Citation Nr: 1810807 Decision Date: 02/21/18 Archive Date: 03/01/18 DOCKET NO. 14-15 809A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an initial disability rating in excess of 10 percent prior to December 14, 2015, and in excess of 50 percent thereafter, for major depressive disorder with anxious distress, previously evaluated as anxiety disorder (psychiatric disability). 2. Entitlement to an initial compensable rating for cellulitis of the left leg. 3. Entitlement to an initial disability rating in excess of 10 percent for Hepatitis C. 4. Entitlement to total disability based on individual unemployability (TDIU). REPRESENTATION Veteran represented by: Ralph J. Bratch, Attorney ATTORNEY FOR THE BOARD J.A. Gelber, Associate Counsel INTRODUCTION The Veteran served on active duty from November 1970 to April 1972. These matters come before the Board of Veterans' Appeals (Board) on appeal from a November 2010 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). This case was previously before the Board in December 2015, at which time it was remanded for further development. As the requested development has been completed, no further action to ensure compliance with the remand directives is required. Stegall v. West, 11 Vet. App. 268, 271 (1998). The Veteran was initially assigned a 10 percent rating for a psychiatric disability. A June 2017 rating decision assigned a 50 percent rating effective December 14, 2015. Although an increased rating was granted for a psychiatric disability, the issue remained in appellate status, as the maximum schedular rating had not been assigned for the entire period on appeal. See AB v. Brown, 6 Vet. App. 35, 38-39 (1993). The issues of an increased rating for Hepatitis C 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. The competent and probative evidence is at least in equipoise as to whether the Veteran's psychiatric symptoms resulted in 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) prior to December 14, 2015. 2. The weight of the competent and probative evidence is against finding that the Veteran's psychiatric symptoms result in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood as of December 14, 2015. 3. The weight of the competent and probative evidence is against finding that the Veteran's skin disability affects at least five percent or more of the entire body or exposed areas, or requires intermittent systemic therapy. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial disability rating of 30 percent, but no higher, for a psychiatric disability prior to December 14, 2015, have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.130, Diagnostic Codes (DCs) 9413, 9434 (2017). 2. The criteria for entitlement to an initial disability rating in excess of 50 percent for a psychiatric disability as of December 14, 2015, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.130, DCs 9413, 9434. 3. The criteria for an initial compensable rating for cellulitis of the left leg have not been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.118, DC 7806 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. VA sent a letter to the Veteran in August 2009, prior to adjudication of his claims. No further notice is required regarding the downstream issues of higher initial ratings for a psychiatric disability and cellulitis as they stem from the grants of service connection, and no prejudice has been alleged. Next, VA has a duty to assist the Veteran in the development of his claims, including assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159 (2017). All available, identified medical records have been associated with the virtual file and considered. The Veteran was afforded relevant VA examinations in October 2010, December 2015, and May 2017. In light of the foregoing, the Board will proceed to the merits of the appeal. II. Increased Ratings Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's disability. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where, as in the instant case, the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). Staged ratings are appropriate when the evidence establishes that the claimed disability manifested symptoms that would warrant different ratings for distinct time periods during the course of the appeal. Id. at 126-27; Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). Disability ratings are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Rating Schedule. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. 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 evaluation will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3; see Gilbert v. Derwinski, 1 Vet. App. 49, 57-58 (1990). In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21 (2017). In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the disorder. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath, 1 Vet. App. at 593. The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. 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; the additional code is shown after the hyphen. 38 C.F.R. § 4.27 (2017). The Veteran is competent to report symptoms and experiences observable by his senses. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); 38 C.F.R. § 3.159(a). A. Psychiatric disability The Veteran was initially assigned a 10 percent rating under Diagnostic Code 9413 for anxiety disorder. A June 2017 rating decision reassigned the disability under Diagnostic Codes 9434-9413 for major depressive disorder with anxious distress, and assigned a 50 percent rating effective December 14, 2015. Psychiatric disabilities are rated based on the General Rating Formula codified in 38 C.F.R. § 4.130, which provides disability ratings based on a spectrum of symptoms. "A veteran may qualify for a given disability rating by demonstrating the particular symptoms associated with that percentage, or others of a similar severity, frequency, and duration." Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013). VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV) and (5th ed. 2013) (DSM-5). See Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). The United States Court of Appeals for Veterans Claims (Court) has observed that the listed symptoms are examples of the type and degree of the manifestations of a mental disability required for a given disability rating, and that "the presence of all, most, or even some, of the enumerated symptoms" is not required to support a disability rating. Mauerhan, 16 Vet. App. at 442. Accordingly, it is not sufficient for the Board to simply match the symptoms listed in the rating criteria against those exhibited by a veteran. Rather, "VA must engage in a holistic analysis" of the severity, frequency, and duration of the signs and symptoms of the veteran's mental disorder, determine the level of occupational and social impairment caused by those signs and symptoms, and assign an evaluation that most nearly approximates that level of occupational and social impairment. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017). Under the General Rating Formula, a 10 percent rating is warranted for occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. 38 C.F.R. § 4.130. The criteria for a 30 percent rating are as follows: Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). Id. The criteria for a 50 percent rating are as follows: Occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. The criteria for a 70 percent rating are as follows: 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; obsessive 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); and an inability to establish and maintain effective relationships. Id. The criteria for a 100 percent rating are as follows: Total occupational and social impairment, due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, own name. Id. 1. Prior to December 14, 2015 After reviewing the relevant medical and lay evidence and applying the above laws and regulations, the Board finds that an initial disability rating of 30 percent, but no higher, for a psychiatric disability prior to December 14, 2015, is warranted. In September 2009, VA received correspondence from the Veteran in which he states that he isolates himself, sleeps 12 to 13 hours per night, and feels like he is losing control at work. 09/09/2009, Correspondence. An April 2010 mental health evaluation indicates avoidance symptoms, restricted range of affect, emotional detachment, arousal symptoms, hypervigilance, and sleep impairment. The Veteran denied suicidal ideation with the exception of an isolated suicidal ideation without plan or intent around Thanksgiving 2009. A mental status examination revealed blunted affect, but was otherwise unremarkable. Based on the foregoing, the clinician assigned a Global Assessment of Functioning (GAF) score of 55. A GAF score between 51 and 60 indicates 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 coworkers). See DSM-IV (emphases added). 05/17/2010, Medical-Government. An October 2010 VA examination reflects symptoms of feelings of detachment or estrangement, restricted range of affect/emotional numbing, marked diminished interest in activities, irritability, hypervigilance, exaggerated startle response, and sleep impairment. A mental status examination was unremarkable. The Veteran reported good relationships with his parents, siblings, and daughter, but that he prefers to isolate himself and has no local friends. The examiner noted that mental health symptoms are controlled by continuous medication and are not severe enough to interfere with occupational and social functioning. Based on the foregoing, the examiner assigned a GAF score of 64. A GAF score between 61 and 70 indicates some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well and has some meaningful interpersonal relationships. See DSM-IV (emphases added). 10/18/2010, VA Examination. In March 2011, VA received correspondence from E.W. and R.R.C., the Veteran's coworkers, and C.P., the Veteran's daughter, in which they describe observing the Veteran exhibiting the following symptoms and behaviors: depressed mood; suspiciousness; isolated; irritability, mood swings, and angry outbursts; hypervigilance and exaggerated startle response; difficulty with concentration; panic attacks; and an inability to handle stress. The lay statements also reflect the Veteran's reports of sleep impairment, nightmares, and flashbacks, and stating that life is not worth living. 03/21/2011, Affidavits. A June 2011 mental health evaluation indicates symptoms of nightmares and anxiety, but the Veteran denied psychotic symptoms or suicidal or homicidal ideation. A mental status examination revealed depressed mood and constricted affect, but was otherwise unremarkable. Based on the foregoing, the clinician assigned a GAF score of 55. 04/21/2014, CAPRI. The Board finds the October 2010 VA examination and April 2010 and June 2011 evaluations to be competent, credible, and highly probative, as they are supported by in-person examinations, mental health expertise, review of the relevant medical records, proper consideration of lay statements, and sufficient rationales. The Board also finds the lay statements by the Veteran, his coworkers, and his daughter to be competent, credible, and probative as to their first-hand observations, with the exception of the observation of panic attacks by the Veteran's coworkers, as such a diagnosis requires medical expertise. See Jandreau, 492 F.3d at 1377; 38 C.F.R. § 3.159(a). Accordingly, the Board finds that competent and probative medical and lay evidence is at least in equipoise as to whether the Veteran's psychiatric symptoms resulted in 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) prior to December 14, 2015. Specifically, the Board finds that the exhibited symptoms of depressed mood, anxiety, suspiciousness, chronic sleep impairment, and mild memory loss resulting in social and occupational impairment support the finding of a higher rating. The Board engaged in a holistic analysis of the severity, frequency, and duration of the signs and symptoms of the Veteran's psychiatric disability, but finds that his mental health symptoms do not more nearly approximate a 50 percent rating prior to December 14, 2015. In fact, the Veteran's symptoms of depressed mood, anxiety, suspiciousness, and chronic sleep impairment, are specifically contemplated under the rating criteria for a 30 percent evaluation. See 38 C.F.R. § 4.130 Regarding employment, the Veteran reported working as a maintenance supervisor from October 2000 to February 2010. 08/18/2010, Medical-SSA. The Board notes that the Veteran's specific occupation would require skills such as logical thinking and employing good judgment and involve interacting with others. Upon 2010 VA examination, he demonstrated no delusions, ability to understand outcome of behavior, average intelligence, and unremarkable thought process and content. Regarding social impairment, the Veteran's 30 percent rating accounts for his lack of friends and diminished interest in hobbies. The Board notes that the evidence reflects that the Veteran had good relationships with his family and a few friends, including at work, weighs against a higher rating as such evidence shows that he can establish and maintain effective work and social relationships. In finding that the weight of the competent evidence does not support occupational and social impairment with reduced reliability and productivity, the Board has also considered as a factor that the evidence does not demonstrate such symptoms as circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- or long-term memory; impaired judgment; or impaired abstract thinking. See 38 C.F.R. § 4.130. All possible applicable diagnostic codes have been considered, but the Veteran could not receive a higher or separate rating for a psychiatric disability prior to December 14, 2015. See 38 C.F.R. § 4.130. Indeed, when a disorder is listed in the Rating Schedule, such as the Veteran's service-connected depressive disorder and anxiety, rating by analogy is not appropriate. Copeland v. McDonald, 27 Vet. App. 333, 336-37 (2015). 2. As of December 14, 2015 After reviewing the relevant medical and lay evidence and applying the above laws and regulations, the Board finds that an initial disability rating in excess of 50 percent for a psychiatric disability as of December 14, 2015, is not warranted. On December 14, 2015, a VA examiner noted that the Veteran had not been active in mental health treatment with VA providers since March 2012 and that he did not appear to be utilizing psychoactive medications at that time. The VA examination reflects symptoms of depressed mood, anxiety, chronic sleep impairment, mild memory loss, flattened affect, and disturbance of motivation and mood. The Veteran did not report panic-level symptoms and denied suicidal impulses or intent, but admitted to morbid thinking revolving around the impact of his medical problems. The examiner noted the following behavioral observations: slowed speech pace and flat invariant affective prosody; the Veteran reported some subjective short-term memory deficits but performed normally on a confrontation mental status examination; verbal abstraction skills were mildly concrete, but no other obvious neurocognitive deficits were observed; mood and affect were flat, invariant, and mildly depressed; evidence of anxiety; alert and oriented to all spheres; no evidence of loose associations, blockages of thought, nor any other indicators of major psychotic level mental disorder; and evidence of persistent depression in the form of isolation, withdrawal, and lowered energy levels. Based on the foregoing, the examiner opined that the Veteran's psychiatric symptoms result in occupational and social impairment with reduced reliability and productivity. 01/09/2016, C&P Exam. The examiner noted that he could not differentiate what portion of occupational and social impairment is due to depression versus posttraumatic stress disorder (PTSD). Accordingly, the Board will give the Veteran the benefit of the doubt and consider all mental health symptoms as part of his service-connected psychiatric disability. See Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam) (explaining that VA must apply the benefit of the doubt doctrine and attribute the inseparable effects of a disability to the claimant's service-connected disability). A May 2017 VA examination indicates symptoms of depressed mood, anxiety, chronic sleep impairment, flattened affect, disturbance of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. A mental status examination revealed mild spontaneous conversation on a few instances, but was otherwise unremarkable. Based on the foregoing, the examiner opined that the Veteran's psychiatric symptoms result in 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. The examiner remarked that the Veteran is likely to evidence frequent tardiness and/or absenteeism; may display lethargy and fatigue; is prone to making careless errors, leaving tasks incomplete, or taking an inordinate amount of time to complete tasks; and is likely to struggle with executive functioning (i.e., planning, organization, attention, concentration). 05/10/2017, C&P Exam. The Board finds the December 2015 and May 2017 VA examinations to be competent, credible, and highly probative, as they are supported by in-person examinations, mental health expertise, review of the relevant medical records, proper consideration of lay statements, and sufficient rationales. Accordingly, the Board finds that the weight of the competent and probative medical and lay evidence is against finding that the Veteran's mental health symptoms result in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood as of December 14, 2015. The Board engaged in a holistic analysis of the severity, frequency, and duration of the signs and symptoms of the Veteran's psychiatric disability, but finds that his mental health symptoms do not more nearly approximate a 70 percent rating as of December 14, 2015. In fact, the Veteran's symptoms of restricted affect, depressed mood, difficulty in understanding complex commands, impairment of short-term memory, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships are specifically contemplated under the rating criteria for a 50 percent evaluation. See 38 C.F.R. § 4.130 Regarding social impairment, the Veteran's 50 percent rating accounts for his lack of friends and diminished interest in hobbies. Indeed, the 2017 VA examiner, stated that the examination of the Veteran revealed a good ability to make and maintain social relationships. Additionally, this examination report reflects that the Veteran had good relationships with his family members. In finding that the weight of the competent evidence does not support occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, the Board has also considered as a factor that the evidence does not demonstrate symptoms such 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; spatial disorientation; or neglect of personal appearance and hygiene. See 38 C.F.R. § 4.130. All possible applicable diagnostic codes have been considered, but the Veteran could not receive a higher or separate rating for his psychiatric symptoms as of December 14, 2015. See 38 C.F.R. § 4.130. Indeed, when a disorder is listed in the Rating Schedule, such as the Veteran's service-connected depressive disorder and anxiety, rating by analogy is not appropriate. Copeland, 27 Vet. App. at 336-37. B. Cellulitis The Veteran contends that he is entitled to an initial compensable rating for cellulitis of the left leg. The Board notes that Diagnostic Code 7820 for infections of the skin not listed elsewhere instructs the rater to rate the disability as disfigurement of the head, face, or neck (DC 7800), scars (DCs 7801, 7802, 7803, 7804, or 7805), or dermatitis (DC 7806), depending on the predominant disability. 38 C.F.R. § 4.118, DC 7820. Accordingly, the Veteran's skin disability has been evaluated as noncompensable under the hyphenated Diagnostic Code 7899-7806. 38 C.F.R. § 4.27 (2017). Under Diagnostic Code 7806, dermatitis or eczema affecting more than 40 percent of the entire body or more than 40 percent of exposed areas or; requiring constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs during the past 12-month period warrants a 60 percent rating. 38 C.F.R. § 4.118, DC 7806. Dermatitis or eczema affecting 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas, or; requiring systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of six weeks or more, but not constantly, during the past 12-month period warrants a 30 percent rating. Id. Dermatitis or eczema affecting at least five percent, but less than 20 percent, of the entire body, or at least five percent, but less than 20 percent, of exposed areas, or; requiring intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of less than six weeks during the past 12-month period warrants a 10 percent rating. Id. After reviewing the relevant medical and lay evidence and applying the above laws and regulations, the Board finds that an initial compensable rating for cellulitis of the left leg is not warranted. In October 2010, a VA examiner noted a 1972 diagnosis of cellulitis of the left leg, but found that cellulitis had been resolved, observing that the left leg was free of any obvious residuals of cellulitis/abscess. In fact, the Veteran denied residuals of cellulitis of the left leg. 10/25/2000, VA Examination. In May 2017, a VA examiner found no evidence of current cellulitis and noted that there has been no treatment for or debilitating episodes of cellulitis in the past 12 months. The report reflect a diagnosis of cellulitis left leg, asymptomatic. 06/06/2017, C&P Exam. The Board finds the October 2010 and May 2017 VA examinations to be competent, credible, and highly probative, as they are supported by in-person examinations, medical expertise, review of the relevant medical records, and sufficient rationales. Accordingly, the Board finds that the weight of the competent and probative evidence is against finding cellulitis affecting at least five percent of the total body or exposed areas or requiring intermittent systemic therapy during any of the period on appeal. See 38 C.F.R. § 4.118, DC 7806. All possibly applicable diagnostic codes have been considered in compliance with Schafrath, 1 Vet. App. at 593, but the Veteran could not receive a higher disability rating for his cellulitis of the left leg based on the competent evidence as described above. See 38 C.F.R. § 4.118. ORDER An initial disability rating of 30 percent, but no higher, for a psychiatric disability prior to December 14, 2015, is granted. An initial disability rating in excess of 50 percent for a psychiatric disability as of December 14, 2015, is denied. An initial compensable rating for cellulitis of the left leg is denied. REMAND In May 2017, the Veteran reported that he has chronic dizziness and syncopal episodes, which the Veteran attributes to medication he took in 2010 and 2011 to treat his service-connected Hepatitis C. The Veteran notes that his first syncopal episode occurred while he was on the Hepatitis C medication. The AOJ should obtain an addendum opinion as to whether the Veteran's current symptoms of dizziness and syncopal episodes are attributable to medication he took to treat Hepatitis C. In its December 2015 Remand, the Board inferred a claim for TDIU under Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). The Board finds that the TDIU matter was not appropriately developed prior to adjudication of the claim in a June 2017 supplemental statement of the case (SSOC). Accordingly, the case is REMANDED for the following actions: 1. Obtain and associate with the virtual file all outstanding VA treatment records from July 2016 to present. If such records are missing or are otherwise unavailable, this fact should be documented and a formal finding of unavailability should be made with notice to the Veteran. 2. Send appropriate notice to the Veteran regarding TDIU and complete any necessary development. This should include sending the Veteran an application form (VA Form 21-8940) and advising the Veteran of the necessity of notifying the AOJ of his employment history and his educational background for proper adjudication of this claim. 3. After completing directives #1 and #2, request that the examiner who conducted the May 2017 VA examination, or other appropriate VA examiner, provide an addendum opinion as to whether the reported symptoms of dizziness and syncopal episodes are attributable to medication he took to treat Hepatitis C. An in-person examination is not required unless deemed necessary by the examiner. The examiner should review the virtual file, including a copy of this Remand. The examiner should address the following: Whether it is at least as likely as not (50 percent or greater probability) that the Veteran's reported symptoms of dizziness and syncopal episodes are attributable to Hepatitis C, to include medication used to treat Hepatitis C. The examiner should note current symptomatology and the resulting impact on social and occupational functioning, if any. A comprehensive rationale for all opinions is to be provided. All pertinent evidence, including both lay and medical, should be considered. If an opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner (does not have the knowledge or training). If the inability to provide an opinion without resorting to speculation is due to a deficiency in the record (additional facts are required), the AOJ should develop the claim to the extent it is necessary to cure any such deficiency. If the inability to provide an opinion is due to the examiner's lack of requisite knowledge or training, then the AOJ should obtain an opinion from a medical professional who has the knowledge and training needed to render such an opinion. 4. Thereafter, if any benefit sought on appeal remains denied, issue a supplemental statement of the case. Then, return the case to the Board, if otherwise in order. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ Paul Sorisio Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs