BVA9501424 DOCKET NO. 93-05 028 ) DATE ) ) On appeal from the decisions of the Department of Veterans Affairs Regional Office in San Juan, Puerto Rico THE ISSUES 1. Entitlement to a rating in excess of 40 percent for status post gastrectomy since August 1, 1985. 2. Entitlement to an effective date earlier than August 1, 1985, but no earlier than August 27, 1981, for a rating in excess of 20 percent for status post gastrectomy. 3. Entitlement to secondary service connection for a nervous disorder. 4. Entitlement to a rating based on individual unemployability. REPRESENTATION Appellant represented by: Puerto Rico Public Advocate for Veterans Affairs ATTORNEY FOR THE BOARD D. B. Weiss, Associate Counsel INTRODUCTION The veteran had active military service from October 1961 to October 1963. The initial issues for appellate review included only issues 1 and 2 on the title page of this decision. These issues arise out of the veteran's claim for a rating in excess of 20 percent for gastrectomy dated August 27, 1981, and his notice of disagreement, received August 31, 1982, with the denial of this claim. This issue was the subject of a Board of Veterans' Appeals (Board) remand with development instructions, dated in April 1988. We note that at that time the veteran was thought to be status post subtotal gastrectomy. For unknown reasons, this disability has since been recharacterized as status post total gastrectomy. Bearing in mind our duty to consider all of the residuals of the service connected disorder, and for reasons of brevity alone, we refer herein to this disorder as simply "status post gastrectomy," "gastrectomy," or "gastrectomy residuals." A rating decision dated in April 1988 awarded a rating of 20 percent for status post gastrectomy, from June 10, 1972, and deferred the issue of the rating for status post gastrectomy after August 27, 1981, pending further development. The veteran was advised of this decision by a letter dated in May 1988. As he did not file a notice of disagreement within one year thereafter, the issue of the rating of gastrectomy from June 10, 1972, to August 27, 1981, became final. The contentions since the May 1988 letter give no indication that the veteran wishes to reopen the award in the April 1988 rating decision covering the rating assigned prior to August 27, 1981. Accordingly, the issue numbered 2 on the title page of this decision excludes from consideration the time period for which the rating for gastrectomy has become final, that is, the period before August 27, 1981. After completion of the development requested by the Board to the extent possible, a rating decision in March 1989 continued the denial of a rating in excess of 20 percent for gastrectomy from August 27, 1981, to August 1, 1985. The March 1989 rating decision, therefore, represented a continued denial of the appeal claim as to the period from August 27, 1981, to August 1, 1985, during which gastrectomy remained rated 20 percent. Thus, the March 1989 rating decision was not, as the veteran points out, a substantial grant of the benefits sought in the appeal which was initiated by the August 1982 notice of disagreement. As the remand development had been completed to the extent possible, and the regional office (RO) had not granted partly or wholly the increased rating claim as to the period delineated in issue number 2, in March 1989, the case should have been promptly returned to the Board for appellate review. Therefore, even though the veteran failed to report for review examination for gastrectomy without good cause in January 1992, which would normally result in the denial of his claim for an increase, we do not construe this failure to report against him. 38 C.F.R. § 3.655(a), (b) (1993). The March 1989 rating decision also assigned a rating of 40 percent for gastrectomy from August 1, 1985, with which rating the veteran has disagreed. Regarding issue number 3, we note that in January 1984, the veteran claimed service connection for a nervous disorder secondary to his service-connected gastrectomy. The RO denied that claim and notified the veteran of that decision by letter dated in October 1985. In December 1985, the veteran noted disagreement with this denial. An April 1988 Board remand referred to the RO the issues of entitlement to service connection for a psychiatric disorder and cholelithiasis. As indicated by the title page of this decision, the veteran's October 1985 notice of disagreement with the denial of service connection for a nervous condition is now developed for appellate review. The claim for service connection for cholelithiasis, however, remains unadjudicated. The RO should, therefore, adjudicate this claim. Regarding issue number 4, this claim was initially received in July 1989 and was developed for appellate review by the September 1989 supplemental statement of the case. This issue will be addressed in the Remand portion of this decision. CONTENTIONS OF APPELLANT ON APPEAL The appellant contends in his notice of disagreement dated June 21, 1989, that he disagrees with the decision made to increase his rating for service-connected gastrectomy to 40 percent. In another statement, dated June 21, 1989, he specifies that an earlier effective date for a rating in excess of 20 percent for his gastrectomy is warranted, because he first appealed for this benefit in 1982. He also believes he has a neuropsychiatric disorder secondary to his gastrectomy. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), has reviewed and considered all of the evidence and material of record in the veteran's claims file. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the preponderance of the evidence is against an earlier effective date for a 40 percent rating prior to August 25, 1981, and against a rating in excess of 40 percent from August 1, 1985, to January 23, 1989. It is the decision of the Board that the evidence warrants a rating of 60 percent for status post total gastrectomy from January 23, 1989, and that it warrants service connection for psychophysiologic gastrointestinal reaction. FINDINGS OF FACT 1. From August 27, 1981, gastrectomy was manifested by symptoms of infrequent episodes of gastric distress with continuous mild manifestations usually controlled by medication, productive of no more than mild gastrectomy residuals. 2. From August 1, 1985, gastrectomy was manifested by moderate symptoms including nausea, and diarrhea, without weight loss or anemia, productive of no more than moderate gastrectomy residuals. 3. From January 23, 1989, gastrectomy was manifested by severe symptoms including nausea, diarrhea, weight loss, and anemia, productive of no more than severe gastrectomy residuals. 4. Superimposed psychophysiologic gastrointestinal reaction cannot be disassociated from gastrectomy. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 20 percent for gastrectomy from August 27, 1981, to August 1, 1985, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.400, 4.7, 4.14, 4.111, 4.112, 4.113, 4.114 (1993). 2. The criteria for a rating in excess of 40 percent for gastrectomy from August 1, 1985, to January 23, 1989, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.400, 4.7, 4.14, 4.111, 4.112, 4.113, 4.114 (1993). 3. The criteria for a rating of 60 percent for gastrectomy from January 23, 1989, are met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.321, 3.400, 4.7, 4.14, 4.111, 4.112, 4.113, 4.114 (1993). 4. Superimposed psychophysiologic gastrointestinal reaction is proximately due to or the result of service-connected gastrectomy. 38 U.S.C.A. § 5107 (West 1991); 38 C.F.R. § 3.310 (1993). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Initially, we note that the provisions of 38 U.S.C.A. § 5107 have been met, in that the claims are well grounded and adequately developed. All relevant evidence necessary for an equitable disposition of the veteran's appeal has been obtained. Disability evaluations are determined by the application of the Department of Veterans Affairs (VA) Schedule for Rating Disabilities, which is based on average impairment of earning capacity. Different diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. 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. Postgastrectomy syndrome is rated 60 percent if severe, associated with nausea, sweating, circulatory disturbance after meals, diarrhea, hypoglycemic symptoms, and weight loss with malnutrition and anemia. It is rated 40 percent if moderate, with less frequent episodes of epigastric disorders with characteristic mild circulatory symptoms after meals but with diarrhea and weight loss. It is rated 20 percent if mild, with infrequent episodes of epigastric distress with characteristic mild circulatory symptoms or continuous mild manifestations. 38 C.F.R. § 4.114, Diagnostic Code 7308. Marginal ulcers (gastrojejunal) are rated 100 percent if pronounced, with periodic or continuous pain unrelieved by standard ulcer therapy, with periodic vomiting, recurring melena, or hematemesis, and weight loss, which is totally incapacitating. They are rated 60 percent if severe, the same as pronounced with less pronounced and less continuous symptoms, with definite impairment of health. They are rated 40 percent if moderately severe with intercurrent episodes of abdominal pain at least once per month, partly or completely relieved by ulcer therapy, with mild and transient episodes of vomiting or melena. They are rated 20 percent if moderate with episodes of recurring symptoms several times per year. They are rated 10 percent if mild with brief episodes of recurrent symptoms once or twice yearly. 38 C.F.R. § 4.114, Diagnostic Code 7306. Vagotomy with pyloroplasty or gastroenterostomy, if followed by demonstrably confirmative complications of stricture or continuing gastric retention, is rated 40 percent. If with symptoms and confirmed diagnosis of alkaline gastritis or of confirmed persisting diarrhea, it is rated 30 percent. If vagotomy is incomplete with recurrent ulcer, then it is rated 20 percent. Recurrent ulcer after complete vagotomy is rated as duodenal ulcer under Diagnostic Code 7305, and the minimum rating is 20 percent. Dumping syndrome is rated under Diagnostic Code 7308. 38 C.F.R. § 4.114, Diagnostic Code 7348. Postgastrectomy syndromes are various, and, when present, those occurring during or immediately after eating are known as the dumping syndrome and are characterized by gastrointestinal complaints and generalized symptoms simulating hypoglycemia; those occurring from 1 to 3 hours after eating usually present definite manifestations of hypoglycemia. 38 C.F.R. § 4.111. Minor weight loss or greater losses of weight for periods of brief duration are not considered of importance in rating. Rather, weight loss becomes of importance where there is appreciable loss which is sustained over a period of time. In evaluating weight loss generally, consideration will be given not only to standard age, height, and weight tables, but also to the particular individual's predominant weight pattern as reflected by the records. 38 C.F.R. § 4.112. There are diseases of the digestive system which, while differing in the site of pathology, produce a common disability picture characterized in the main by varying degrees of abdominal distress or pain, anemia, and disturbance in nutrition. Consequently, certain coexisting diseases in this area, as indicated in the instructions in the Schedule for Rating Disabilities, do not lend themselves to distinct and separate disability ratings without violating the fundamental principle relating to pyramiding as outlined in § 4.14. 38 C.F.R. § 4.113. The evaluation of the same disability under various diagnoses is to be avoided. Both the use of manifestations not resulting from service-connected disease or injury in establishing the service- connected rating and the rating of the same manifestation under different diagnoses is to be avoided. 38 C.F.R. § 4.14. Ratings under Diagnostic Codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348, inclusive, will not be combined with each other. A single rating will be assigned under the Diagnostic Code which reflects the predominant disability picture, with the rating elevated to the next higher evaluation where the severity of the overall disability warrants such evaluation. 38 C.F.R. § 4.114. The effective date of an award of increased compensation shall be the earliest date as of which it is ascertainable that an increase in disability had occurred, if application is received within one year from such date. 38 C.F.R. § 3.400(o)(2). Also, "evidence in a claimant's file which demonstrates that an increase in disability was 'ascertainable' up to one year prior to the claimant's submission of a 'claim' for VA compensation should be dispositive on the question of an effective date for any award that ensues." Quarles v Derwinski, 3 Vet.App. 129, 135 (1992). The award of an increased rating should normally be effective either on the date of the claim or on some date in the preceding year if it was ascertainable that the disability had increased in severity during that time. See Scott v. Brown, No. 93-288 (U.S. Vet. App. Nov. 21, 1994). In the instant case, as noted above, the claim for a rating in excess of 20 percent for gastrectomy was received August 27, 1981. The rating up to August 27, 1981, however, has become final, and the veteran has not indicated any desire to reopen that claim. 38 C.F.R. § 3.400(r). Thus, in this appeal, the effective date of any award granted herein may not be before the date of claim, August 27, 1981. Service medical records reveal that the veteran weighed 145 lbs. at service separation in 1963. In 1975, he underwent subtotal gastrectomy. From August 24, to August 27, 1981, he underwent VA hospitalization for post-gastrectomy diarrhea, and it was noted that his weight was 143 lbs. From December 1982 to February 1983, the veteran received private and VA treatment because of epigastric pain of one month's duration, which was exacerbated on the day of initial presentation, with diarrhea, vomiting, and insomnia. That day, the abdomen was tender over the epigastric area, without palpable masses. The diagnosis was epigastric pain, rule out peptic ulcer disease. In January 1983, he presented to the VA for outpatient treatment for complaints of continuous hyperacidity and diarrhea with discomfort and insomnia. Private upper gastrointestinal study in January 1983 showed evidence of previous vagotomy and subtotal gastrectomy with a well-functioning gastroenterostomy. A 5-millimeter active ulcer crater in the jejunal side of anastomosis was noted, as was coarsing of the mucosal folds of the jejunum. Private endoscopy in February 1983 resulted in a diagnosis of bile reflux gastritis. Marked hyperemia was also noted. The veteran has submitted copies of prescription labels reflecting that he received anti-diarrheal prescription medicine privately in 1982 and 1983. At VA outpatient treatment in October 1983, the assessments were generalized anxiety disorder and malabsorption syndrome. He was noted to be 5'7" and 148 lbs. Other VA outpatient treatment in October 1983 yielded assessments of rule out generalized anxiety disorder and rule out psychological factors affecting physical condition. In December 1983, he received VA treatment for diarrhea; the assessments were status post subtotal gastrectomy, malabsorption syndrome, and functional gastrointestinal (GI) disease. He weighed 147 lbs. In February 1984, the veteran was seen at the emergency room of Damas Hospital with complaints of vomiting, diarrhea, headache, and fever of 3 days' duration. He also complained of chronic occasional abdominal pain. Epigastric tenderness was noted on deep palpation. The assessment was malabsorption syndrome. He was treated and discharged to home without admission. Also in February 1984, the veteran complained to his private doctor of diarrhea and vomiting of 2 weeks' duration, with epigastric pain. The doctor noted increased peristalsis. The diagnosis was abdominal pain-gastroenteritis. In May 1984, VA outpatient treating physicians assessed status post partial gastrectomy and malabsorption syndrome, with complaints of persistent diarrhea, nausea, and weight loss, and feeling anxious. In July 1984, the veteran underwent VA hospitalization for psychologic diagnostic reasons. He was observed to be 42 years old, divorced, and a father of two, with 2 years' college education in accounting but presently unemployed. He stated that he could not sleep well, had frequent headaches, constant diarrhea, nausea, and vomiting. He reported that he had lost weight and thought that he had a nervous condition. Testing failed to reveal signs of gross thinking or perceptual disorders, but judgment was impoverished and contact with reality fluctuating between marginal and normal. His self esteem was low, and his self-image was threatened by feelings of depersonalization. He had a definitive lack of self-acceptance. He expressed fear of failing, as he had in the past. He had a poor tolerance of stress and conflicts, and resorted to evasiveness, displacement, and somatization of conflicts. His defenses had decreased considerably in effectiveness, and his ego integration was failing. The psychologist opined that the veteran was in a process of decompensation that was covered up and defended against by his somatization. He underwent VA outpatient treatment for dumping syndrome the same month. In September 1984, the veteran reported to his private doctor that he had been suffering from diarrhea for the past 2 1/2 months. He was noted to look dehydrated and weak. The diagnosis was malabsorption syndrome; depressive neurosis was a second impression. Also in September 1984, his private doctor advised that the veteran's diarrhea continued for one month or so with nausea, general malaise, and weight loss. The diagnosis was malabsorption syndrome. The veteran also received VA treatment for dumping syndrome in September 1984, when he weighed 139 lbs. In December 1984, he underwent VA hospitalization for a history of epigastric discomfort, weight loss, and diarrhea. Increased peristalsis was noted on examination. He complained of losing 30 pounds in 6 months. In January 1985, a private doctor advised that the veteran had gall bladder disease versus status post gastrectomy malabsorption syndrome. In February 1985, on a VA physical examination, he complained of frequent diarrhea, nausea, and vomiting. A gallbladder scan had failed to visualize his gallbladder. The impressions were neuropsychiatric disorder, status post partial gastrectomy with Billroth II and dumping syndrome, and rule out gallbladder disease. He weighed 142 lbs. On the June 1985 VA gastrointestinal examination, the veteran was reported to have had a 15-year history of diarrheal ulcer disease. After surgery, he said, he felt better. Then in 1980, he reportedly began to present episodes of diarrhea that persisted to the time of the examination. A workup for malabsorption syndrome had reportedly been negative. It was noted that he had recently presented with food intolerance and been found to have gallstones by sonogram. His weight had been around 145-150 lbs. for several years. He complained of watery, explosive diarrhea following meals. The diagnoses after examination were post gastrectomy status with dumping syndrome, cholelithiases, and superimposed psychophysiologic GI reaction. This concludes the review of the evidence pertinent to the severity of gastrectomy prior to August 1, 1985. In essence, the evidence shows that from August 27, 1981, to August 1, 1985, the veteran's symptoms were commensurate with a 20 percent rating for gastrectomy. That is, while he required episodic treatment, his symptoms were generally controlled by medication. He did not experience weight loss which was significant under the terms of the rating schedule. Despite his history in December 1984 of losing 30 pounds in 6 months, other reliable evidence shows that he weighed around 140-150 pounds during this entire period, with a one-time drop in September 1984 to 139 lbs. While we recognize that the veteran had continuous manifestations of his gastrectomy, these were generally mild, and exacerbations not controlled by his regular medicine were infrequent. Thus, we find that the preponderance of the evidence is against a rating in excess of 20 percent for gastrectomy prior to August 1, 1985. In October 1985, an addendum to a VA preoperative note apparently for gallbladder surgery stated that the veteran was advised that the surgery would not in any way ameliorate "his present symptoms of diarrhea or dumping syndrome secondary to surgery for PUD." In January 1986, VA GI study with fluoroscopy showed an apparent collection of barium in the stomach pouch which could be due to an ulcer. Gastroscopy was suggested for further evaluation. Otherwise, the X-ray showed essentially negative post partial gastrectomy. In July 1986, a small bowel series showed increased fluid retention with matting together of several ileal loops suggesting early malabsorption syndrome. The mucosal pattern at the terminal ileum was within normal limits. A reference slip, dated in August 1986, shows that Imodium was prescribed because the veteran had chronic diarrhea and was unable to use Lomotil. The same month, he complained of persistent epigastric pain and diarrhea. In April 1987, a private doctor, E. Marquez, described the veteran as having constant epigastric discomfort and postprandial diarrhea with dizziness since his gastrectomy. The impressions were post-vagotomy diarrhea, dumping syndrome, and depressive neurosis. A December 1988 GI X-ray showed previous surgical changes, free esophageal reflux, and active peptic ulceration in the distal esophagus secondary to reflux esophagitis. There was evidence of status post gastrectomy and gastrojejunostomy in a well- functioning state without evidence of marginal ulceration. In January 1989, the veteran underwent VA GI examination, where he gave a history of persistent dumping since his gastrectomy, despite a diet of 6 small meals per day. He reported diarrhea 3 to 5 times per day and 2 to 3 times per night, which was worse following a meal. The veteran gave a history of cholecystitis and cholelithiasis. In 1985, cholecystectomy had reportedly been performed at a VA hospital. He had since complained of pain at this scar site and was noted to have a hernia, which was slowly increasing in size. In the past few years, his chief complaints were diarrhea and epigastric pain. He had been able to control the diarrhea with Imodium. He took other medicine for his burning epigastric pain, with fairly good results. He had occasional nausea, with bloating, and no recent bleeding. On examination, he was well developed but poorly nourished and pale. He weighed about 130 pounds and had a tender epigastrium without rebound. There was no visceromegaly, although the examiner noted that splenomegaly had been seen by other observers. Peristalsis was normal, and hemoglobin was 10.5 gms. The diagnoses were status post subtotal gastrectomy for duodenal ulcer, with dumping, severe, and anemia, status post cholecystectomy, and reflux esophagitis with active ulceration secondary to the gastrectomy. On January 8, 1992, the veteran failed to report for a scheduled VA examination without providing any reason for so doing. The evidence reveals that after August 1, 1985, the veteran's symptoms were moderate in severity for several years, without anemia, or weight loss which was significant in terms of the rating schedule. He had nausea, diarrhea, reflux esophagitis with ulceration secondary to gastrectomy, and dumping syndrome. Malabsorption syndrome was described as "early" in 1986. These symptoms were more frequent than prior to August 1, 1985, but did not rise to the level of severe until his January 1989 VA examination. Then, he was shown to additionally have anemia, dumping syndrome characterized as severe, and a weight of only 130 pounds. While we are unsure that his symptoms remained severe because of his failure to report for the January 1992 VA examination, the evidence which is of record and which should have been forwarded to the Board promptly after the March 1989 rating decision shows that gastrectomy residuals were severe, as of the January 1989 VA examination. Thus, while we are unable to discern a reasonable basis on which to grant a rating in excess of 40 percent from August 1, 1985, to January 1989, a rating of 60 percent is warranted from January 23, 1989, the date on which is was ascertainable that symptoms were severe. 38 C.F.R. § 3.400. We have also considered the pertinent provisions of 38 C.F.R. Parts 3 and 4 and 38 C.F.R. § 3.321(b)(1). In this regard, the veteran's gastrectomy is not so unusual or extraordinary as to warrant extraschedular rating. For example, gastrectomy does not result in marked interference with employment or in frequent hospitalization, other than as anticipated by the regular rating schedule. His symptoms shown at the January 1989 VA examination are adequately anticipated by the 60 percent rating assigned herein from that date. Thus, the regular rating schedule applies, and no more than 60 percent, the highest schedular rating, may be assigned for gastrectomy residuals. We have also considered whether the veteran's psychophysiologic GI reaction is secondary to his gastrectomy. Service connection may be granted for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310. The service medical records show that the veteran had a personality disorder. Congenital or developmental defects such as personality disorders are not diseases or injuries within the meaning of the applicable legislation. 38 C.F.R. § 3.303(c)(1993). However, after service, the veteran's mentally related complaints went from nonexistent to complaints of insomnia (in 1983) to an assessment of functional GI disease in December 1983. In July 1984, he was thought to be in decompensation and defending against this by somatization. A neuropsychiatric disorder has been plainly visible to several examiners since then. The June 1985 VA GI examiner diagnosed psychophysiologic GI reaction superimposed over his gastrectomy residuals. Given this longitudinal view of the events of the veteran's mental health assessments, concurrent with his progressive deterioration physically related to his gastrectomy, we are unable to disassociate his psychophysiologic GI reaction from his gastrectomy. Therefore, we must find that his psychophysiologic GI reaction is proximately due to or the result of his gastrectomy. ORDER A rating in excess of 20 percent for gastrectomy from August 27, 1981, to August 1, 1985, is denied. A rating in excess of 40 percent for gastrectomy from August 1, 1985, to January 23, 1989, is denied. A rating of 60 percent for gastrectomy from January 23, 1989, is granted, subject to the provisions pertinent to the disbursement of monetary funds. Service connection is granted for psychophysiologic gastrointestinal reaction secondary to gastrectomy residuals. REMAND In July 1989, the veteran filed his claim for a total rating based on individual unemployability and stated that he had last worked in November 1979 in "molding" for Mid-State Plastic in Chicago, Illinois. He had applied for 3 different jobs since he had allegedly become disabled from working in August 1981. He contends that he is totally unable to obtain and maintain substantially gainful employment due to gastrectomy residuals. In his application for a total rating dated July 1989, he states, I have to leave the job because the company had have camera all over the floor and I have to use the bathroom so many time that I have to quit the job before they come to me and lay-off me. I couldn't tell them the real problem about my health because I knew that they will fire me cause the production they have to keep. He reported that, although he had trained in accounting from 1983 to 1986, "I have to take all classes from 8 AM to 12 AM to attend appointment at the VA in the afternoon and then eat and stay in home close to the bathroom." As noted in the Introduction section, the veteran has a pending claim for service connection for cholelithiasis which should be adjudicated. This issue is inextricably intertwined with the issue of entitlement to a total rating based on individual unemployability. To ensure that the VA has met its duty to assist the claimant in developing the facts pertinent to the claim and to ensure full compliance with due process requirements, the case is REMANDED to the RO for the following development: 1. The RO should obtain the names and addresses of all medical care providers who treated the veteran for all service- connected disorders since January 1989. After securing the necessary release, the RO should attempt to obtain these records. 2. The RO should take appropriate rating action on the veteran's claim for service connection for cholelithiasis. If the benefit sought is not granted, the veteran should be given notice of the determination and of his appellate rights. If the issue is placed in appellate status, appropriate action should be taken, including issuance of a statement of the case containing a recitation of the pertinent evidence, law, and regulations and reasons and bases for the determination. 3. Thereafter, the veteran should be afforded special psychiatric and gastrointestinal examinations to determine the current degree of severity of all his service-connected disabilities. All indicated tests and studies should be accomplished. The veteran's claims folder should be made available to the examiners for study in this case. 4. Thereafter, the veteran should be afforded a VA social and industrial survey to assess his employment history and day- to-day functioning. A written copy of the report should be inserted into the claims folder. 5. After the development requested above has been completed to the extent possible, the RO should again review the record and should consider the claim for a total rating based on individual unemployability with regard to our decision herein, increasing the assigned rating for the gastrectomy and granting service connection for a psychiatric disorder, and the development set forth above. If any benefit sought on appeal, for which a notice of disagreement has been filed, remains denied, the appellant and representative should be furnished a supplemental statement of the case and given the opportunity to respond thereto. Thereafter, the case should be returned to the Board, if in order. The Board intimates no opinion as to the ultimate outcome of this case. The appellant need take no action until otherwise notified. V. L. JORDAN Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. Under 38 U.S.C.A. § 7252 (West 1991), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Veterans Appeals. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (1993).