Citation Nr: 0007779 Decision Date: 03/23/00 Archive Date: 03/28/00 DOCKET NO. 93-03 922 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri THE ISSUES 1. Entitlement to service connection for a chronic respiratory disorder, to include asthma and chronic obstructive pulmonary disease (COPD), claimed as secondary to exposure to mustard gas. 2. Entitlement to an increased rating for right sacroiliac sprain, with right hip and right leg involvement (right sacroiliac disorder herein), currently evaluated as 10 percent disabling. 3. Entitlement to an increased (compensable) evaluation for malaria. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The veteran ATTORNEY FOR THE BOARD K. Ehrman, Counsel INTRODUCTION The veteran had active military service from January 1943 to November 1945. This matter initially came before the Board of Veterans' Appeals (Board) on appeal from a November 1991 RO rating decision, which, among other actions not on appeal, denied increased disability evaluations for the veteran's service- connected right sacroiliac and malaria disorders. Since then, the veteran has also completed an appeal of a June 1995 RO rating decision which denied a claim of service connection for a chronic respiratory disorder, to include asthma and COPD, claimed as due to exposure to mustard gas during his military service. In October 1995, the RO granted secondary service connection for right hip and right leg disorders, expanding the veteran's service-connected right sacroiliac disorder to include such secondary right hip and leg involvement. The 10 percent evaluation was continued for this expanded disability, and the appeal continued. Both in January 1995 and August 1996, the Board remanded the appeal for various development which has now been completed with regard to the above two claims for increased ratings. Additionally, in August 1996, the Board denied service connection for a left shoulder disorder. The veteran also failed to complete an appeal of his claims for service connection for degenerative disc disease and degenerative joint disease of the lumbosacral spine, which were denied by RO rating decisions of November 1996 and April 1997. Service connection for post-traumatic stress disorder (PTSD) was granted at the RO in October 1999. Accordingly, these matters are not on appeal before the Board. FINDINGS OF FACT 1. Service-connected sacroiliac sprain, with right hip and leg involvement, is manifested by: a full range of motion of the right hip joint; degenerative joint disease of the right hip, consistent with age-related arthritis; complaints of radiating pain into the right leg and hip, occasionally into the toes; tenderness over the right hip and right sacroiliac joints on examination; with additional demonstration of lumbosacral strain, with degenerative joint disease consistent with age-related arthritis; muscle spasm; and limitation of motion of the lumbosacral spine. 2. The veteran last manifested malarial symptomatology in 1949; competent medical evidence of record exhibits no chronic malarial residuals, or current disability associated with malaria. CONCLUSIONS OF LAW 1. The criteria for no more than a 20 percent rating for sacroiliac sprain, with right hip and leg involvement, are met. 38 U.S.C.A. §§ 1155, 5107, 7104 (West 1991); 38 C.F.R. §§ 4.20, 4.40, 4.45, 4.71a, including Diagnostic Codes 5250, 5251, 5252, 5253, 5294, 5295 (1999). 2. The criteria for a compensable disability evaluation for malaria are not met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. § 4.88b, Diagnostic Code 6304 (1996 & 1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Increased Ratings As a preliminary matter, the Board finds that the veteran's claims for increased ratings are "well grounded" within the meaning of 38 U.S.C.A. § 5107(a) (West 1991). See Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). That is, the Board finds that the veteran has presented claims which are not implausible when his contentions and the evidence of record are viewed in a most favorable light. The Board is also satisfied that all relevant facts have been properly and sufficiently developed. Accordingly, no further assistance to the veteran is required to comply with the duty to assist mandated by 38 U.S.C.A. § 5107(a) (West 1991). Disability evaluations are determined by the application of a schedule of rating disabilities that is based, as far as can practicably be determined, on the average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. § 4.1 (1999). Each service-connected disability is rated on the basis of specific criteria identified by diagnostic codes. 38 C.F.R. § 4.27 (1999). Although regulations require that a disability be viewed in relation to its recorded history, 38 C.F.R. §§ 4.1, 4.2 (1999), where entitlement to compensation has already been established, and an increase in a disability rating is at issue, it is the present level of disability which is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). Where there is a question as to which of two evaluations shall be applied, 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. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. When the evidence is in relative equipoise, the veteran is accorded the benefit of the doubt. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). Sacroiliac Sprain, with Right Hip and Leg Involvement The veteran complains of right constant sacroiliac, hip and leg pain, as well as associated functional impairment. The majority of his complaints, however, regard low back pain associated with lumbosacral degenerative joint and lumbosacral degenerative disc disease. As noted in the Introduction section of this Board decision, the veteran failed to complete an appeal of the RO's November 1996 and April 1997 denials of his claims of secondary service connection for lumbosacral degenerative joint disease and degenerative disc disease. Accordingly, in this context, his complaints would not usually be for consideration at the Board. However, VA regulations require that the lumbosacral and sacroiliac joint be considered as one anatomical segment for rating purposes. See 38 C.F.R. § 4.66 (1999). Given the above, a brief historical note is indicated for clarity. Service connection for right sacroiliac sprain was established by RO rating decision dated in November 1946. As noted in that rating decision, a September 1946 VA examination report was negative for x-ray evidence of any skeletal injury of the lower dorsal, lumbar and sacral spine, or the coccyx. A diagnosis of right, mild sacroiliac sprain was made, primarily upon complaints and demonstrated sacroiliac tenderness, with notation of no limitation of motion of the low back. Service-connection was established for sacroiliac sprain, in partial recognition of a November 1944 in-service x-ray which revealed an upward and left tilt of the pelvis toward the lumbosacral area. A 10 percent rating for the veteran's service-connected sacroiliac sprain has remained in effect from September 1946. Disability of the musculoskeletal system is bases primarily on 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 absence of part or all of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology or it may be due to pain supported by adequate pathology. Weakness is as important as limitation of motion and a part which becomes painful on use must be regarded as disabled. 38 C.F.R. § 4.40. As regards the joints, the factors of disability reside in reductions of their normal excursions of movements in different planes. Inquiry will be directed to less movement than normal, more movement than normal, excess fatigability, incoordination, impaired ability to execute skilled movements smoothly, pain on movement, swelling, deformity or atrophy of disuse. For the purpose of rating disability from arthritis, the hip is considered a major joint. The lumbosacral articulation and both sacroiliac joints are considered to be a group of minor joints, ratable on disturbance of lumbar spine functions. 38 C.F.R. § 4.45. With any form of arthritis, painful motion is an important factor of disability. It is the intention of the schedule 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. The common cause of disability of the sacroiliac joint is arthritis. It is significant to note that the lumbosacral and sacroiliac joints should be considered as one anatomical segment for rating purposes. 38 C.F.R. § 4.66. The variability of residuals following fractures of the pelvis necessitates rating on specific residuals, faulty posture, limitation of motion, muscle injury, painful motion of the lumbar spine, manifested by muscle spasm, mild to moderate sciatic neuritis, peripheral nerve injury, or limitation of hip motion. 38 C.F.R. § 4.67. Full range of motion of the hip is from zero to 125 degrees of flexion and from zero to 45 degrees of abduction. 38 C.F.R. § 4.71, Plate II. Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a, Diagnostic Code 5003. The veteran's service connected right sacroiliac disorder is rated primarily on the basis of limitation of motion of the thigh. Extension of the thigh limited to 5 degrees warrants a 10 percent evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5251. Limitation of flexion of the thigh to 45 degrees warrants a 10 percent evaluation; limitation to 30 degrees warrants a 20 percent evaluation; limitation to 20 degrees warrants a 30 percent evaluation; and, limitation to 10 degrees warrants a 40 percent evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5252. The veteran's right sacroiliac, hip and leg disorder is shown to include a range of motion which was within normal limits on repeated VA examination. See Reports of VA examinations dated in August 1992 and September 1995, as well as March 1997 and May 1999. Consideration has been given to VA and private treatment records, which primarily show treatment for non-service-connected low back disorders, including degenerative joint disease and degenerative disc disease of the lumbosacral spine. It is noted that while the veteran's right sacroiliac and right hip joints were normal on VA x-ray testing in September 1995, degenerative disease was found on VA examination in March 1997. Significantly, however, the March 1997 VA examining physician was of the medical opinion that both the veteran's degenerative joint disease of the lumbosacral spine and the bilateral hips were consistent with the veteran's age. Accordingly, given the normal range of motion of the right hip, and in light of this VA examiner's medical opinion, the Board finds that the criteria for an increased rating based on limitation of motion of the right hip is not demonstrated: Diagnostic Codes 5251, 5252 and 5253 provide no basis for an evaluation in excess of 10 percent, based on limitation of motion. The Board also notes that a rating greater than 10 percent would be warranted where the evidence showed favorable ankylosis of the hip in flexion at an angle between 20 degrees and 40 degrees, and slight adduction or abduction (Diagnostic Code 5250); flail joint of the hip (Diagnostic Code 5254); or fracture of the shaft or anatomical neck of the femur, with nonunion, without loose motion, and with weight-bearing preserved with the aid of a brace; fracture of the surgical neck of the femur with false joint; or malunion of the femur with moderate knee or hip disability (Diagnostic Code 5255). 38 C.F.R. § 4.71a. However, the medical evidence does not show ankylosis of either hip, nor does the evidence show fracture or malunion of the femur. Thus, an evaluation under these diagnostic codes would not be appropriate. Diagnostic Code 5294 directs that sacroiliac injury and weakness is evaluated as lumbosacral strain. See also 38 C.F.R. § 4.66. The Board considers this code provision, although a medical history of sacroiliac injury is not clear. The criteria for ascertaining the degree of severity of impairment caused by sacroiliac injury and weakness, rated as lumbosacral strain, are delineated in Diagnostic Code 5295. Under this code, a 10 percent evaluation may be granted with a showing of characteristic pain on motion. If muscle spasm on extreme forward bending or loss of lateral spine motion is demonstrated, a 20 percent rating may be assigned. In order to merit a 40 percent evaluation, however, the lumbosacral strain must be severe, with listing of the whole spine to the opposite side, positive Goldwaithe's sign, marked limitation of forward bending in a standing position, loss of lateral motion with osteoarthritic changes, or narrowing or irregularity of joint space, or some of the above with abnormal mobility on forced motion. The criteria for a 40 percent evaluation for the veteran's sacroiliac disorder, rated as lumbosacral strain under Diagnostic Code 5295, are not met, primarily as no severe lumbosacral strain is demonstrated by the medical evidence of record. As noted earlier above, a March 1997 VA examiner's medical opinion was that there is no relationship between the veteran's lumbosacral spine degenerative joint disease and service-connected sacroiliac disorder. Of primary weight, however, is the lack of demonstration of such severe symptomatology as to warrant a 40 percent rating under Diagnostic Code 5295: there was no showing of any listing of the whole spine to opposite side, positive Goldthwait's sign, loss of lateral motion, or abnormal mobility of forced motion. On most recent VA examination in May 1999, forward flexion was to 30 degrees without pain, 40 degrees with pain; extension was limited to 10 degrees without pain, to 20 degrees with pain; and right and left rotational movements were restricted to 75%; and lower extremity strength was 4-/5 bilaterally. Accordingly, the Board is of the opinion that the criteria for a 40 percent rating are not met or more closely approximated under Diagnostic Code 5295. The Board is also of the opinion that the criteria for a 20 percent evaluation are essentially met. The veteran's service connection sacroiliac disorder includes arthritis of the hip joint, and his complaints of constant pain, including pain which radiates into the right leg, are given due consideration. Muscle spasm of the lumbosacral spine was demonstrated on VA examination in September 1995, and all of the evidence of record shows some limitation of motion of the lumbosacral spine. With application of 38 C.F.R. §§ 4.40, 4.45, as well as 4.66, a 20 percent evaluation under Diagnostic Code 5295 is warranted for service-connected sacroiliac sprain, with right hip and leg involvement. In finding so, the Board has given due consideration to the veteran's complaints of constant pain and resulting functional impairment. However, the Board is of the opinion that any pain and functional impairment due to service- connected sacroiliac disorder equates to no more than lumbosacral strain with muscle spasm on extreme bending or loss of lateral spine motion, which, in turn, warrants no more than a 20 percent evaluation. On VA examination in September 1995, and since then, the veteran reports, and examinations confirm, a constant "dull aching" to "sharp" low back pain -- particularly in the right sacroiliac joint. The pain radiates to the right hip and down the lateral aspect of the right leg, occasionally radiating to the toes. As noted above, on more recent VA examination in May 1999, lower extremity strength was 4-/5, bilaterally, and while sensation was intact to light bilateral touch, deep tendon reflexes were reduced to 1/4 for bilateral knee and ankle jerks. The pain is reportedly aggravated by almost all activities, particularly by lifting, stooping, bending, riding sitting, and driving an automobile. In finding so, the Board notes that on VA examinations there was no swelling, redness, heat, subluxation, or deformity of the right hip. The veteran also displayed brisk deep tendon reflexes. The Board finds that although the veteran's subjective pain certainly causes some discomfort, he does not exhibit any functional loss due to pain which would warrant a rating in excess of 20 percent under the provisions of 38 C.F.R. §§ 4.40, 4.45 and 4.59. The veteran has not alleged receiving any medical treatment for his sacroiliac, right hip and leg disorders, other than physical therapy which was completed several years ago. Additionally, private treatment records of March 1999 show the veteran reporting thoracic and lumbosacral spine pain subsequent to a motor vehicle accident in November 1998. The evidence of record supports no more than a 20 percent evaluation for service-connected sacroiliac disorder, with right hip and leg involvement. 38 U.S.C.A. §§ 1155, 5107, 7104 (West 1991); 38 C.F.R. §§ 4.20, 4.40, 4.45, 4.71a, including Diagnostic Codes 5250, 5251, 5252, 5253, 5294, 5295 (1999). Additional argument is contained in the Final Considerations portion of the instant Board decision. Malaria A 10 percent disability evaluation is warranted for malaria which has been recently active with one relapse in the preceding year, or for old cases of malaria with moderate disability. 38 C.F.R. Part 4, Diagnostic Code 6304 (1996). After malaria has been identified by clinical and laboratory methods or by clinical methods alone where the disease is endemic, determinations as to residual disability should be based upon the clinical course of the disease; the frequency and severity of recurrences; and the necessity for and the reaction to medication rather than the presence or absence of parasites. When there have been relapses following the initial course of treatment, further relapses are to be expected and for some time, the veteran must be given the benefit of the doubt as to unexplained fever of short duration which is controlled by medication specific for treatment of malaria. 38 C.F.R. § 4.88b (1996). In 1996, the rating criteria applicable for evaluation of malaria were revised. Under the revised criteria, a 100 percent rating is assigned for malaria as an active disease. Thereafter, malaria is to be rated on the basis of residuals such as liver or spleen damage. 38 C.F.R. Part 4, Diagnostic Code 6304 (1999). The diagnosis of malaria depends on the identification of the malarial parasites in blood smears. If the veteran served in an endemic area and presents signs and symptoms compatible with malaria, the diagnosis may be based on clinical grounds alone. Relapses must be confirmed by the presence of malarial parasites in blood smears. 38 C.F.R. § 4.88b (1999). In various written statements following in July 1991 claims, the veteran argues that he monthly experiences "chills," a "freezing sensation, " and sweats since 1994. He denies any treatment, however, other than over the counter medications. The evidence of record shows no active malaria, or any resulting disability. In December 1996, the veteran denied any tuberculosis or exposure. A chest X-ray revealed an old healed granulomatous disease, otherwise normal for the patient's age. On VA systemic examination in March 1997, the veteran was found to have no jaundice, and left upper quadrant tenderness, but with no hepatosplenomegaly clinically. Malaria smears, both thick and thin, were negative. The examiner found no renal impairment, normal mental changes, and no other pertinent findings. The diagnosis was no active disease, and no evidence of significant disability residual effect. While the veteran is shown to receive occasional treatment for what he reports as "chills," no examiner has associated his complaints with past malaria or residuals of past malaria. See VA treatment records dated in January 1998. The veteran is not competent, as a lay person, to offer an opinion as to medical diagnosis or nexus. See Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). The veteran's statements that his "chills" are residuals of past malaria tend to advance an unsupported medical conclusion. Id. A longitudinal review of the record indicates that the veteran last exhibited malarial symptoms in May 1949. See VA examination report dated in August 1949. Although the veteran is competent to report that he is worse, the opinions of competent professionals are more probative than his own lay statement. Examining VA physicians have identified no recent malarial symptoms. There is no evidence of fever controlled by medication specific for treatment for malaria. The Board observes that the most recent clinical documentation of record shows no current malaria-related disability. In light of such objective medical findings, the Board concludes that a compensable evaluation is not warranted for malaria, under either the criteria previously in effect or the revised rating criteria effective in 1996. Final Considerations An extraschedular evaluation may be warranted under 38 C.F.R. § 3.321(b)(1) only if the case presents such an exceptional or unusual disability picture, with such related factors as marked interference with employment or regular periods of hospitalization, as to render impractical the application of the regular schedular standards. In the present case, the evidence does not establish this. In particular, neither the veteran's service-connected malaria nor his sacroiliac sprain, with right hip and leg involvement, have required frequent periods of hospitalization; nor has marked interference with employment been shown. In this regard, it is noted that the veteran's primary argument on appeal is that he is impaired as a result of low back disability, which includes non-service- connected degenerative joint disease and degenerative disc disease. While his non-service-connected low back disorders require on-going treatment, there is no recent hospitalization or regular treatment for service-connected sacroiliac disorder. Accordingly, there is no extraschedular basis for an evaluation in excess of 20 percent. 38 C.F.R. § 3.321(b). Similarly, as no hospitalization or treatment is shown for the veteran's malaria, no extraschedular basis for more than a noncompensable evaluation is warranted for service-connected malaria. Id. It is also noted that the veteran's service-connected sacroiliac sprain, with right hip and leg involvement, is not shown to have resulted in any impairment of ability to engage in employment. It bears emphasis that, "[g]enerally, the degrees of disability specified [in the rating schedule] are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." 38 C.F.R. § 4.1. In this case, the record does not establish that the sacroiliac sprain constitutes any more of an interference with employment than would be found in the case of any other individual with a 20 percent rating for this disability. The evidence does not show that the circumstances of the veteran's individual disability render impractical the application of the regular schedular standards for the rating of a service-connected disability. Therefore, a preponderance of the evidence establishes that the service-connected residuals of the veteran's right sacroiliac sprain are not of such nature or severity as to satisfy the criteria for a rating higher than 20 percent under any of the applicable codes. Since the positive and negative evidence in this matter is not in relative equipoise, the benefit of the doubt rule does not apply. 38 U.S.C.A. § 5107(b) (West 1991). The Board finds that the RO's conclusion that the veteran's claim did not meet the criteria for submission of the case to appropriate VA officials in the Central Office for consideration of an extraschedular rating was consistent with the evidence of record. ORDER A 20 percent evaluation for service-connected sacroiliac sprain, with right hip and leg involvement, is granted subject to the controlling regulations governing the award of monetary benefits. The claim for an increased (compensable) rating for service- connected malaria is denied. REMAND In written statements dated or received at the RO in February and November 1995, the veteran asserts that he was exposed to mustard gas in the active service of the military in February 1943, while stationed at Ft. Knox, Kentucky. While his service medical records do not reflect any such exposure, additional necessary development remains to be completed prior to any determination as to the validity of his claim. It is noted that evidentiary assertions by the veteran must be accepted as true for the purposes of determining whether a claim is well grounded, except where the evidentiary assertion is inherently incredible or when the fact asserted is beyond the competence of the person making the assertion. King v. Brown, 5 Vet. App. 19, 21 (1993). Under 38 C.F.R. § 3.316 (1999), exposure to mustard gas while participating in full-body, field, or chamber experiments to test protective clothing or equipment during World War II, together with the development of a chronic form of any of the following conditions manifested subsequent thereto, is sufficient to establish service connection for that condition: conjunctivitis, keratitis, corneal opacities, scar formation, laryngitis, bronchitis, emphysema, asthma or chronic obstructive pulmonary disease, acute non-lymphocytic leukemia, or various cancers not listed here. (Emphasis added). While the veteran initially claimed service connection for only asthma, due to reported mustard gas exposure, he supported his claim of service connection with VA medical records showing treatment for COPD. The issue has, accordingly, been recharacterized to comport with the essence of his assertions. The above regulation codifies the VA's acknowledgment that certain chronic disabilities may have been caused by inservice exposure to mustard gas during chemical warfare testing conducted by the Navy from 1942 to 1945, and the Army dating from World War II until 1975. See VA Adjudication Procedures Manual, M21-1, Part III, para. 5.18 (added by Change 55, Apr. 30, 1996) (VA Manual herein). The regulation does not require the development of the disease within any specified time period during or post service. Additionally, the VA Manual contemplates certain preliminary development at the RO, including contacting the National Personnel Records Center (NPRC herein) and requesting confirmation of any participation in any field or chamber tests. Specifically, there is no indication within the record that inquiry was made through NPRC or other appropriate channels for information regarding the veteran's alleged participation in mustard gas "chamber" experiments. See veteran's statements of mustard gas exposure dated in February 1995 and November 1995. Additionally, no NPRC inquiry was made nor was the VA's Office of the Director of C & P Services contacted and asked to determine whether the veteran's name was on the VA's Mustard Gas Testing List. Accordingly, this specific mustard gas exposure development should be undertaken by the RO. As explanatory comment, in the recent case of Pearlman v. West, 11 Vet. App. 443 (1998), the United States Court of Appeals for Veterans Claims (Court) addressed the application of 38 C.F.R. § 3.316 in determining the well groundedness of claims such as the veteran's. The Court indicated that under 38 C.F.R. § 3.316, the initial burden for a well-grounded claim was relaxed for veterans who subsequently developed conditions specified by the regulation, to the extent that the regulation did not require evidence of a medical nexus for those conditions, but rather a nexus was presumed if the other conditions required by the regulation were met. Pearlman at 446. The Court specified that "the veteran is relieved of his burden of providing medical evidence of a nexus between the current disability and the in-service exposure. Rather, service connection is granted if the appellant has experienced: (1) full body exposure, (2) to the specified vesicant agent, (3) during active military service, and (4) has subsequently developed the specified conditions;" subject to the regulatory exceptions in paragraph (b). Id. The Board notes that, in Pearlman, the claimant had stated that the veteran had participated in secret testing involving mustard gas exposure and he had subsequently developed respiratory disorders which were among the conditions specified within 38 C.F.R. § 3.316. Although all efforts by VA to substantiate his claimed exposure were unsuccessful, the Court held "that for the purpose of submitting a well- grounded claim relating to exposure to toxic gases under this regulation, the Board must assume that the lay testimony of exposure is true." Pearlman at 447. However, the Court further noted that "whether or not the veteran meets the requirements of this regulation, including whether or not the veteran was actually exposed to the specified vesicant agents, is a question of fact for the Board to determine after full development of the facts." Id. (Emphasis added). In the instant case, the RO must complete the above requested development, prior to making any further determination of the claim. Accordingly, this case is remanded for the following development: 1. The RO should appropriately contact the veteran and request that he specifically identify any post-service medical records regarding treatment for any respiratory disorder, to include asthma or COPD, including records of ongoing treatment for disabilities from November 1945 to the present. The veteran should be requested to obtain, from all private medical sources, any available medical records for his claimed conditions, from November 1945 to the present time, in order to support his claim. The RO also should review the entire claims file and prepare a summary including the veteran's name, claim number, social security number, military identification number, branch of service, units to which the veteran was assigned, dates and locations of the alleged mustard gas or other vesicant agent exposure in service, details of the alleged exposure (including types of gas to which he believes he was exposed), and any other pertinent information, including alleged medical symptoms or treatment after exposures. The veteran should be appropriately contacted, provided a copy of this summary, and asked to make any necessary additions or corrections. The veteran should be advised that it is vitally important that he fully cooperate in the effort to provide as specific information as possible, since an effective search for additional records may depend heavily upon the quantity and quality of the information he supplies. He should also be requested to supply any buddy statements or documentary evidence of his participation in experiments or subsequent treatment. 2. The RO should contact the Compensation and Pension Service, through the Program Management Staff, and request verification as to whether the veteran's name is on any list of Army volunteers who participated in any chemical testing during W.W. II. The results of this request should be documented, with a copy maintained in the claims file. 3. The RO should also request any service and personnel records pertinent to the alleged mustard gas exposure, including any exposure of the veteran in February 1943 at Ft. Knox, Kentucky, through the National Personnel Record Center, by submitting a VA Form 3101, Request for Information. A cross- referenced request should also be made to: Commander, U.S. Army Chemical and Biological Defense Agency, Attn: AMSCB-CIH Aberdeen Proving Ground, MD 21010- 5423. The results of these requests must be documented, with copies maintained in the VA claims file. 4. After the above is complete, and all reports are associated with the claims folder, and if the veteran is found to have been exposed to mustard gas, then the veteran should be afforded a VA examination by an appropriate specialist for diagnosis of all current disabilities of the respiratory system. The claims folder including a copy of this remand must be made available to, and reviewed by, the specialist prior to examination. If the veteran was found to have been exposed to mustard gas, and if the veteran is diagnosed with COPD, emphysema, asthma, or chronic bronchitis, the examiner should express an opinion as to whether or not such disability is clearly the result of a supervening non- service related cause. 5. Thereafter, the RO should readjudicate the veteran's claim of entitlement to service connection for a respiratory disorder, to include asthma and COPD, claimed as due to mustard gas or other vesicant agent exposure, considering all applicable criteria including, but not limited, to 38 C.F.R. § 3.316. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded to the regional office. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment by the RO. 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 The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 1999) (Historical and Statutory Notes). In addition, VBA's Adjudication Procedure Manual, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44- 8.45 and 38.02-38.03. D. C. Spickler Member, Board of Veterans' Appeals