Citation Nr: 1821144 Decision Date: 04/09/18 Archive Date: 04/19/18 DOCKET NO. 13-28 435A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to a higher initial rating for posttraumatic stress disorder (PTSD), in excess of 30 percent for the period prior to June 15, 2010. 2. Entitlement to a higher initial rating for PTSD, in excess of 30 percent from June 15, 2010 to December 1, 2015 and in excess of 50 percent thereafter (exclusive of periods of temporary total evaluation from June 12, 2013 through November 30, 2013 and August 5, 2015 through November 30, 2015). 3. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU) for the period prior to June 15, 2010. 4. Entitlement to a TDIU beginning June 15, 2010. 5. Entitlement to service connection for human immunodeficiency virus infection (HIV)/acquired immune deficiency syndrome (AIDS). 6. Entitlement to service connection for hemorrhoids. 7. Entitlement to service connection for chronic obstructive pulmonary disease (COPD). 8. Entitlement to service connection for hypertension. 9. Entitlement to service connection for a left shoulder disorder. 10. Entitlement to service connection for a right shoulder disorder. 11. Whether new and material evidence has been received in order to reopen a claim of entitlement to service connection for a low back disorder. REPRESENTATION Appellant represented by: Joseph R. Moore, Attorney ATTORNEY FOR THE BOARD Matthew Schlickenmaier, Associate Counsel INTRODUCTION The Veteran had active duty service in the U.S. Army from June 1975 to February 1980 and from March 1982 to March 1985. This matter comes before the Board of Veterans' Appeals (Board) on appeal from December 2009, November 2010, May 2012, April 2014 and May 2016 rating decisions issued by the Department of Veterans Affairs (VA) Appeals Management Center and Regional Office (RO) in Montgomery, Alabama. This appeal was processed using the Virtual VA and Veterans Benefits Management System (VBMS) paperless claims processing systems. Accordingly, any future consideration of this appellant's case should take into account the existence of these electronic records. The issues of entitlement to a higher initial rating for PTSD prior to June 15, 2010, entitlement to a TDIU prior to June 15, 2010, and entitlement to service connection for HIV/AIDS are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. In August 2017, prior to the promulgation of a decision in the appeal, the Board received the appellant's request to withdraw the substantive appeal as to the issues of entitlement to service connection for hemorrhoids, COPD, hypertension, and left and right shoulder disorders, as well as the issue of whether new and material evidence has been received in order to reopen a claim of entitlement to service connection for a low back disorder. 2. For the period beginning June 15, 2010, and with reasonable doubt resolved in favor of the Veteran, the evidence of record shows that the Veteran's PTSD symptomatology more nearly approximates total occupational and social impairment. 3. As the Veteran has been granted a 100 percent schedular rating for his PTSD beginning June 15, 2010, the issue of entitlement to TDIU beginning June 15, 2010 is moot. CONCLUSIONS OF LAW 1. The criteria for withdrawal of the Veteran's substantive appeal as to the issues of entitlement to service connection for hemorrhoids, COPD, hypertension, and left and right shoulder disorders, as well as the issue of whether new and material evidence has been received in order to reopen a claim of entitlement to service connection for a low back disorder have been met. 38 U.S.C. § 7105; 38 C.F.R. § 20.204 (2017). 2. With reasonable doubt resolved in favor of the Veteran, for the period beginning June 15, 2010, the criteria for a 100 percent evaluation for PTSD have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2017). 3. Entitlement to a TDIU beginning June 15, 2010 is moot. 38 U.S.C. § 1155; 38 C.F.R. § 4.16 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Withdrawal The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204 (2017). Withdrawal may be made by the appellant or by his or her authorized representative. 38 C.F.R. § 20.204. Except for appeals withdrawn on the record at a hearing, appeal withdrawals must be in writing. They must include the name of the veteran, the name of the claimant or appellant if other than the veteran (e.g., a veteran's survivor, a guardian, or a fiduciary appointed to receive VA benefits on an individual's behalf), the applicable Department of Veterans Affairs file number, and a statement that the appeal is withdrawn. If the appeal involves multiple issues, the withdrawal must specify that the appeal is withdrawn in its entirety, or list the issue(s) withdrawn from the appeal. 38 C.F.R. § 20.204(b)(1). In this case, in August 2017, the representative submitted a signed statement from the Veteran wherein he requested to withdraw the appeals regarding the issues of entitlement to service connection for hemorrhoids, COPD, hypertension, and left and right shoulder disorders, as well as the issue of whether new and material evidence has been received in order to reopen a claim of entitlement to service connection for a low back disorder. Hence, in the present case, the Board finds that the appellant has withdrawn the substantive appeal as to these issues and that there remain no allegations of errors of fact or law for appellate consideration. 38 C.F.R. § 20.204. Accordingly, the Board does not have jurisdiction to review the appeal and these issues are dismissed. PTSD Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4 (2017). The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. All reasonable doubt as to the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. PTSD is evaluated under the general rating formula for mental disorders. See 38 C.F.R. § 4.130, Diagnostic Code 9411. Under this general rating formula, a 30 percent rating is warranted where the evidence shows occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, Diagnostic Code 9411. A 50 percent rating is warranted when the evidence shows occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g. retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing effective work and social relationships. Id. Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships warrants a 70 percent rating. Id. Total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name warrants a 100 percent rating. Id. Global Assessment of Functioning (GAF) scores are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health- illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) [citing the American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS, Fourth Edition (DSM-IV), p. 32]. Scores ranging from 41 to 50 are assigned when there are serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting), or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). Scores ranging from 51 to 60 reflect more moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). Scores ranging from 61 to 70 reflect mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful relationships. See 38 C.F.R. § 4.130 (incorporating by reference the VA's adoption of the DSM-IV for rating purposes). The criteria set forth in the rating formula for mental disorders do not constitute an exhaustive list of symptoms, but rather are examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Nevertheless, the Veteran must demonstrate the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013) (also explaining that VA intended the General Rating Formula to provide a regulatory framework for placing veterans on the disability spectrum based upon their objectively observable symptoms). In this case, a June 15, 2010 VA treatment record shows that the Veteran reported to the emergency room for suicidal ideation. He stated that if he hurts himself, he plans on overdosing on sleeping pills. It was noted that he self-isolates and that he used to hear voices but does not currently. A GAF score of 50 was noted. A July 2010 VA treatment record indicates that the Veteran was severely depressed and that he recently relapsed and used marijuana and cocaine. There was a history of a previous suicide attempt. He reported suicidal ideation by shooting himself in the head with a pistol and also reported thoughts of hurting or killing his ex-girlfriend. He indicating hearing noises and sounds for many years but not voices. A GAF score of 55 was noted. An August 2010 VA treatment record shows that after the Veteran reported to the emergency room, he was hospitalized. The Veteran was noted to be unable to socialize and reported that he sometimes feels like hurting someone. He reported that he intends to hurt himself and has a plan to overdose on pills. The GAF score was 50. The Veteran was afforded a VA examination in October 2010. He reported irritability, moodiness, drug use to "self-medicate," nightmares, difficulty concentrating, difficulty sleeping and some avoidance behavior, particularly concerning crowds. The examiner noted that the Veteran had been receiving treatment for his mental health issues through the Central Alabama Health Care System and that in August 2010, he had a brief inpatient stay at Hillcrest Hospital due to depression and after being diagnosed with cocaine dependence and cannabis dependence. The Veteran reported that his prescription medications used to help but currently had no effect. The Veteran stopped working around 1997 after his diagnosis with HIV. He was currently living with his two brothers. He said he gets along with one of his brothers better than the other. The Veteran did not have a significant other. He also reported having one son who is in the Navy but he had not seen him in over a year. He reported that he likes to spend time socializing with one of his cousins and said that he also goes out to quiet country roads and listens to the radio. The Veteran denied significant alcohol use but reported using crack cocaine and marijuana frequently to self-medicate. The examiner's conclusion was that the Veteran had very little insight into the problems associated with his use of cannabis and cocaine because he actually referred to this as helping his mental health. The examiner opined that the Veteran's mood was being affected by his use of drugs, to include affecting his mood swings, irritability, sleeping patterns, anxiety and depression. Due to the fact that the Veteran was using the drugs on a regular basis and had been diagnosed with a substance-induced mood disorder, the examiner opined that it was very likely that if he received treatment for substance abuse, he would have a noticeable improvement in his current mental health symptoms. The examiner further concluded that the Veteran's PTSD was not such that it would interfere with his ability to maintain gainful employment. The examiner diagnosed substance-induced mood disorder with depressed features, cannabis dependence, cocaine dependence and PTSD and assigned a GAF score of 55. The examiner indicated that he had reviewed the Veteran's medical records but not the claims file. December 2010 VA treatment records show GAF scores of 55 and 65. A February 2011 VA treatment record shows a GAF score of 55. VA treatment records show that in late March 2011, the Veteran was again admitted for hospitalization for suicidal ideation. An April 2011 VA treatment record indicates that he had thoughts of overdosing on pills, using his brother's gun to shoot himself or running in front of a car on a highway. A May 2011 VA treatment record shows that the Veteran reported feeling more depressed. He was noted to be on the facility's high risk suicidal ideation list. In a May 2011 letter, a private psychologist who reported having treated the Veteran since June 2009 opined that the Veteran had not been able to engage in gainful employment as a result of his PTSD. He noted that the Veteran's symptoms included chronic insomnia, ruminating thoughts about the accident, thoughts of fear and death, social isolation and withdrawal. The Veteran also experienced a constriction of interests, difficulty concentrating and focusing mentally and emotionally which further prevented employability because of PTSD. The psychologist noted that although the Veteran had been engaged in individual psychotherapy geared toward decreasing his symptoms, because his symptoms are chronic, it was unlikely that they were to abate sufficiently anytime in the future. He assigned a GAF score of 42. VA treatment records from June 2011 show that the Veteran was again admitted for hospitalization for suicidal ideation and drug abuse. He reported increasing depression in the last several days, now with suicidal ideation and feelings of hopelessness. He had called a hotline reporting suicidal ideation without intent but stated that the feelings were getting stronger and that he was not sure how long he could keep himself safe. A VA treatment record from late June 2011 shows that the day after he was discharged, he phoned the homeless call center and again reported suicidal ideation. An August 2012 VA treatment record shows that the Veteran was referred to a substance abuse clinic after getting a DUI. The GAF score was 55. An April 2013 VA treatment record shows that the Veteran denied suicidal or homicidal ideation and denied using drugs. A February 2015 VA treatment record shows that the Veteran reported feeling "OK" although he continued to report nightmares and flashbacks. He was not as angry as before but he still reported isolative behavior. He currently lived alone and had no daytime activities. The GAF score was 65. A March 2015 VA treatment record shows that he reported nightmares and flashbacks four times per week, was still depressed and reported forgetting things and isolative behavior. He lived alone. He denied intent to hurt himself or others. The GAF score was 60. April 2015 VA treatment records show that the Veteran reported to the emergency department with complaints of suicidal ideation on and off for the past two weeks. He reported that he planned to walk into incoming traffic on the interstate. The Veteran underwent another VA examination in August 2015. The examiner noted anxiety, chronic sleep impairment, flattened affect, disturbances of motivation and mood, difficulty in establishing effective work and social relationships, and difficulty in adapting to stressful circumstance, including work or a worklike setting. The Veteran reported continued crack cocaine dependence but admitted that he was struggling with symptoms of physical withdrawal since entering a VA domiciliary about one week ago. He also reported that he continued to struggle with PTSD which had been exacerbated by the recent death of a cousin as well as orthopedic problems, financial pressures and detoxification from cocaine. The Veteran reported that he was living in a VA domiciliary where he expected to remain until November 2015 but that typically, he lived alone in an apartment and had few or no friends and he does not attend church. The examiner diagnosed PTSD and stimulant (cocaine) withdrawal which he assessed as causing occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. Although the examiner checked a box indicating that he could differentiate the impairment caused by each disorder, he wrote that because symptoms of physical withdrawal from cocaine include anxiety, tremors, excessive perspiration and disrupted sleep, distinguishing cocaine withdrawal from PTSD symptoms was "quite challenging." In an addendum, the examiner opined that the PTSD symptoms affected but did not preclude occupational functioning. A February 2016 VA treatment record shows that the Veteran was referred to the mental health clinic because of suicidal ideation with a plan to overdose on medications. He was subsequently admitted to an inpatient psychiatric facility. June and July 2016 VA treatment records show GAF scores of 60. In August 2017, the Veteran's representative submitted a private psychological evaluation from Dr. Michael Cesta who indicated that he had interviewed the Veteran, reviewed the medical records, service records, compensation and pension examinations, and various other lay statements and ancillary information. Following a review of this evidence, the doctor concluded that the Veteran's substance abuse and PTSD were intertwined because they developed concomitantly. He further concluded that the Veteran's PTSD, by itself, has been totally disabling throughout the period on appeal and noted that although he also has HIV/AIDS, this would not prevent him from working because he has been medically stable. The examiner reasoned that the medical records portrayed a picture of an individual who is severely mentally ill and interviewing the Veteran makes it extraordinarily clear that his mental illness would be considered chronic and pervasive. The Veteran is extremely socially isolated and manifested a constellation of symptoms that prevents him from engaging in even simple interpersonal interactions, let alone the complex environment of an occupational setting. His PTSD symptoms included periods of dissociation that are unpredictable, irritability, anger, restlessness, negativistic thoughts, an escalated startle response and hypervigilance. This causes him to place himself and others at risk, as his behaviors are completely volatile and unpredictable. Furthermore, the Veteran has ongoing suicidal ideation, as well as homicidal ideation that, at times, he feels he cannot control. He states that the targets of his homicide would be a matter of convenience, which, the examiner opined, is not a clinical scenario that can be tolerated in any occupational setting. In sum, the examiner concluded that his mental illness is an insurmountable barrier to employment because there is no employment setting that would accept an individual with this constellation and intensity of symptoms. Upon review of the evidence, and with reasonable doubt resolved in favor of the Veteran, the Board finds that a 100 percent rating is warranted beginning June 15, 2010. The evidence during this period shows that the Veteran's mental health issues have resulted in total occupational and social impairment due in large part to persistent danger of hurting himself or others. Although the evidence above shows that there is some debate as to whether the root cause of the Veteran's substance abuse is related to his nonservice-connected orthopedic and HIV problems or to his service-connected PTSD, the Veteran has presented competent and credible medical evidence of sufficient weight - namely, the August 2017 private medical opinion - to render the evidence related to this issue at least in equipoise. There is less debate as to the severity of his overall disability picture when considering the effect of his PTSD and the effects of his substance abuse. Indeed, in addition to the hospital admissions from June through November 2013 and August through November 2015, for which the Veteran has already received temporary total evaluations, the Veteran was also hospitalized for suicidal ideation in August 2010, March 2011, and February 2016. Numerous other records document incidents where the Veteran reported suicidal and/or homicidal ideation and, significantly, many times such ideation included a concrete plan such as to steal a gun, overdose on pills, or walk onto the highway. In addition to these serious symptoms involving the danger of hurting self or others, the Veteran's PTSD has also consistently been manifested by anxiety, irritability, moodiness, nightmares, difficulty concentrating, difficulty sleeping and avoidance behavior. Although the evidence at times shows that the Veteran reported feeling "OK," denied suicidal or homicidal ideation, and GAF scores reflecting moderate or even mild symptoms, these periods are counterbalanced by extremely severe symptoms including suicidal/homicidal ideation with a plan, social isolation with few or no friends and no recent occupational history. While there is some evidence indicating that the Veteran's occupational impairment is related to his nonservice-connected orthopedic and/or HIV and that his PTSD symptoms do not prevent employment, the Veteran has presented competent and credible medical evidence of sufficient weight - namely, the May 2011 and August 2017 private medical opinions - to render the evidence related to this issue at least in equipoise. In sum, the evidence reflects an overall disability picture indicating total occupational and social impairment and while there is some question as to whether this is solely the result of his service-connected PTSD, with reasonable doubt resolved in favor of the Veteran, the Board concludes that it is. Accordingly, the Board finds that for the period beginning June 15, 2010, a 100 percent schedular rating for PTSD is warranted. TDIU The Veteran has claimed entitlement to a TDIU to include for the period beginning June 15, 2010. As discussed above, the Veteran has been awarded a 100 percent schedular rating for his PTSD beginning June 15, 2010. The United States Court of Appeals for Veterans Claims (Court) has recognized that a 100 percent rating under the Schedule for Rating Disabilities means that a Veteran is totally disabled. Holland v. Brown, 6 Vet. App. 443, 446 (1994), citing Swan v. Derwinski, 1 Vet. App. 20, 22 (1990). Thus, if VA has found a veteran to be totally disabled as a result of a particular service-connected disability or combination of disabilities pursuant to the rating schedule, there is no need, and no authority, to otherwise rate that veteran totally disabled on any other basis. See Herlehy v. Principi, 15 Vet. App. 33, 35 (2001) (finding a request for TDIU moot where 100 percent schedular rating was awarded for the same period). Thus, the Veteran's claim for a TDIU beginning June 15, 2010 is moot as he has been awarded a 100 percent schedular rating beginning June 15, 2010 for this period when TDIU was under appeal as well. ORDER Entitlement to a 100 percent schedular rating for PTSD beginning June 15, 2010 is granted, subject to the regulations governing payment of monetary awards. Entitlement to a TDIU beginning June 15, 2010 is dismissed. The appeal as to the issue of entitlement to service connection for hemorrhoids is dismissed. The appeal as to the issue of entitlement to service connection for COPD is dismissed. The appeal as to the issue of entitlement to service connection for hypertension is dismissed. The appeal as to the issue of entitlement to service connection for a left shoulder disorder is dismissed. The appeal as to the issue of entitlement to service connection for a right shoulder disorder is dismissed. The appeal as to the issue of whether new and material evidence has been received in order to reopen a claim of entitlement to service connection for a low back disorder is dismissed. REMAND As to entitlement to a higher initial rating for PTSD prior to June 15, 2010 and entitlement to a TDIU prior to June 15, 2010, the record indicates that there are pertinent VA treatment records relating to these issues that remain outstanding. Indeed, although the October 2010 VA examiner stated that the Veteran had been receiving treatment for his mental health issues through the VA Central Alabama Health Care System, record relating to these facilities for the period from March 2003 through June 2013 appear to be outstanding. In this regard, although the Legacy Content Manager (previously Virtual VA) includes one September 2013 CAPRI entry showing 35 pages of documents from this healthcare system as early as May 2003 and as late as September 2013, it appears incomplete. In October 2011, the representative submitted approximately 57 pages of documents from this healthcare system spanning the period from June 2010 through June 2011, most of which were not included in the CAPRI entry. Hence, as these outstanding treatment records appear relevant to these issues, on remand they must be associated with the claims file. As to service connection for HIV/AIDS, the Veteran contends that he contracted HIV in the Army. In support, he points to a June 1982 service treatment record noting a history of gonococcus - bacteria related to a sexually transmitted disease -diagnosed in March 1979 during his first period of active duty and was seen the following month for bumps on his face and neck of unknown origin. In August 1982 he was again seen for gonococcus. See August 2017 correspondence. Since the Veteran has a current diagnosis of HIV/AIDS, the Board finds that the low threshold for obtaining an etiological VA examination regarding this issue has been met. See McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). Accordingly, the case is REMANDED for the following action: 1. Associate with the claims file any outstanding VA treatment records, to include any records from the VA Central Alabama Health Care System from March 2003 through June 2013. Archived records should be reviewed if necessary. 2. Thereafter, schedule the Veteran for a VA examination to address the etiology of his HIV/AIDS. All necessary tests should be conducted. The claims file must be sent to the examiner for review. The examiner should indicate whether it is at least as likely as not (50 percent probability or more) that the Veteran's HIV/AIDS is related to or had its onset during the Veteran's periods of active duty service. The examiner should address the Veteran's contentions regarding his HIV onset being related to his treatment for gonococcus in service. A complete rationale should accompany any opinion provided. 3. After completion of the above, readjudicate the claims. If any benefit requested on appeal is denied, the appellant and his representative should be furnished a supplemental statement of the case, which addresses all of the evidence obtained after the issuance of the last supplemental statement of the case. 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. ______________________________________________ GAYLE E. STROMMEN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs