996); Smith v. Derwinski, 2 Vet. App. 241, 244 (1992). Additionally, the element of knowledge of or wanton or reckless disregard of the probable consequences must be specifically addressed. Myore v. Brown, 9 Vet. App. 498, 503-04 (1996). STRs show that the Veteran sustained injuries in a November 1981 motor vehicle accident where he was the driver. He was transported to a private hospital by ambulance and found to have a blood alcohol content of .21. He was treated for his injuries, including a head injury, severe nasal laceration, and a left finger fracture, and transferred to the Camp Pendleton Naval Regional Medical Center the next day. He received further evaluation and treatment and was discharged to duty one date later. A November 2011 Line of Duty determination by the VA RO made a formal finding that the injuries sustained by the Veteran in the November 1981 motor vehicle accident were not incurred in the line of duty but were the result of his willful misconduct. The RO noted that when the Veteran was brought into the emergency room, he had a blood alcohol content of 0.21%, over twice the legal limit. He was intoxicated when he made the decision to drive. The RO concluded that the Veteran's injuries were not incurred in the line of duty, but rather, the result of his wanton disregard for the probable consequences of driving at an excessive speed while intoxicated. Having reviewed the evidence the Board finds that service connection for a head injury, severe nasal laceration, and a left finger fracture, is not warranted. The evidence confirms that the Veteran did sustain injuries to his head, face and left finger from his November 1981 motor vehicle accident; however this accident is shown by the preponderance of the evidence to be the result of willful misconduct. Here, the motor vehicle accident resulting in the injuries was a result of the Veteran's abuse of alcohol. It was also the result of his willful misconduct in electing to operate a motor vehicle while legally intoxicated. As such, his claim for any injuries (including a head injury, nasal laceration and left finger fracture) based on this incident must be denied. There is also no allegation or any probative evidence suggesting an insanity defense. See 38 C.F.R. § 3.354(a). As such, the Veteran's alcohol abuse followed by his choice to drive while intoxicated amounted to willful misconduct. Therefore, the resulting injuries, including head injury, nasal laceration and left finger fracture, sustained in the motor vehicle accident were not incurred in the line of duty. C. Right and Left Hands As an initial point of clarification, the Board notes that the Veteran is seeking service connection for a residuals of a hand injury. See December 2011 VA Form 21-526. As noted above, he also seeks service connection for a right fourth finger disability and residuals of a left finger fracture; these issues are considered separately. STRs, including a May 1982 separation examination report, are silent for any diagnosis related to the hands (other than the two fingers considered separately in this decision). Following service, the Veteran was afforded a VA hand and fingers examination in January 2012. X-ray studies note findings of osteoarthritis of both hands. The diagnosis included degenerative joint disease of the bilateral hands. The VA examiner opined that the right hand degenerative joint disease was not at least as likely related to the right hand strain [sic] diagnosed in service. The examiner also opined that the right and left hand arthritis was not related to a November 1981 motor vehicle accident because the injuries resulting from that accident were due to the Veteran's misconduct as a result of his blood alcohol level over twice the legal limit. In an April 2016 VA examination addendum, the examiner again opined that the Veteran's hand arthritis was not related to his military service. In this regard, the examiner noted that the Veteran sustained a mild sprain to the right fourth finger in service, and that current X-ray studies showed mild degenerative joint disease of the right first finger and thumb. The examiner explained that the sprain sustained in service did not contribute to the Veteran's current arthritis because a sprain was a soft tissue injury not involving the bone. Having reviewed the evidence of record, the Board finds that the preponderance of the evidence is against the claims for service connection for a right and left hand disability, and the appeal must be denied. Although there is a current disability as arthritis of the right and left hands was diagnosed on VA X-ray in 2012, the Board finds that a chronic disability of the hands was not established during service. Additionally, no clinical evidence shows that arthritis was manifest within one year of service separation. See 38 C.F.R. §§ 3.307, 3.309(a). There are no available medical records until several decades after service. Accordingly, service connection on these bases is not warranted. Regarding whether the Veteran's right hand and left hand disability are otherwise related to service, the Board finds that the most probative evidence of record supports a finding that the current hand disability, diagnosed as degenerative joint disease, is not related to service. See 38 C.F.R. § 3.303. The service separation examination noted no hand disabilities and normal clinical evaluation of the upper extremities. Finally, the 2012 and 2016 VA examiners provided opinions that the current hand disability was unrelated to active service. The examiners examined the Veteran, reviewed the claims file, and provided supporting explanations with reference to the evidence in the file. The Board accords these opinions, taken together, significant probative value. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (noting that the central issue in determining the probative value of an opinion is whether the examiner was informed of the relevant facts in rendering a medical opinion). There is no medical evidence to the contrary. Although the Veteran has reported that his hand disability is related to active service, the Board finds him not competent to make such a nexus opinion (as opposed to his competency to report continuous symptoms). A nexus between an internal disease such as arthritis and any incident during service is not capable of lay observation, and requires medical training, expertise, or credentials. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012). Even if the Veteran were competent to make such a nexus opinion, it is outweighed by the VA medical examiner's opinion, which was based not only upon review of the claims file and medical expertise, but also on an examination of the Veteran. As the preponderance of the evidence is against the claim, that doctrine is not applicable. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). As such, the claim is denied. ORDER Service connection for a right wrist disability is denied. Service connection for a left wrist disability is denied. Service connection for a disability of the fourth finger of the right hand is denied. Service connection for a disability manifested by shortness of breath is denied. Service connection for a nose disability, claimed as nasal laceration and blockage, is denied. Service connection for residuals of a head injury, claimed as concussion, dizziness, and fainting spells, is denied. Service connection for residuals of left finger fracture is denied. Service connection for a right and left hand disability, including degenerative joint disease, is denied. REMAND Sinusitis, Depression, Lumbar Spine Disability and Cervical Spine Disability VA has a duty to assist claimants to obtain evidence needed to substantiate a claim. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. VA's duty to assist includes providing a medical examination when is necessary to make a decision on a claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). Such development is necessary if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim, but (1) contains competent evidence of diagnosed disability or symptoms of disability, (2) establishes that the veteran suffered an event, injury or disease in service, or has a presumptive disease during the pertinent presumptive period, and (3) indicates that the claimed disability may be associated with the in-service event, injury, or disease, or with another service-connected disability. 38 C.F.R. § 3.159 (c)(4); McLendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006) (noting that the third element establishes a low threshold and requires only that the evidence "indicates" that there "may" be a nexus between the current disability or symptoms and active service, including equivocal or non-specific medical evidence or credible lay evidence of continuity of symptomatology). Here, the RO did not provide the Veteran with an examination for his claims of service connection for sinusitis, depression, a lumbar spine disability, and a cervical spine disability. There is, however, post-service evidence of chronic sinusitis, complaints of headaches and nasal congestion in the STRs, and the Veteran's statements that the two are related. There is also post-service evidence of current depression, low back disability and neck disability, and the Veteran's statements that his depression, low back disability and neck disability began in service and have persisted since that time. Accordingly, VA examinations are required. Right and Left Leg Numbness, Cervical Radiculopathy and TDIU As the service connection issues being remanded are inextricably intertwined with the issues of entitlement to service connection for right leg numbness, left leg numbness and cervical radiculopathy (to include on a secondary basis) and entitlement to TDIU, they must be adjudicated prior to further consideration of the TDIU issue. See Harris v. Derwinski, 1 Vet. App. 180 (1991). Accordingly, the case is REMANDED for the following actions: 1. Contact the appropriate VA Medical Center and obtain and associate with the claims file all outstanding records of pertinent treatment. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. The non-existence or unavailability of such records must be verified and this should be documented for the record. Required notice must be provided to the Veteran and his representative. 2. Contact the Veteran and afford him the opportunity to identify by name, address and dates of treatment or examination any relevant medical records. Subsequently, and after securing the proper authorizations where necessary, make arrangements to obtain all the records of treatment or examination from all the sources listed by the Veteran which are not already on file. All information obtained must be made part of the file. All attempts to secure this evidence must be documented in the claims file, and if, after making reasonable efforts to obtain named records, they are not able to be secured, provide the required notice and opportunity to respond to the Veteran and his representative. 3. After any additional records are associated with the claims file, afford the Veteran an appropriate VA examination to determine the etiology of his current depression. The entire claims file must be made available to and be reviewed by the examiner. All necessary tests should be completed. An explanation for all opinions expressed must be provided. The examiner must provide the following opinions: a. Is it at least as likely as not (50 percent or greater probability) that the Veteran's depression had its onset in, or is otherwise caused by, active service, to include his motor vehicle accident in November 1981? The examiner must address the Veteran's statements that his depression has persisted since service. b. Is it at least as likely as not (50 percent or greater) that any identified disability was caused or aggravated by any service-connected disability? The examiner must explain the rationale for any opinion given. If the examiner is unable to provide an opinion without resorting to speculation, he/she should so state and provide an explanation as to the reason(s) therefor 4. After any additional records are associated with the claims file, afford the Veteran an appropriate VA examination to determine the etiology of his current sinusitis. The entire claims file must be made available to and be reviewed by the examiner. All necessary tests should be completed. An explanation for all opinions expressed must be provided. The examiner must provide the following opinion: Is it at least as likely as not (50 percent or greater probability) that the Veteran's sinusitis had its onset in, or is otherwise caused by, active service? The examiner must address the Veteran's statements that his sinusitis had its onset in and has persisted since service. The examiner must explain the rationale for any opinion given. If the examiner is unable to provide an opinion without resorting to speculation, he/she should so state and provide an explanation as to the reason(s) therefor 5. After any additional records are associated with the claims file, afford the Veteran an appropriate VA examination to determine the etiology of his current lumbar spine and cervical spine disabilities. The entire claims file must be made available to and be reviewed by the examiner. All necessary tests should be completed. An explanation for all opinions expressed must be provided. The examiner must provide the following opinions: a. Is it at least as likely as not (50 percent or greater probability) that the Veteran's lumbar spine disability had its onset in, or is otherwise caused by, active service, to include his motor vehicle accident in November 1981? The examiner must address the Veteran's statements that his lumbar spine disability was incurred in and has persisted since service. b. Is it at least as likely as not (50 percent or greater probability) that the Veteran's cervical spine disability had its onset in, or is otherwise caused by, active service, to include his motor vehicle accident in November 1981? The examiner must address the Veteran's statements that his cervical spine disability was incurred in and has persisted since service. The examiner must explain the rationale for any opinion given. If the examiner is unable to provide an opinion without resorting to speculation, he/she should so state and provide an explanation as to the reason(s) therefor 6. Review the examination reports to ensure that they are in complete compliance with the directives of this remand. If a report is deficient in any manner, the AOJ must implement corrective procedures. Stegall v. West, 11 Vet. App. 268, 271 (1998). 6. After completing the above action, and any other development as may be indicated by any response received as a consequence of the actions taken in the paragraphs above, the claims must be readjudicated. If any claim remains denied, a supplemental statement of the case must be provided to the Veteran and his representative. They must be provided an adequate opportunity to respond. Thereafter, the case should be returned to the Board. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board 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). ____________________________________________ A. ISHIZAWAR Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs