Citation Nr: 1807720 Decision Date: 02/06/18 Archive Date: 02/14/18 DOCKET NO. 12-11 239A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to an initial compensable evaluation for a left ankle disability prior to October 17, 2011. 2. Entitlement to an evaluation in excess of 10 percent for a left ankle disability since October 17, 2011. 2. Entitlement to an initial evaluation in excess of 10 percent for sinusitis. 3. Entitlement to an initial evaluation in excess of 30 percent for a mood disorder, not otherwise specified. 4. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). ATTORNEY FOR THE BOARD H. Fisher, Associate Counsel INTRODUCTION The Veteran had honorable active duty service with the United States Army from November 1973 to November 1993. These matters are before the Board of Veterans' Appeals (Board) on appeal from August 2011 and March 2014 rating decisions from the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. The Veteran timely perfected his Substantive Appeals to the Board. The August 2011 rating decision granted service connection for sinusitis (rated at 10 percent disabling) and left ankle instability with Achilles calcaneal tendonitis (rated at 0 percent disabling), both effective as of June 16, 2008. The Veteran's left ankle disability evaluation was increased to 10 percent, effective as of October 17, 2011, in a March 2012 rating decision. The effective date of the original grant of service connection (rated at 0 percent disabling) was changed to July 2, 2007, in an October 2013 rating decision based on clear and unmistakable error (CUE). The effective date of the subsequently assigned 10 percent evaluation was not changed at this time. The Veteran was also granted service connection for a mood disorder (claimed as a psychological disorder and posttraumatic stress disorder (PTSD)) in a March 2014 rating decision. A 30 percent evaluation was assigned, effective as of July 2, 2007. The claim of entitlement to TDIU benefits was denied at this time. In October 2016, the Board remanded these issues on appeal for additional evidentiary development, to include new examinations. It is further noted that the Veteran was previously represented by a Veterans Service Organization, but indicated his wish to revoke the representation in an August 2017 signed statement. The Veteran may revoke representation at any time. See 38 C.F.R. § 14.631(f)(1) (2017). The Veteran stated that he wished to represent himself in his ongoing appeal. Therefore, the Board finds that the Veteran is currently representing himself, and shall proceed accordingly. The issues of entitlement to an increased initial evaluation for a mood disorder, not otherwise specified, a left ankle disability since October 17, 2011, and entitlement to TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. Resolving doubt in favor of the Veteran, evidence of record reflects that, prior to October 17, 2011, the Veteran's left ankle demonstrated moderate limits in range of motion with subjective reports of pain, stiffness and swelling. 2. Throughout the period on appeal, the Veteran's sinusitis has presented with fewer than six non-incapacitating episodes of sinusitis per year characterized by headaches, pain, and purulent discharge or crusting. CONCLUSIONS OF LAW 1. Resolving doubt in favor of the Veteran, prior to October 17, 2011, the criteria for a 10 percent evaluation, but no higher, for a left ankle disability have been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.40, 4.4, 4.71a, Diagnostic Codes 5024, 5271 (2017). 2. Throughout the period on appeal, the criteria for an initial evaluation in excess of 10 percent for sinusitis have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. § 4.97, Diagnostic Code 6513 (2017). (CONTINUED ON NEXT PAGE) REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist VA has completed the necessary steps in order to meet its duties to notify and assist in this case. The Veteran has not raised any procedural arguments regarding the notice or assistance provided. Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). The Board also finds that the October 2016 remand directives have been substantially complied with. Stegall v. West, 11 Vet. App. 268 (1998). II. Increased Evaluations Disability ratings are determined by application of a ratings schedule which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27 (2017). The degrees of disability specified are considered adequate to compensate for a loss of working time proportionate to the severity of the disability. 38 C.F.R. § 4.1. If two evaluations are potentially applicable, the higher evaluation 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. Any reasonable doubt regarding a degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2017). However, pyramiding, that is the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when evaluating a Veteran's service-connected disability. 38 C.F.R. § 4.14; see Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). In a claim for a greater original rating after an initial award of service connection, all of the evidence submitted in support of the Veteran's claim is to be considered. In initial rating cases, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); 38 C.F.R. § 4.2. VA's determination of the "present level" of a disability may result in a conclusion that the disability has undergone varying and distinct levels of severity throughout the entire time period the increased rating claim has been pending and, consequently, staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Disabilities must be reviewed in relation to their entire history. 