Citation Nr: 0602720 Decision Date: 01/31/06 Archive Date: 02/07/06 DOCKET NO. 93-06 131 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUES 1. Entitlement to service connection for a skin disorder, as a residual of Agent Orange exposure. 2. Entitlement to service connection for a disability manifested by paralysis of the neck, as a residual of Agent Orange exposure. 3. Entitlement to service connection for a disability manifested by paralysis of the shoulders, as a residual of Agent Orange exposure. (The issues of entitlement to an effective date earlier than January 23, 1991, for the grant of service connection for residuals of leech bites, entitlement to a rating in excess of 30 percent prior to April 8, 1997, for residuals of leech bites, and entitlement to a rating in excess of 10 percent subsequent to April 7, 1997, for residuals of leech bites, are the subject of a separate decision. See September 2001 Board remand decision which addressed the aforementioned issues and directed the RO to schedule the veteran for a Travel Board hearing.) REPRESENTATION Appellant represented by: Michael R. Viterna, Attorney at Law WITNESSES AT HEARING ON APPEAL Appellant and his wife ATTORNEY FOR THE BOARD E. Pomeranz, Counsel INTRODUCTION The appellant had active military service from January 1966 to January 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) located in Detroit, Michigan. In an October 1995 decision, the Board remanded the appellant's claim of entitlement to service connection for a skin disability, as due to residuals of leech bites or Agent Orange exposure, and the claims of entitlement to service connection for disabilities manifested by rectal bleeding, peripheral neuropathy and paralysis of the neck and shoulders, as residuals of Agent Orange exposure, to the RO for further evidentiary development. By a decision dated in November 1999, the Board granted service connection for a skin disability, to include residuals of leech bites. In the same decision, it reopened the previously denied claim of entitlement to service connection for a skin disability, claimed as a residual of Agent Orange exposure, but denied the claim as not well grounded. The Board also denied as not well grounded claims of entitlement to service connection for a disability manifested by rectal bleeding, a disability manifested by paralysis of the neck, and a disability manifested by paralysis of the shoulders, all claimed as residuals of Agent Orange exposure. In addition, in the November 1999 decision, the Board denied on the merits the claim of entitlement to service connection for peripheral neuropathy. The veteran appealed to the United States Court of Appeals for Veterans Claims (Court). In a Joint Motion for Partial Remand and to Stay Further Proceedings (Joint Motion), the parties noted that the appellant was not pursuing his appeal with respect to the claim of entitlement to service connection for a skin disability as a residual of leech bites or the claim of entitlement to service connection for peripheral neuropathy. In the Joint Motion, the parties jointly moved to vacate and remand those parts of the November 1999 Board decision that found the appellant's claims to be not well grounded. The parties observed that remand was required due to the enactment of the Veterans Claims Assistance Act of 2000 (VCAA). See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2005). In an order dated in January 2001, the Court granted the motion and vacated that part of the Board's decision that denied service connection for (1) a skin disorder; (2) a disability manifested by rectal bleeding; (3) a disability manifested by paralysis of the neck; and (4) a disability manifested by paralysis of the shoulders, all claimed as residuals of Agent Orange exposure. The Court dismissed the remainder of the appeal. By a September 2001 decision, the Board concluded that new and material evidence had been received sufficient to reopen the previously denied claim of service connection for a skin disorder, claimed as a residual of Agent Orange exposure. In the same decision, the Board remanded the appellant's claims for service connection for (1) a skin disorder; (2) a disability manifested by rectal bleeding; (3) a disability manifested by paralysis of the neck; and (4) a disability manifested by paralysis of the shoulders, all claimed as residuals of Agent Orange exposure, for development of the evidence. In an August 2004 decision, the Board denied the appellant's claim for service connection for a disability manifested by rectal bleeding, as a residual of Agent Orange exposure. In the same decision, the Board remanded the appellant's claims for service connection for (1) a skin disorder; (2) a disability manifested by paralysis of the neck; and (3) a disability manifested by paralysis of the shoulders, all claimed as residuals of Agent Orange exposure, for additional development. The issues of entitlement to service connection for a disability manifested by paralysis of the neck, and entitlement to service connection for a disability manifested by paralysis of the shoulders, both claimed as residuals of Agent Orange, will be discussed in the remand portion of this decision; these issues are remanded to the RO via the Appeals Management Center in Washington D.C. In a September 2003 letter from the appellant's attorney- representative, the appellant's attorney-representative raised the issue of entitlement to service connection for post-traumatic stress disorder (PTSD). In addition, in a September 2005 letter from the appellant, the appellant raised the issue of whether new and material evidence had been submitted to reopen a claim of entitlement to service connection for peripheral neuropathy, as a residual of Agent Orange exposure. These issues have not been developed for appellate consideration and are referred to the RO for appropriate action. By a private medical statement from C.N. Bash, M.D., dated in May 2004, Dr. Bash diagnosed the appellant with central neuropathy and opined that the appellant's central neuropathy was likely due to his in-service exposure to Agent Orange. As will be explained further in the remand portion of this decision, the Board finds that the aforementioned statement raises an inferred claim for entitlement to service connection for central neuropathy, as a residual of Agent Orange. This issue is referred to the RO for appropriate disposition. FINDING OF FACT Other than eczema and dermatitis as the residuals of leech bites, the appellant does not have a skin disorder that is a result of exposure to Agent Orange, or some other herbicide, during service. CONCLUSION OF LAW Other than eczema and dermatitis as the residuals of leech bites, a skin disorder, as a result of exposure to Agent Orange or some other herbicide, was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 5103A, 5107 (West 2002 & Supp. 2005); 38 C.F.R. § 3.303 (2005). REASONS AND BASES FOR FINDING AND CONCLUSION I. Veterans Claims Assistance Act of 2000 In November 2000, the VCAA was signed into law. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2005). Regulations implementing the VCAA are applicable to the appellant's claim. 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2005). With respect to VA's duty to notify, the RO sent a letter to the appellant's attorney-representative in February 2002, and a letter to the appellant in August 2004, in which he was notified of the types of evidence he needed to submit, and the development the VA would undertake. See Quartuccio v. Principi, 16 Vet. App. 183 (2002). The letters specifically informed the appellant what was needed from him and what VA would obtain on his behalf. Id. For example, the August 2004 the letter told him that VA would help obtain medical records, employment records, or records from other Federal agencies. The appellant was informed that he was responsible for providing sufficient information to VA so records could be requested. In addition, the Board observes that the January 2004 supplemental statement of the case provided the appellant with the text of the relevant portions of the VCAA, as well as the implementing regulations. Therefore, in light of the above, the Board finds that the VA's duty to notify has been fully satisfied, and that any defect with respect to the VCAA notice requirement in this case was harmless error. Simply put, in this case, the claimant was provided every opportunity to submit evidence. He was also provided with notice of the requirements pertinent to his service connection claim. The appellant was further provided notice of what evidence he needed to submit, and notice of what evidence VA would secure on his behalf. He was given ample time to respond. In the present case, the Board observes that it was not until after the original rating action on appeal was promulgated did the RO provide notice to the appellant regarding the duty to notify him of the evidence he must provide, and the evidence that VA would obtain on his behalf. See Pelegrini v. Principi, 17 Vet. App. 412 (2004). Nevertheless, the Board notes that in regard to the issue on appeal, there is no indication that there is additional evidence that has not been obtained and that would be pertinent to the present claim. In addition, the appellant has been afforded the opportunity to present evidence and argument in support of the claim, including at a personal hearing at the RO. Quartuccio, 16 Vet. App. at 183, 187. Moreover, the appellant has also been notified of the applicable laws and regulations that set forth the criteria for the claim for service connection for a skin disorder, as a residual of Agent Orange exposure. The discussions in the statement of the case and the supplemental statements of the case have further informed the appellant of the information and evidence necessary to warrant entitlement to the benefits sought. Hence, notwithstanding Pelegrini, to allow the appeal to continue would not be prejudicial error to the claimant. Under the facts of this case, "the record has been fully developed," and "it is difficult to discern what additional guidance VA could have provided to the veteran [appellant] regarding what further evidence he should submit to substantiate his claim." Conway v. Principi, No. 03-7072 (Fed. Cir. Jan. 7, 2004). VA also has a duty to assist the appellant in obtaining evidence necessary to substantiate a claim. 38 C.F.R. § 3.159(c). The duty to assist includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim. In this regard, the Board notes that in January 1984, April 1997, and July 2003, the appellant underwent VA examinations which were pertinent to his service connection claim. The Board further observes that in this case, there is no outstanding evidence to be obtained, either by VA or the appellant. The RO has obtained all relevant VA and private medical records identified by the appellant. Consequently, given the standard of the new regulation, the Board finds that VA did not have a duty to assist that was unmet. The Board also finds, in light of the above, that the facts relevant to this appeal have been fully developed and there is no further action to be undertaken to comply with the provisions of the regulations implementing the VCAA. Therefore, the appellant will not be prejudiced as a result of the Board proceeding to the merits of the claim. See Bernard v. Brown, 4 Vet. App. 384, 392-94 (1993). Finally, to the extent that VA has failed to fulfill any duty to notify and assist the appellant, the Board finds that error to be harmless. Of course, an error is not harmless when it "reasonably affect(s) the outcome of the case." ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed.Cir. 1998). In this case, however, as there is no evidence that any failure on the part of VA to further comply with the VCAA reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See also Mayfield v. Nicholson, 19 Vet. App. 103 (2005). II. Analysis Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a pre-existing injury suffered or disease contracted in line of duty. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Direct service connection requires a finding that there is a current disability that has a definite relationship with an injury or disease or some other manifestation of the disability during service. Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992); Cuevas v. Principi, 3 Vet. App. 542, 548 (1992). Service connection may also be granted on the basis of a post-service initial diagnosis of a disease, where the physician relates the current condition to the period of service. See Cosman v. Principi, 3 Vet. App. 503, 505 (1992). In such instances, a grant of service connection is warranted only when "all of the evidence, including that pertinent to service, establishes that the disease was incurred during service." 38 C.F.R. § 3.303(d). Alternatively, under 38 C.F.R. § 3.303(b), service connection may be awarded for a "chronic" condition when (1) a chronic disease manifests itself and is identified as such in service (or within the presumptive period under 38 C.F.R. § 3.307) and the veteran presently has the same condition; or (2) a disease manifests itself during service (or during the presumptive period), but is not identified until later, and there is a showing of continuity of related symptomatology after discharge, and medical evidence relates that symptomatology to the veteran's present condition. Savage v. Gober, 10 Vet. App. 488, 495-98 (1997). In this case, the appellant maintains that he developed a skin disorder as a result of exposure to Agent Orange in service. The Board notes that a change in the law has taken place with respect to the adjudication of claims based upon exposure to Agent Orange during service in Vietnam. On December 27, 2001, the President signed the Veterans Education and Benefits Expansion Act of 2001 (VEBEA), Pub. L. No. 107-113, 115 Stat. 976 (2001). That new statute, in pertinent part, redesignated and amended 38 U.S.C.A. § 1116(f) to provide that, for purposes of establishing service connection for a disability or death resulting from exposure to an herbicide agent, including a presumption of service connection under this section, a veteran who, during active military, naval, or air service, served in Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed during such service to an herbicide agent of the kind specified in section 1116, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. Prior to December 27, 2001, the provisions of 38 U.S.C.A. § 1116 and its implementing regulations found at 38 C.F.R. § 3.307(a)(6)(iii), were interpreted as providing that, only if a veteran who served on active duty in Vietnam during the Vietnam era developed one of the listed diseases which is presumed to have resulted from exposure to herbicides under 38 C.F.R. § 3.309(e), the veteran was then presumed to have been exposed to Agent Orange or similar herbicide. McCartt v. West, 12 Vet. App. 164 (1999). In other words, the presumption of exposure was applicable only if the veteran had one of the listed diseases specifically enumerated under 38 C.F.R. § 3.309(e). Now, the law as it currently stands provides a presumption of exposure to herbicides for all veterans who served in Vietnam during the Vietnam Era, eliminating the requirement that a veteran must also have one of the conditions specifically enumerated under 38 C.F.R. § 3.309(e) (2005). The last date on which such a veteran shall be presumed to have been exposed to a herbicide agent shall be the last date on which he or she served in the Republic of Vietnam during the Vietnam era. "Service in the Republic of Vietnam" includes service in the waters offshore and service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam. 38 C.F.R. § 3.307(a)(6)(iii) (2005). If a veteran was exposed to an herbicide agent during active military, naval, or air service, the following diseases shall be service-connected if the requirements of 38 U.S.C.A. § 1116 and 38 C.F.R. § 3.307(a)(6)(iii) are met, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 U.S.C.A. § 1113 and 38 C.F.R. § 3.307(d) are also satisfied: chloracne or other acneform disease consistent with chloracne; type II diabetes mellitus; Hodgkin's disease; multiple myeloma; non-Hodgkin's lymphoma; acute and subacute peripheral neuropathy; porphyria cutanea tarda (PCT); prostate cancer; respiratory cancers (cancer of the lung, bronchus, larynx, or trachea); and soft-tissue sarcomas (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). 38 C.F.R. § 3.309(e) (2005). The diseases listed at 38 C.F.R. § 3.309(e) shall have become manifest to a degree of 10 percent or more at any time after service, except that chloracne or other acneform disease consistent with chloracne, PCT, or acute and subacute peripheral neuropathy shall have become manifest to a degree of 10 percent or more within a year, after the last date on which the veteran was exposed to an herbicide agent during active military, naval, or air service. 38 C.F.R. § 3.307(a)(6)(ii) (2005). The Board further notes that 38 U.S.C. § 1116(a)(2)(F), as added by § 201(c) of the VEBEA, eliminated the requirement that respiratory cancers must be manifested within 30 years following service in the Republic of Vietnam. VA has determined that a presumption of service connection based on exposure to herbicides used in the Republic of Vietnam during the Vietnam era is not warranted for any condition for which VA has not specifically determined a presumption of service connection is warranted. See 59 Fed. Reg. 341-46 (1994); 61 Fed. Reg. 414421 (1996); see also 64 Fed. Reg. 59232 (1999); 67 Fed. Reg. 42600-42608 (2002). More recently, VA clarified that a presumption of service connection based on exposure to herbicides used in the Republic of Vietnam during the Vietnam Era is not warranted for the following conditions: hepatobiliary cancers, nasopharyngeal cancer, bone and joint cancer, breast cancer, cancers of the female reproductive system, urinary bladder cancer, renal cancer, testicular cancer, leukemia (other than CLL), abnormal sperm parameters and infertility, Parkinson's disease and parkinsonism, amyotrophic lateral sclerosis (ALS), chronic persistent peripheral neuropathy, lipid and lipoprotein disorders, gastrointestinal and digestive disease, immune system disorders, circulatory disorders, respiratory disorders (other than certain respiratory cancers), skin cancer, cognitive and neuropsychiatric effects, gastrointestinal tract tumors, brain tumors, light chain-associated (AL) amyloidosis, endometriosis, adverse effects on thyroid homeostasis, and any other condition for which the Secretary has not specifically determined a presumption of service connection is warranted. See 68 Fed. Reg. 27,630-41 (May 20, 2003). Notwithstanding the foregoing, the United States Court of Appeals for the Federal Circuit ruled that the Veterans' Dioxin and Radiation Exposure Compensation Standards (Radiation Compensation) Act, Pub. L. No. 98-542, § 5, 98 Stat. 2725, 2727-29 (1984) does not preclude a veteran from establishing service connection with proof of actual direct causation. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). The Court has specifically held that the provisions of Combee are applicable in cases involving Agent Orange exposure. McCartt, 12 Vet. App. at 164, 167. Initially, it is noted that service records confirm that the appellant had active service in Vietnam during the Vietnam era. The appellant's DD Form 214, Armed Forces of the United States Report of Transfer or Discharge, shows that he had active military service from January 1966 to January 1968, which included 1 year, 1 month, and 16 days of foreign service. The appellant's Military Occupational Specialty (MOS) was as an anti-tank assaultman, and he received the National Defense Service Medal, the Vietnam Service Medal, and the Vietnam Campaign Medal. Therefore, the appellant is presumed to have been exposed to herbicides in service. 38 U.S.C.A. § 1116(f). However, there is no evidence of record showing that the appellant has the specific Agent Orange skin conditions of chloracne (or other acneform disease consistent with chloracne) and/or porphyria cutanea tarda. Thus, he does not have a condition enumerated as a presumptive disability. Nevertheless, as indicated above, the appellant is not precluded from establishing service connection on a direct basis. See Combee, 34 F.3d at 1039; McCartt, 12 Vet. App. at 164. In this case, the Board has reviewed the evidence of record, to include the appellant's service medical records, medical records from the Ford Motor Company medical clinic, dated in September 1965 and February 1968, VA Medical Center (VAMC) outpatient treatment records, from January 1980 to February 1991, and from March 2000 to September 2002, a February 1980 VA initial database examination for possible exposure to toxic chemicals, a VA Hospital Summary which shows that the appellant was hospitalized from January to February 1991 for atopic dermatitis, VA examinations dated in January 1984, April 1997, and July 2003 (showing diagnoses of post inflammatory pigmentation (leech bite history), atopic dermatitis, and eczematous dermatitis, respectively), VA memorandums, dated in May and December 1998, private medical records showing treatment for eczema, dated in September 1980, a private clinical record from the University of Michigan, dated in September 1980, a private medical statement from Michael Harbut, M.D., M.P.H., dated in July 1989, along with a copy of a deposition taken from Dr. Harbut in November 1991, and a private medical statement from Dr. C.N. Bash, dated in May 2004. The aforementioned evidence primarily shows treatment for, or diagnoses of, eczema and/or dermatitis. In this regard, in the May 2004 private medical statement from Dr. Bash, Dr. Bash stated that the appellant had both eczema and atopic dermatitis, and he opined that the appellant's eczema first started while he was in the military. Specifically, Dr. Bash indicated that during service, the appellant had leech bites which likely caused his atopic dermatitis. Dr. Bash also noted that while the appellant was in the military, he was exposed to a very wet environment and that wet environments were known to aggravate or cause eczema. However, in regard to the appellant's currently diagnosed eczema and dermatitis, the appellant is already service-connected for these disorders. As per the Board's November 1999 decision, the RO, in a December 1999 rating action, granted service connection for the residuals of leech bites. Moreover, in an October 2004 rating action, the RO recharacterized the appellant's service-connected residuals of leech bites as eczema and dermatitis, as the residuals of leech bites. Thus, the appellant's service- connected skin disability includes his diagnosed eczema and dermatitis. In the instant case, there is no competent medical evidence of record which shows a connection between any skin disorder that the appellant may now have, and his in-service Agent Orange exposure. The appellant's service medical records reflect that in December 1967, the appellant was treated for multiple granulomatous lesions on his legs from leech bites. The biopsy was compatible with history of leech granulomas. No skin abnormality was noted at the appellant's service separation examination in January 1968. In addition, as stated above, the post-service evidence of record mostly shows treatment for eczema and dermatitis. In fact, at present, the appellant's only diagnosed skin disorders are his diagnosed eczema and dermatitis. In the appellant's July 2003 VA examination, the diagnosis was eczematous dermatitis. Furthermore, in the May 2004 private medical statement from Dr. Bash, Dr. Bash diagnosed the appellant with both eczema and atopic dermatitis. Thus, given that the appellant is already service-connected for eczema and dermatitis, in the absence of proof of a present skin disability, other than eczema and dermatitis, there is no valid claim. Brammer v. Derwinski, 3 Vet. App. 223 (1993). Regardless, there is no competent medical evidence in the record which shows that any skin disorder that the appellant may now have is due to herbicide or Agent Orange exposure. In the appellant's July 2003 VA examination, the examining physician stated that current findings were not consistent with skin disorders consistent with Agent Orange exposure. The only evidence of record supporting the appellant's claim is his own lay opinion that he currently has a skin disorder that is related to his in-service Agent Orange exposure. However, the appellant has not been shown to possess the training or credentials needed to render a diagnosis or a competent opinion as to medical causation, and his opinion thus does not constitute competent medical evidence. See Routen v. Brown, 10 Vet. App. 183, 186 (1997), aff'd, 142 F.3d 1434 (Fed. Cir. 1988); YT v. Brown, 9 Vet. App. 195, 201 (1996); Espiritu v. Derwinski, 2 Vet. App. 492, 494-95 (1992). In the instant case, there is no evidence of chloracne or an acneform disease consistent with chloracne, or porphyria cutanea tarda within one year following herbicide or Agent Orange exposure, and there is no competent evidence that the appellant presently has these diseases or any other skin disease, other than his service-connected eczema and dermatitis. In addition, there is no competent medical evidence in the record to show that any skin disease that the appellant may now have is due to herbicide or Agent Orange exposure. Accordingly, in light of the above, other than eczema and dermatitis as the residuals of leech bites, service connection for a skin disorder secondary to Agent Orange exposure is not warranted. 38 U.S.C.A. §§ 1110, 1113, 1116 (West 2002 & Supp. 2005); 38 C.F.R. §§ 3.303, 3.307, 3.309(e) (2005). In reaching this decision, the Board considered the doctrine of reasonable doubt. However, as the preponderance of the evidence is against the appellant's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Other than eczema and dermatitis as the residuals of leech bites, service connection for a skin disorder, as a residual of Agent Orange exposure, is denied. REMAND In this case, the appellant contends that due to his in- service Agent Orange exposure, he developed a disability manifested by paralysis of the neck and a disability manifested by paralysis of the shoulders. In support of his contentions, he submitted a private medical statement from Dr. C.N. Bash, dated in May 2004. In the May 2004 statement, Dr. Bash diagnosed the appellant with central neuropathy and opined that the appellant's central neuropathy was likely due to his in-service exposure to Agent Orange. Specifically, Dr. Bash stated that the appellant had nervous system problems, namely (1) cervical spine disc disease; (2) lumbar spine disc disease; and (3) paresthesias/central neuropathy. According to Dr. Bash, the appellant's cervical spine and lumbar spine disc disease postdated his period of service and his paresthesias. Dr. Bash reported that the appellant's paresthesias were first noted in 1981, and that that type of neurologic problem was classic for a central neuropathy such as Parkinson's disease or some other basal ganglia toxic neuropathy. According to Dr. Bash, the appellant was in Vietnam and was therefore likely exposed to Agent Orange. Dr. Bash indicated that Agent Orange was biologically known to cause central neuropathies by way of its neurologic toxic effects. In light of the above, the Board concludes that the May 2004 statement from Dr. Bash raises an inferred claim for entitlement to service connection for central neuropathy, as a residual of Agent Orange exposure. In addition, this raised claim is inextricably intertwined with the appellant's pending claims for entitlement to service connection for disabilities manifested by paralysis of the neck and shoulders, as residuals of Agent Orange exposure. In this regard, the Board notes that although Dr. Bash does not specifically diagnose the appellant with paralysis of the neck and shoulders, he does diagnose the appellant with paresthesias, and he notes that the appellant's diagnosed central neuropathy encompasses his paresthesias. In addition, Dr. Bash indicated that the appellant's neuropathy symptoms included left sided paralysis and difficulty controlling his left arm. Therefore, it appears that the opinion from Dr. Bash has been offered to show that the appellant has disabilities manifested by paralysis of the neck and shoulders, and that those disabilities are encompassed by the diagnosed central neuropathy, which is related to in-service Agent Orange exposure. Accordingly, the outcome of the claim for service connection for central neuropathy, as a residual of Agent Orange exposure, could have an impact on the pending claims for service connection for disabilities manifested by paralysis of the neck and shoulders, as residuals of Agent Orange. Thus, the RO must adjudicate this raised claim of service connection for central neuropathy, as a residual of Agent Orange exposure, prior to any appellate action on the claims for service connection for disabilities manifested by paralysis of the neck and shoulders, as residuals of Agent Orange exposure. Accordingly, this case is remanded to the RO for the following actions: 1. The RO is instructed to adjudicate the appellant's inferred claim of entitlement to service connection for central neuropathy, as a residual of Agent Orange exposure. 2. The RO must then review and re- adjudicate the issues of entitlement to service connection for a disability manifested by paralysis of the neck, as a residual of Agent Orange, and entitlement to service connection for a disability manifested by paralysis of the shoulders, as a residual of Agent Orange exposure. If any such action does not resolve each claim to the appellant's satisfaction, the RO should provide the appellant and his representative a supplemental statement of the case and an appropriate period of time should be allowed for response. Thereafter, the case should be returned to this Board for appellate review. By this remand, the Board intimates no opinion as to any final outcome warranted. No action is required of the appellant until he is notified by the RO. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2005). ______________________________________________ ROBERT E. SULLIVAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs