Citation Nr: 0005111 Decision Date: 02/28/00 Archive Date: 03/07/00 DOCKET NO. 97-01 434 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Honolulu, Hawaii THE ISSUES 1. Entitlement to service connection for loss of reproductive capability, secondary to the veteran's service- connected shell fragment wound to the right thigh. 2. Entitlement to service connection for degenerative joint disease of the neck, right shoulder, left side of body, and skeletal condition. 3. Entitlement to compensation under the provisions of 38 U.S.C.A. § 1151 for residuals of a low back injury. 4. Entitlement to an evaluation in excess of 20 percent for degenerative arthritis, right hip. 5. Entitlement to an evaluation in excess of 10 percent for a shell fragment wound to the right thigh. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Robin M. Webb, Associate Counsel INTRODUCTION The veteran had active service from April 1968 to August 1973. This appeal arises before the Board of Veterans' Appeals (Board) from rating actions of the Department of Veterans Affairs (VA) Regional Office (RO) in Honolulu, Hawaii. With respect to the veteran's claim for compensation under the provisions of 38 U.S.C.A. § 1151, the Board notes that when the veteran initially filed his claim, he indicated that he had injured both his low back and his ribs. In an April 1998 rating decision, the RO denied the veteran's claim as to both his low back and ribs. However, in his Notice of Disagreement and his Substantive Appeal, the veteran discussed only his low back condition and the great pain experienced therefrom. As such, the Board finds that the veteran failed to perfect an appeal to the Board regarding the claim of entitlement as to a rib injury. See 38 C.F.R. § 20.200. Accordingly, then, the Board finds the issue now before it for consideration to be as framed on the title page of this decision, notwithstanding the June 1999 Statement of the Case that addressed both the veteran's low back and ribs. The issues of entitlement to service connection for loss of reproductive capability, secondary to the veteran's service- connected shell fragment wound of the right thigh; entitlement to an evaluation in excess of 20 percent for degenerative arthritis, right hip; and entitlement to an evaluation in excess of 10 percent for a shell fragment wound to the right thigh will be discussed in the REMAND section, following the decision below. FINDINGS OF FACT 1. Competent medical evidence of a nexus, or link, between the veteran's claimed degenerative joint disease of the neck, shoulder, left side of body, and skeletal condition and his service has not been presented. 2. With respect to the veteran's claim for compensation under the provisions of 38 U.S.C.A. § 1151 or residuals of a low back injury, all evidence necessary for an equitable disposition of this issue has been obtained by the RO. 3. The veteran fell into a ditch on August 2, 1995, during a period of VA hospitalization. 4. The record contains competent medical evidence showing that the veteran's degenerative joint disease of the lumbosacral spine was exacerbated by the August 2, 1995, fall. CONCLUSIONS OF LAW 1. The claim of entitlement to service connection for degenerative joint disease of the neck, shoulder, left side of body, and skeletal condition is not well grounded. 38 U.S.C.A. §§ 1110, 5107(a) (West 1991). 2. The criteria for VA compensation benefits pursuant to 38 U.S.C.A. § 1151 for aggravation of existing degenerative joint disease of the lumbosacral spine have been met. 38 U.S.C.A. §§ 1151, 5107(b) (West Supp. 1998); 38 C.F.R. §§ 3.102, 3.358 (effective March 16, 1995). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service Connection I. Pertinent Law and Regulations A veteran claiming entitlement to VA benefits has the burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that the claim is well grounded. 38 U.S.C.A. § 5107(a). A well-grounded claim is a plausible claim, capable of substantiation. Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992). A well-grounded claim requires more than mere allegations that the veteran's service, or an incident which occurred therein, resulted in injury, illness, or death. The veteran must submit supporting evidence that would justify the belief that the claim is a plausible one. See Tirpak, 2 Vet. App. at 609. Where a claim is not well grounded, VA does not have a statutory duty to assist the veteran further in the development of his claim. 38 U.S.C.A. § 5107(a); see also Morton v. West, 12 Vet. App. 477 (1999). The United States Court of Appeals for Veterans Claims (known as the U.S. Court of Veterans Appeals prior to March 1, 1999) (hereinafter, Court) has held that the three elements of a well-grounded claim for service connection are: 1) evidence of a current disability as provided by a medical diagnosis; 2) evidence of incurrence or aggravation of a disease or injury in service, as provided by either lay or medical evidence; and 3) a nexus, or link, between the service related disease or injury and the current disability, as provided by competent medical evidence. Caluza v. Brown, 7 Vet. App. 498, 506 (1994). The quality and quantity of evidence required to meet the statutory burden for establishing a well-grounded claim depends upon the issue presented by the claim. Where the determinative issue involves medical causation or a medical diagnosis, competent medical evidence that the claim is plausible is required. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). Controlling law provides that service connection may be established for disability resulting from personal injury or disease incurred in or aggravated by service. 38 U.S.C.A. § 1110 (West 1991); 38 C.F.R. §§ 3.303, 3.304 (1999). Service connection may also be presumed where a chronic disease, including arthritis, manifests itself to a compensable degree within one year after separation from service. 38 C.F.R. §§ 3.307, 3.309 (1999). II. Factual Background The veteran's service medical records are negative for any findings of degenerative arthritis, other than in the veteran's right hip. A September 1974 VA examination is also negative for any findings of degenerative arthritis of the veteran's neck, shoulder, left side of body, and skeletal condition. Medical records from LBJ Tropical Medical Center (dated from October 1978 to June 1995) indicate that the veteran was assessed as having degenerative joint disease in the right knee and gout. These records are silent as to the veteran's service medical history and offer no opinion relating any of the veteran's diagnosed disorders to service. VA treatment records (dated from June 1994 to February 1997) reflect the diagnosis of multiple arthralgias, involving the veteran's shoulders, back, elbows, and knees. The veteran probably had degenerative joint disease. There is no clinical discussion as to the etiology and onset of these disorders, including any causal relationship with the veteran's service. Medical records from Tripler Army Medical Center (dated from July 1995 to February 1996) indicate that the veteran was diagnosed with gout and with rheumatoid arthritis on the right side. These records are silent as to the veteran's service medical history and offer no opinion relating either gout or rheumatoid arthritis to his service and events therein. A September 1997 VA examination (conducted in connection with the veteran's claim for compensation under the provisions of 38 U.S.C.A. § 1151) indicates that the veteran had degenerative joint disease of the lumbosacral spine. There was no clinical discussion as to its relationship to the veteran's service and events therein. III. Analysis The Board recognizes the veteran's contentions that he is entitled to service connection for degenerative joint disease of the neck, shoulder, left side of body, and skeletal condition. However, the Board must adhere to established laws and regulations in its determinations. As such, the veteran's claim as to this issue must be denied, as it is not well grounded. There is no clinical evidence of record linking the veteran's claimed arthritis of the neck, shoulder, left side of body, and skeletal condition to his service and events therein. See Caluza v. Brown, supra. Specifically, upon review of the veteran's claims file and the evidence contained therein, the Board finds competent medical evidence of a current disability (multiple arthralgias and degenerative joint disease). The Board also finds the veteran's own assertions (although unsupported by his service medical records) constitute sufficient lay evidence of in-service incurrence for purposes of rendering the claim well-grounded. In analyzing whether a claim for VA benefits is well grounded, the credibility of the appellant's testimony and evidence presented is presumed unless the evidence is inherently incredible or the matter is beyond the competence of the party so testifying. King v. Brown, 5 Vet. App. 19 (1993). However, as just stated, the Board does not find any competent clinical evidence of a nexus, or link, between the veteran's multiple arthralgias and events in service. Such evidence is necessary for a well-grounded claim of entitlement to service connection. In this respect, the Board notes that the veteran's service medical records are negative for any indication of degenerative arthritis, other than in his right hip, as was a September 1974 VA examination. Indeed, the clinical evidence of record does not reflect a diagnosis of arthritis, other than in the right hip, until approximately October 1978, almost five years after the veteran's separation from service. As such, presumptive service connection is not warranted. See 38 C.F.R. §§ 3.307, 3.309. Further, none of the veteran's post-service medical records speak to the etiology of the veteran's multiple arthralgias (degenerative joint disease) or offer an opinion relating any of the disorders to his service. In effect, to demonstrate a nexus to service, the veteran has proffered only his own assertions that degenerative joint disease of the neck, shoulder, left side of body, and skeletal condition are related to his service and events therein. Nothing in the record indicates that the veteran possesses the medical expertise necessary to render such an opinion. See Espiritu v. Derwinski, 2 Vet. App. 492 (1992). Lay assertions as to causation and diagnosis are inadequate, as medical determinations are outside the competence of lay parties. Id. Where the determinative issue involves medical causation or diagnosis, competent medical evidence is required. See Grottveit v. Brown, supra. Here, the only evidence of record relating the veteran's claimed degenerative joint disease of the neck, shoulder, left side of body, and skeletal condition is the veteran's own lay assertions. Therefore, absent competent medical evidence of a nexus, or link, between the veteran's claimed degenerative joint disease of the neck, shoulder, left side of body, and skeletal condition and events in service, the veteran has not submitted a well-grounded claim of entitlement to service connection for any or all of these disorders. See Caluza v. Brown, supra. The Board notes that the veteran was put on notice as to the evidence required to support his claim in the April 1996 rating decision and in the June 1996 Statement of the Case, as he was informed of the evidentiary requirements of a well- grounded claim and told that medical evidence as to a relationship between the veteran's claimed degenerative joint disease and his service was necessary. Moreover, the veteran has not provided any indication of the existence of additional evidence that would make this claim well grounded. See Epps v. Gober, 126 F.3d 1464 (Fed. Cir. 1997); Robinette v. Brown, 8 Vet. App. 69 (1995). 38 U.S.C.A. § 1151 I. Pertinent Law and Regulations In pertinent part, 38 U.S.C.A. § 1151 (in effect at the time the veteran filed this claim for benefits) provided that where any veteran suffered an injury, or an aggravation of an injury, as the result of hospitalization or medical or surgical treatment, which was not the result of the veteran's own willful misconduct, and such injury or aggravation resulted in additional disability or death, disability compensation was to be awarded in the same manner as if such disability, aggravation, or death were service-connected. The Court has held that the requirements for a well-grounded claim under 38 U.S.C.A. § 1151 parallel those generally set forth for establishing entitlement to service connection. In effect, the requirements are 1) medical evidence, or in certain circumstances, lay evidence of incurrence or aggravation of an injury or disease as the result of hospitalization, medical or surgical treatment, or the pursuit of a course of vocational rehabilitation under chapter 31 of title 38, United States Code; 2) medical evidence of a current disability; and 3) medical evidence of a nexus between that asserted injury or disease and the current disability. Jones v. West, 12 Vet. App. 460 (1999). In determining whether additional disability exists, the veteran's physical condition immediately prior to the disease or injury that is the basis for the claim for compensation will be compared with the subsequent physical condition resulting from the disease or injury. 38 C.F.R. § 3.358(b)(1). However, compensation is not payable under the provisions of 38 U.S.C.A. § 1151 for the continuance or natural progress of diseases or injuries, for which the hospitalization, etc., was authorized. 38 C.F.R. § 3.358(b)(2). In determining whether such additional disability resulted from a disease or injury, or the aggravation of an existing disease or injury, suffered as a result of hospitalization, etc., it is necessary to show that the additional disability is actually the result of such disease or injury, or its aggravation, and not merely coincidental therewith. 38 C.F.R. § 3.358(c)(1). The mere fact that aggravation occurred will not suffice to make the additional disability compensable, in the absence of proof that it resulted from disease or injury, or the aggravation of an existing disease or injury, as the result of hospitalization, etc. 38 C.F.R. § 3.358(c)(2). When the proximate cause of the injury suffered was the veteran's willful misconduct or failure to follow instructions, the veteran is barred from receipt of such compensation, except in the case of incompetent veterans. 38 C.F.R. § 3.358(c)(4). In an opinion intended to govern cases decided under the provisions of 38 U.S.C.A. § 1151 in effect prior to October 1, 1997, the VA Office of the General Counsel held that compensation under 38 U.S.C.A. § 1151 for injuries suffered "as the result of hospitalization" was not limited to injuries resulting from the provision of hospital care and treatment, but could encompass injuries resulting from risks created by any circumstances or incidents of hospitalization. An injury caused by a fall could be considered a result of hospitalization where the conditions or incidents of hospitalization caused or contributed to the fall or the severity of the injury. A fall due solely to the patient's inadvertence, want of care, or preexisting disability generally did not result from hospitalization. An injury incurred due to recreational activity could be considered a result of hospitalization where VA required or encouraged participation in the activity, administered or controlled the activity, or facilitated the activity in furtherance of treatment objectives. In individual cases, the question of whether an injury resulted from hospitalization was essentially an issue of fact to be determined by the factfinder upon consideration of all pertinent circumstances. VAOPGCPREC 7-97 (Jan. 29, 1997). In its analysis, VA Office of General Counsel noted that: [w]here the precipitating cause of a fall may reasonably be attributed to any conditions or circumstances of the hospitalization, rather than some circumstance originating with the claimant, the resulting injuries would be the result of hospitalization. This would include cases where the fall was caused by some unique feature of the hospital premises. For example, if the fall was precipitated by the unusually steep grade of the staircase, poor lighting conditions, or other unique features of the stairwell, the hospitalization would have created the "zone of special danger" out of which the injury arose. Similarly, if the fall was precipitated when the veteran tripped over some object left on or near the stairs or slipped on water, grease, or other foreign matter, it might reasonably be concluded that the ensuing injuries resulted from hospitalization. Id. In determining whether injuries suffered in a fall are the "result of hospitalization" for purposes of 38 U.S.C.A. § 1151, it is necessary for the factfinder to determine the cause or risks which precipitated the fall and the injuries and then to determine whether those causes or risks arose from the claimant or from the conditions or circumstances of hospitalization. Id. II. Factual Background Medical records from LBJ Tropical Medical Center (dated from October 1978 to June 1995) indicate that the veteran had arthritis, for which he was prescribed Naprosyn and Ecotrin. The veteran received VA inpatient treatment for PTSD from July 25, 1995, to August 14, 1995. The veteran reported falling outside the hospital, into a ditch on August 2, 1995. A contemporaneous x-ray study of the veteran's chest revealed evidence of mild arteriosclerotic vascular disease of the aorta but was otherwise unremarkable. It was noted at that time that the veteran complained of pain, especially with palpation to the right lower back, and a rib fracture needed to be ruled out. The veteran's back was not x-rayed. No other treatment for the veteran's back is reflected in these records. Additional VA treatment records (dated from June 1994 to February 1997) reflect the diagnosis of multiple arthralgias, including the veteran's back. It was noted that the veteran probably had degenerative joint disease. These records also indicate that the veteran was morbidly obese. It was noted in a December 1995 entry that the veteran complained of some intermittent back pain. At that time, the veteran's lumbosacral spine showed limited range of motion, secondary to the pain. An April 1996 entry reflects the veteran's history of having fallen in a hole while on hospital grounds in August 1995. It was noted that the x-rays at that time were negative. The veteran stated that he had then had pain for about a week and that it had resolved. The pain then returned. Physical examination found the veteran to have good trunk flexion and lateral bending. There was slight, local tenderness in the L-5 area. The diagnosis was mechanical low back pain, and the veteran was referred for rehabilitative therapy. A May 1996 entry reflects the diagnosis of mild degenerative joint disease at L4-L5. A contemporaneous x-ray study of the veteran's lumbosacral spine showed mild degenerative disc disease and osteoarthritis of the L4-L5 apophyseal joint. A September 1997 VA examination reflects the veteran's history of having fallen into a ditch in August 1995. The veteran stated that he had landed on his lower back and that since then, he had had daily back pain, with radiation to the left buttock and thigh. The veteran also stated that this was made worse with prolonged sitting, standing, and walking. Physical examination of the veteran's lumbar spine revealed marked tenderness to palpation over the left paravertebral areas, L1-L5. Range of motion testing found extension to 16 degrees, flexion to 66 degrees, side-to-side bending to 30 degrees, and lateral rotation to 42 degrees. In comparing previous x-ray studies with the present findings, the examiner noted that the 1996 x-rays showed acute degenerative osteoarthritic changes but no evidence of acute fracture or dislocation. The examiner also noted that the x-ray taken at the time of the veteran's injury in August 1995 was only of the veteran's chest, not of his back. That had been taken to rule out a fractured rib. The examiner commented that the veteran had degenerative joint disease of the lumbosacral spine, which had been exacerbated by the August 2, 1995, fall. III. Analysis Initially, the Board states that it finds the veteran's claim to be well grounded within the meaning of 38 U.S.C.A. § 5107(a), as articulated in Jones v. West, supra. Specifically, the Board finds evidence of an injury to the veteran's back while receiving VA treatment for PTSD, competent clinical evidence of a current disability (aggravation of existing degenerative joint disease of the veteran's lumbosacral spine), and competent clinical evidence that the fall in August 1995 exacerbated the veteran's degenerative joint disease of the lumbosacral spine. Further, the Board is satisfied that all relevant facts have been properly developed, pursuant to VA's duty to assist the veteran in the development of facts pertinent to his claim. 38 U.S.C.A. § 5107(a). As such, the facts and law in this case present three questions that must be answered in the affirmative, in order for the veteran to prevail in this instance. First, there must be evidence that an injury (the veteran's fall) occurred as the result of hospitalization in a VA facility. Second, there must be evidence that additional disability resulted from this injury, and third, it must be determined whether the provisions of 38 U.S.C.A. § 1151 permit recovery in a slip and fall situation. See 38 C.F.R. § 3.358. Specifically, as to the first requirement, the Board finds that the record is unequivocal as to the August 2, 1995, fall, which the veteran experienced while on activity at a VA facility. As to the second requirement, the Board finds that the opinion expressed upon VA examination in September 1997 indicates that the veteran's degenerative joint disease of the lumbosacral spine was exacerbated by the August 2, 1995, fall. The Board also notes that the record is negative for any contradictory clinical opinions. As to the third (and most problematic) requirement, the Board finds that the provisions of 38 U.S.C.A. § 1151, as interpreted in VAOPGCPREC 7-97, permit recovery in this instance. Here, the Board concludes that the causes or risks that precipitated the veteran's fall arose from the conditions and circumstances of VA hospitalization, not from the veteran. Specifically, the Board notes that the veteran was overweight, and according to the veteran's assertions, he was advised to lose weight. The record indicates that the veteran was "on activity" on the hospital grounds on August 2, 1995, when his fall into the ditch occurred. Also, as to the existence of the ditch, into which the veteran fell and sustained injury, the Board can only assume that it was a "zone of special danger" created by or for the facility and for which the facility was responsible. Further, nothing in the record indicates (or has been proffered) that the veteran's fall into a ditch was the result of his own inadvertence, want of care, willful misconduct, or failure to follow instructions. See 38 U.S.C.A. § 1151; see also VAOPGCPREC 7-97. Indeed, the veteran appeared to be following the advice of his physician to lose weight, as he was "on activity." In light of the above, therefore, the Board concludes that the veteran is entitled to compensation under the provisions of 38 U.S.C.A. § 1151 for that amount of his overall low back disability which is the result of aggravation sustained during the August 1995 fall. ORDER Entitlement to service connection for degenerative joint disease of the neck, shoulder, left side of body, and skeletal condition is denied. Entitlement to compensation benefits under the provisions of 38 U.S.C.A. § 1151 for residuals of a low back injury consisting of aggravation of existing degenerative joint disease of the lumbosacral spine, as a result of VA hospitalization, is granted. REMAND With respect to the issue of entitlement to service connection for loss of reproductive capability, secondary to the veteran's service-connected shell fragment wound to the right thigh, review of the record shows that the RO, in an April 1996 rating decision, denied such entitlement. A Notice of Disagreement as to this issue was received by the RO in May 1996. The RO then provided the veteran with a Statement of the Case in June 1996. No substantive appeal as to this issue was then received from the veteran. Rather, in December 1996, the veteran submitted VA Form 9 (Appeal to Board of Veterans' Appeals), in which he specifically discussed his symptomatology as to his arthritis. The veteran did not reference the earlier Statement of the Case in any way, which had addressed service connection for loss of reproductive capability, nor did he reference his claim for service connection for loss of reproductive capability, secondary to his service-connected right thigh disability. In effect, the veteran did not perfect a timely substantive appeal as to this issue. Subsequently, without any action on the part of the veteran, the RO issued an August 1997 rating decision, in which the RO stated that the veteran's claim for service connection for loss of reproductive capability, secondary to his service- connected right thigh disability, remained denied. The veteran responded with VA Form 9 (Appeal to Board of Veterans' Appeals), signed and dated in September 1997, in which he stated that he wanted to be granted service connection for his loss of reproductive capability. In this instance, in practical effect, the Board finds that the veteran filed a Notice of Disagreement specifically as to the RO's August 1997 rating decision. To date, in response to this communication from the veteran, the RO has not provided the veteran with a Statement of the Case as to entitlement to service connection for loss of reproductive capability, secondary to the veteran's service-connected right thigh disability. Due process concerns require such action. See Fenderson v. West, 12 Vet. App. 119 (1999); Manlincon v. West, 12 Vet. App. 238 (1999). Indeed, until such action is taken, the Board does not have jurisdiction to consider this issue, although it is in appellate status. With respect to the issues of entitlement to increased evaluations for the veteran's degenerative arthritis of the right hip and for a shell fragment wound to the right thigh, review of the record shows that the veteran was last examined in connection with his right hip and right thigh disabilities in March 1997. Subsequent to this, however, in VA Form 21- 4138 (Statement in Support of Claim), signed and dated by the veteran in October 1999, the veteran indicated that both disabilities had increased in severity since his last examination. To constitute a useful and pertinent rating tool, rating examinations must be sufficiently contemporaneous to allow adjudicators to make an informed decision regarding the veteran's current level of impairment. Especially where evidence indicates that there has been a material change in the veteran's disability or that the current rating may be incorrect, a reexamination is required. See Caffrey v. Brown, 6 Vet. App. 377 (1994). Therefore, in light of the above, appellate review of the issues of entitlement to service connection for loss of reproductive capability, secondary to the veteran's service- connected shell fragment wound to the right thigh, and entitlement to increased evaluations for the veteran's degenerative arthritis of the right hip and for a shell fragment wound to the right thigh will be deferred pending a REMAND for the following actions: 1. The RO should provide the veteran and his representative with a Statement of the Case as to the issue of entitlement to service connection for loss of reproductive capability, secondary to the veteran's service-connected shell fragment wound to the right thigh. The veteran and his representative should be provided with the applicable laws and regulations in this instance and informed of the evidence considered and the reasons and bases for the RO's determination. In light of the previous confusion, all applicable time limits should be clearly specified. Should the veteran's claim remain in a denied status, and a substantive appeal is timely filed, the veteran's appeal as to this issue should be returned to the Board for further appellate consideration. 2. After any necessary information and authorization are obtained from the veteran, copies of any post-December 1996 treatment records, VA and private, inpatient and outpatient, and associated with the veteran's service-connected degenerative arthritis of the right hip and shell fragment wound to the right thigh, should be obtained by the RO and incorporated into the claims file. 3. A VA general medical examination should be scheduled and conducted, in order to determine the severity of the veteran's right hip and thigh disabilities. All suggested studies should be performed, including range of motion testing and X-ray studies, and the examiner should elicit all of the veteran's subjective complaints as to both disabilities. The examiner is requested to specifically assess all functional limitation, including weakness, incoordination, loss of endurance, fatigability, and pain on use arising from the service-connected disabilities. All findings should be recorded in detail. 4. The claims files must be made available to and be reviewed by the examiner in conjunction with the examination. 5. The veteran should be advised that failure to report for the scheduled examination could have adverse consequences in the adjudication of his claim. 38 C.F.R. § 3.655 (1999). 6. The RO should carefully review the examination report to ensure that it is in complete compliance with this remand, including all requested findings and opinions. If not, the report should be returned to the examiner for corrective action. 7. The RO should then review the veteran's claim as to the propriety of a 20 percent evaluation for his degenerative arthritis of the right hip and the propriety of a 10 percent evaluation for a shell fragment wound to the right thigh, and consider all pertinent law and regulation, in light of the examination report, and any conclusions expressed therein. The RO is reminded of the recent regulatory amendments and the application of Karnas v. Derwinski, 1 Vet. App. 308 (1991), as to evaluation of muscle injuries. If the veteran's claim as to either of these issues remains in a denied status, he and his representative should be provided with a Supplemental Statement of the Case, which should include a full discussion of actions taken and the reasons and bases for such actions. The applicable response time should be allowed. In taking this action, the Board implies no conclusion as to any outcome warranted. The veteran 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 or by the Court 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. Heather J. Harter Acting Member, Board of Veterans' Appeals