38 C.F.R. § 4.1. VA must also interpret reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability. 38 C.F.R. § 4.2. VA is also required to evaluate functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person's ordinary activity. 38 C.F.R. § 4.10. Where functional loss is alleged due to pain upon motion, the provisions of 38 C.F.R. § 4.40 and § 4.45 must be considered. DeLuca v. Brown, 8 Vet. App. 202, 207-08 (1995). Functional loss may be due to pain if supported by adequate pathology and evidenced by the visible behavior of the veteran undertaking the motion. Functional impairment may be due to pain, including during flare-ups, or from repetitive use. Mitchell v. Shinseki, 25 Vet. App. 32, 43-44 (2011). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the veteran. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Board determinations with respect to the weight and credibility of evidence are factual determinations going to the probative value of the evidence. Layno v. Brown, 6 Vet. App. 465, 469 (1994). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno, 6 Vet. App. at 465. Lay statements may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 C.F.R. § 3.159; see Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, 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 claim on appeal. Left Ankle Disability The Veteran contends that he is entitled to an initial compensable evaluation for a left ankle disability prior to October 2011. As outlined below, when viewed in a light most favorable to the Veteran, the evidence of record demonstrates that a 10 percent evaluation is warranted prior to October 2011. The Veteran's left ankle disability is presently rated under Diagnostic Code 5024-5271. Hyphenated Diagnostic Codes are used when a rating under one Diagnostic Code requires use of an additional Diagnostic Code to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27 (2017). Diagnostic Code 5024 pertains to tenosynovitis, which states that the condition should be evaluated based upon the limitation of motion of the affected joint. Diagnostic Code 5271 provides the rating criteria for limitation of motion of the ankle. Moderate limitation of motion of an ankle warrants a 10 percent evaluation; while marked limitation of motion of an ankle warrants a 20 percent evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5271. Normal range of motion for the ankle is zero to 20 degrees of dorsiflexion and zero to 45 degrees of plantar flexion. See 38 C.F.R. § 4.71a, Plate II. The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity, or atrophy of disuse. 38 C.F.R. § 4.45. In Burton v. Shinseki, 25 Vet. App 1 (2011), the Court held that in claims for increased ratings for musculoskeletal disabilities where the Veteran has a noncompensable rating and complains of pain on motion, 38 C.F.R. § 4.59 must be addressed. That regulation, in turn, states that the intent of the Rating Schedule is to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Prior to October 2011, the Veteran's post-service treatment records are limited with respect to complaints pertaining to his left ankle. In February 2008, the Veteran's private treatment records reflect examination of his bilateral ankles in order to assess complaints regarding his right ankle. In that examination, the Veteran's left ankle presented with no redness, heat, nor abnormal movement. His alignment was normal and there was no ankylosis. The left ankle passive range of motion on dorsiflexion was to 20 degrees and plantar flexion was to 28 degrees. Active range of motion on dorsiflexion was to 8 degrees and plantar flexion to 18 degrees. However, the Veteran's left ankle range of motion improved after repetitive use, and dorsiflexion was to 8 degrees and plantar flexion was to 38 degrees. Muscle strength was normal, and there was no evidence of pain on motion for the left ankle. As the examiner was not assessing the left ankle, no explanation was provided as to these inconsistent ranges of motion. Shortly thereafter, in May 2008, the Veteran's VA Medical Center (VAMC) records reflect a normal ankle examination. While the Veteran complained of ankle pain, he could not verbalize what was specifically wrong pertaining to the left ankle. Examination found the ankle to be within normal limits. An imaging study found mild degenerative joint disease and arthritic changes in the heel with spur formation in the left ankle. In June 2009, VAMC records reflect that the ankle joint was freely moveable. The Veteran reported subjective symptoms of pain and occasional light swelling. In June 2011, the Veteran reported ankle swelling with no swelling found on examination. There was no erythema, nor was the ankle warm, misaligned, or tender. The left ankle had normal motion. There was no pain on motion, laxity, instability, nor was it tender on ambulation. That same month, the Veteran underwent a VA examination to assess his left ankle. He reported subjective symptoms of weakness, stiffness, swelling, giving way, deformity, tenderness and pain. He did not experience heat, redness, a lack of endurance, locking, fatigability, drainage, effusion, subluxation or dislocation. He reported flare ups once per week that did not cause functional impairment or limitation of motion of the joint. He reported difficulty standing and walking. The Veteran did not report any overall functional impairment from this condition. Range of motion was within normal limits and there was no additional limitation with repetitive use. Joint function was not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination after repetitive use. A left ankle x-ray showed calcaneal osteophytes. While the Veteran's left ankle ranges of motion have fluctuated over this period, at worst, they have demonstrated a moderate impairment with either periods of functional limitation due to symptoms such as pain and swelling, or moderate impairment of the range of motion. In February 2008, active range of motion was limited approximately to half of the normal range of motion, with an unexplained increase in range of motion after repetitive use. The Veteran voiced a number of complaints of subjective symptoms of pain, swelling and stiffness throughout VAMC treatment records and VA examinations. While ranges of motion remained within normal limits in June 2011, the Veteran reported subjective symptoms of pain and stiffness that caused difficulty with prolonged standing and walking. The Board notes that in adjudicating a claim, the competence and credibility of the Veteran must be considered. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Washington v. Nicholson, 19 Vet. App. 362, 368-69 (2005). The Board acknowledges that the Veteran is competent to give evidence about what he observes or experiences. For example, he is competent to report that he experiences certain symptoms, such as pain. See, e.g., Layno v. Brown, 6 Vet. App. 465 (1994). The Veteran's belief that his disability is worse than an assigned disability rating, however, is outweighed by the competent and credible medical examinations that evaluated the true extent of impairment based on objective data coupled with the lay complaints. The medical professionals have the training and expertise necessary to administer the appropriate tests for a determination of the type and degree of the impairment associated with the Veteran's complaints. For these reasons, greater evidentiary weight is placed on the physical examination findings than the Veteran's lay statements in determining whether an evaluation in excess of 10 percent is warranted. Evidence of record, however, does not reflect a more severe impairment during this period on appeal. Predominantly, the Veteran retained full range of motion, and objective examination did not note more severe impairments of the left ankle. The Veteran reported no functional impairment during flare ups of his left ankle disability. Imaging studies found mild degenerative changes and calcaneal osteophytes of the joint. The Board has considered the other Diagnostic Codes related to the ankles to determine whether an increased rating is warranted for either ankle under these provisions. The remaining Diagnostic Codes, however, are not for application in this case as there is no evidence of ankylosis, or subastragalar or tarsal joint, malunion of the os calcis or astragalus, or astagalectomy. Rating the left ankle for degenerative arthritis instead would only refer back to the limitation of motion rating under which the condition is currently rated. Resolving doubt in favor of the Veteran, the Board finds that he is entitled to a 10 percent evaluation for a left ankle disability prior to October 17, 2011. Since the preponderance of the evidence is against an evaluation in excess of 10 percent for this period on appeal, the provisions of 38 U.S.C. § 5107(b) regarding reasonable doubt are not applicable. The Veteran's claim of entitlement to an evaluation in excess of 10 percent for a left ankle disability prior to October 17, 2011 must be denied. Sinusitis The Veteran also contends that he is entitled to an evaluation in excess of 10 percent for sinusitis. However, as outlined below, the preponderance of the evidence of record is against a finding of entitlement to an evaluation in excess of 10 percent for sinusitis at any time during the pendency of this claim. The Veteran's service-connected sinusitis is rated under 38 C.F.R. § 4.97, Diagnostic Code 6513. Under the General Rating Formula for sinusitis, a 10 percent evaluation is assigned with evidence of one or two incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or three to six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. A 30 percent evaluation is assigned with evidence of three or more incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or more than six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. A 50 percent evaluation is assigned with evidence of following radical surgery with chronic osteomyelitis, or near constant sinusitis characterized by headaches, pain and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries. A Note to Diagnostic Code 6513 provides that an incapacitating episode of sinusitis means one that requires bed rest and treatment by a physician. In February 2008, the Veteran's private treatment records reflect reports of frequent sinus pain with intensity related to the changing of the seasons. There was no purulent discharge, but he did show crusting bilaterally. In May 2008, VAMC treatment records report that the Veteran sought treatment for nasal discharge. Subsequently, in November 2008, treatment records reflect a diagnosis of chronic sinusitis. In July 2009, private treatment records diagnosed the Veteran with hyperplasia of the nasal concha, and testing was ordered to rule out sinusitis. The Veteran complained of difficulty breathing, and a low level septum deviation was found in the left sinus cavity. In June 2011, the Veteran underwent a VA examination to assess the severity of his sinusitis. He described his sinus problems as constant. The Veteran denied incapacitating episodes, but did report 3 non-incapacitating episodes per year without headaches. The Veteran denied prescriptions for antibiotics to treat the condition. He reported interference with breathing through his nose and pain, described as chronic congestion. There was no purulent discharge, hoarseness of the voice, or crusting. He did not report functional impairment from the condition. A sinus x-ray was within normal limits. The objective examination found normal sinuses. In October 2011, the Veteran reported to the VAMC with an episode of acute sinusitis. Subsequently, the Veteran made an urgent appointment with the VAMC in order to obtain a letter about his sinus history for compensation purposes, according to the treating physician. He complained of a runny nose with headaches that were worse when he woke up. He did not recall being on medication for the condition. In June 2017, the Veteran underwent a second VA examination to assess the severity of his sinusitis. The Veteran reported 2, non-incapacitating episodes of sinusitis characterized by headaches, pain and purulent discharge or crusting within the previous year. No incapacitating episodes were reported. In sum, the Veteran experienced, at most, 3 non-incapacitating episodes of sinusitis per year, characterized by headaches, pain and purulent discharge or crusting. The Veteran did not report taking antibiotics for the condition. He did not report incapacitating episodes of sinusitis during which a physician ordered bedrest. He did not undergo radical surgery, nor was his sinusitis near constant, characterized by headaches, pain and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries. As such, the Board finds that a 10 percent evaluation, but no higher, is appropriate for the period on appeal. The weight of the probative evidence of record reflects symptoms entirely consistent with the 10 percent evaluation criteria. The Board notes that in adjudicating a claim, the competence and credibility of the Veteran must be considered. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Washington, 19 Vet. App. at 368-69. The Board acknowledges that the Veteran is competent to give evidence about what he observes or experiences. For example, he is competent to report that he experiences certain symptoms, such as pain. See, e.g., Layno v. Brown, 6 Vet. App. 465 (1994). The Veteran's belief that his disability is worse than the assigned disability rating, however, is outweighed by the competent and credible medical examinations that evaluated the true extent of impairment based on objective data coupled with the lay complaints. The VA examiners have the training and expertise necessary to administer the appropriate tests for a determination of the type and degree of the impairment associated with the Veteran's complaints. For these reasons, greater evidentiary weight is placed on the physical examination findings than the Veteran's lay statements. Since the preponderance of the evidence is against the claim, the provisions of 38 U.S.C. § 5107(b) regarding reasonable doubt are not applicable. The Veteran's claim of entitlement to an evaluation in excess of 10 percent for sinusitis must be denied. ORDER The claim of entitlement to an initial evaluation of 10 percent, but no higher, for a left ankle disability prior to October 17, 2011, is granted. The claim of entitlement to an initial evaluation in excess of 10 percent for sinusitis is denied. REMAND Unfortunately, remand is necessary to adjudicate the remaining matters on appeal. At the outset, the Board notes that relevant medical records associated with the claims file appear to be incomplete. In January 2016, VAMC treatment records indicate that the Veteran primarily obtains his mental health care from a non-VA source. In November 2016, a one-page letter listing the Veteran's diagnoses was provided by a private psychiatric nurse practitioner. In January 2017, a VA examiner responded to the one-page letter from the nurse practitioner, but did not note any other treatment records from that provider. Records must be sought from the Veteran's treating psychiatric nurse practitioner in order to fully develop the evidentiary record prior to adjudication. See 38 U.S.C.A. § 5103A(b), (c); 38 C.F.R. § 3.159(b); see also Bell v. Derwinski, 2 Vet. App. 611 (1992). Additionally, while medical evidence of record presented a more complete picture of the Veteran's left ankle disability prior to October 17, 2011, treatment records since that date are inconsistent with respect to the severity of his condition. Range of motion assessments in January 2012 VAMC treatment records appear to present a worsening of limitation of motion; however, a September 2012 VA examination measures markedly improved range of motion in the left ankle. The January 2017 VA examination indicates that active range of motion had improved, but passive range of motion was extremely limited. While the examiner noted no pain on examination, pain was later noted in passive range of motion. Additionally, the examiner first indicated that there was no pain on weight-bearing, but then remarked that pain with weight-bearing on the left causes functional loss. These inconsistencies must be resolved with a new VA examination that more clearly assesses the present nature of the Veteran's disability, and provides an explanation for previous medical findings. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Finally, given the evidentiary development necessary on remand, TDIU must be readjudicated following completion of the remand instructions as it is inextricably intertwined with the remaining issues on appeal. Accordingly, the case is REMANDED for the following action: 1. Contact the Veteran in order to identify any outstanding non-VA treatment records regarding his acquired psychiatric disorder. If non-VA providers are identified, obtain releases for those records. Make all reasonable attempts to obtain the non-VA treatment records and associate them with the claims file. If such records cannot be obtained, inform the Veteran, and afford an opportunity for him to provide these outstanding records. 2. Obtain any relevant, outstanding VA treatment records that are not already associated with the claims file. If no records are available, the claims folder must indicate this fact and the Veteran should be notified in accordance with 38 C.F.R. § 3.159 (e). All attempts to contact the Veteran should be documented in the record. 3. Once the aforementioned evidentiary development is complete, schedule the Veteran for a new VA examination to assess the present severity of his left ankle disability. The entire claims file must be reviewed, including a copy of this remand. Review of these documents should be noted in the claims file. The examiner must consider the Veteran's lay reports of the onset of observable symptomatology. Once a review of the file has been conducted, the examiner must opine as to the following: (a) Describe with sufficient detail and clarity the present nature and severity of the Veteran's left ankle disability, including in terms of active and passive ranges of motion, as well as weight-bearing and nonweight-bearing. If the passive range of motion is less than the active range of motion provide an explanation as to the cause for this discrepancy. (b) Provide a retrospective opinion regarding the overall severity of the Veteran's left ankle disability since October 17, 2011. Please discuss the ranges of motion noted in the Veteran's treatment records. If any assessments, including ranges of motion, are determined to be outliers, provide a detailed explanation to support that conclusion. Opine as to the cause of the difference between active and passive ranges of motion in the Veteran's January 2017 VA examination. The examination report should specifically state that a review of the record was conducted. The examiner should provide a complete rationale for all opinions provided. If an opinion cannot be provided without to resorting to mere speculation, the examiner should identify all medical and lay evidence considered in this conclusion, fully explain why this is the case and identify what additional evidence (if any) would allow for a more definitive opinion. 4. Once the aforementioned evidentiary development is complete, obtain an addendum opinion from the previous examiner, if possible, regarding the Veteran's mood disorder, not otherwise specified. The entire claims file must be reviewed, including a copy of this remand. Review of these documents should be noted in the claims file. If obtained, the examiner must discuss the treatment records from the Veteran's treating psychiatric nurse practitioner. Once a review of the file has been conducted, the examiner must opine as to the following: (a) Describe the present nature and severity of the Veteran's mood disorder, not otherwise specified; (b) Provide a retrospective opinion regarding the severity of the Veteran's disability in light of the new treatment records, if introduced into the record. The examination report should specifically state that a review of the record was conducted. The examiner should provide a complete rationale for all opinions provided. If an opinion cannot be provided without to resorting to mere speculation, the examiner should identify all medical and lay evidence considered in this conclusion, fully explain why this is the case and identify what additional evidence (if any) would allow for a more definitive opinion. 5. Following completion of the foregoing, the AOJ should review the record and readjudicate the claims on appeal. If any remain denied, the AOJ should issue an appropriate supplemental SOC, afford the Veteran an opportunity to respond, and return the case to the Board. 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.A. §§ 5109B, 7112 (West 2014). ______________________________________________ B. MULLINS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs