Citation Nr: 0003905 Decision Date: 02/15/00 Archive Date: 02/23/00 DOCKET NO. 93-15 386 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to a certificate of eligibility for assistance in acquiring specially adaptive housing or a special home adaptation grant. 2. Entitlement to service connection for a right leg disability as secondary to a service-connected disability. 3. Entitlement to an initial evaluation in excess of 10 percent for right carpal tunnel syndrome (major). 4. Entitlement to an increased (compensable) evaluation for residuals of a fracture of the right wrist. REPRESENTATION Appellant represented by: Paralyzed Veterans of America, Inc. INTRODUCTION The veteran served on active duty from December 1978 to June 1990. The current appeal arose from a December 1991 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. The RO denied entitlement to a certificate of eligibility for assistance in acquiring specially adaptive housing or a special home adaptation grant. The Board of Veterans' Appeals (Board) remanded the case to the RO for further development in June 1995. In April 1996 the RO, in pertinent part, denied entitlement to service connection for a right leg disability; granted entitlement to service connection for right carpal tunnel syndrome with assignment of a 10 percent evaluation effective March 22, 1995; and affirmed the determination previously entered. In September 1998 the RO denied entitlement to an increased (compensable) evaluation for residuals of a fracture of the right wrist. In his January 1999 statement on the veteran's behalf, the representative at the RO included the issue of an increased (compensable) evaluation for residuals of a fracture of the right wrist. The Board has construed this statement as a notice of disagreement with the September 1998 RO denial. This issue has been placed in appellate status and is addressed in the remand portion of this decision. The case has been returned to the Board for further appellate review. In view of the Board's grant of entitlement to a certificate of disability for financial assistance in acquiring specially adaptive housing, the greater of the two possible housing benefits, the issue of entitlement to a certificate of eligibility for assistance in acquiring a special home adaptation grant, the lesser of the two benefits, has been rendered no longer appropriate for appellate review. FINDINGS OF FACT 1. The veteran's service-connected loss of use of the left foot, together with her status post surgery times three, herniated nucleus pulposus with failed back syndrome, have so affected the functions of balance and propulsion as to preclude locomotion without the aid of braces, crutches, canes, or a wheelchair. 2. A right leg disability is causally related to the service-connected status post surgery times three, herniated nucleus pulposus with failed back syndrome. 3. Right carpal tunnel syndrome is productive of not more than mild incomplete paralysis of the major median nerve. CONCLUSIONS OF LAW 1. The criteria for a certificate of eligibility for assistance in acquiring specially adaptive housing have been met. 38 U.S.C.A. §§ 2101(a), 5107 (West 1991); 38 C.F.R. §§ 3.809, 4.63 (1999). 2. A right leg disability is proximately due to or the result of service-connected status post surgery times three, herniated nucleus pulposus. 38 U.S.C.A. § 5107 (West 1991); 38 C.F.R. § 3.310(a) (1999). 3. The criteria for an initial evaluation in excess of 10 percent for right carpal tunnel syndrome have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.7, 4.124(a), Diagnostic Code 8515 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Factual Background Service connection has been granted for impairment of rectal and anal sphincter control, evaluated as 100 percent disabling; neurogenic bladder, evaluated as 60 percent disabling; status post surgery times three, herniated nucleus pulposus with failed back syndrome, evaluated as 60 percent disabling; left foot drop secondary to surgery, evaluated as 40 percent disabling; right carpal tunnel syndrome, evaluated as 10 percent disabling; left carpal tunnel syndrome, residuals of a fracture of the right wrist, and vulvar intra- epithelial neoplasia, status post multiple surgery, each evaluated as noncompensable. Entitlement has been established to a total disability rating for compensation purposes on the basis of individual unemployability. Entitlement has been established to special monthly compensation on account of loss of use of one foot pursuant to the criteria of 38 U.S.C.A. § 1114(k) (West 1991 & Supp. 1999); 38 C.F.R. § 3.350(a) (1999). Entitlement has been established to special monthly compensation at the housebound rate pursuant to the criteria of 38 U.S.C.A. § 1114(s) (West 1991 & Supp. 1999); 38 C.F.R. § 3.350(i) (1999) on account of impairment of rectal and sphincter control rated as 100 percent disabling and additional service-connected disabilities of neurogenic bladder, status post surgery times three herniated nucleus pulposus with failed back syndrome, left foot drop secondary to surgery and carpal tunnel syndrome, right wrist independently ratable at 60 percent or more from January 25, 1996. A September 1991 VA medical examination report shows the veteran had undergone multiple back surgeries and had subsequent left lower extremity weakness for which she wore a brace and ambulated with a cane. Pertinent clinical findings obtained on examination show she had a metallic left ankle posterior splint in place. She ambulated with a limp to the right utilizing a cane. The pertinent diagnosis shows history of multiple surgical procedures on the low back with left lower extremity weakness. A March 1995 VA nerve conduction study concluded in a clinical impression of right greater than left carpal tunnel syndrome. VA conducted a special orthopedic examination of the veteran in August 1995. By history it was noted that she had been in a wheelchair or at least had had a wheel chair for the last seven years, but she walked about the house with a cane and a drop foot brace on the left leg. She complained of chronic low back pain into both legs, worse on the left. She complained of numbness over most of the left lower extremity below the knee and in patchy areas on the right lower extremity below the knee mainly on the inner aspect of the right calf and over the inner aspect of her right foot. Pertinent clinical findings obtained on examination show the veteran could stand up on her good right leg but could barely bear weight on the left leg. She walked using her cane with a gait that included dragging her left lower extremity behind her and sort of pulling it up into place with the foot turned outwards and the whole lower extremity sort of turned outwards dragging it on its inner side. She got up on the table by getting her good leg up and then with the help of her husband up to the sitting position. Deep tendon reflexes were 2+ bilaterally at the knees and equal bilaterally. The right ankle jerk was 1+. The right planter surface was 1+ and Babinski was normal. Straight leg raising was positive in the seated position on the right at about 80 degrees. The examiner noted that the veteran had a good right leg which functioned quite well and so far as being able to do any kind of work she could certainly function from the standpoint of working in a chair in a seated position. An August 1995 VA special neurological examination pertinently shows that the veteran had minimal weakness of the right leg which was rated at 5-/5. Sensory examination disclosed slight decrease to pinprick in the right leg. The examiner opined that the veteran was able to ambulate for very short distances only with her cane. It was noted that she would require a wheelchair for any prolonged traveling. A November 1995 VA hospital summary report shows an admission diagnosis of cauda equina syndrome from 1986 with a new onset of bilateral lower extremity pain. There was reported a history of cauda equina syndrome secondary to a fall in 1986. The veteran had an approximately five week history of an area on the dorsum of the right foot with a burning type pain which had spread to a somewhat stocking glove type distribution from approximately the mid calf down and was somewhat worse along the lateral aspect of the leg and dorsum of the foot laterally. The pain was constant with variable intensity. She reported times where she had areas of her extremities which became red and inflamed; however, this was only transient and the inflammation and redness quickly resolved in a few hours. She obtained some relief from symptoms with a peripheral nerve block; however, this lasted for four to five days. She obtained some relief with ice. After a full work-up by neurology, it was felt that she could still have the possibility of reflex sympathetic dystrophy. VA conducted a special surgical examination of the veteran in February 1996. Pertinent clinical findings obtained on examination show she was unable to stand on her own. VA conducted an examination of the veteran for aid and attendance/housebound status in February 1996. She reported as history that she had fallen down on ice in 1986 while stationed in Alaska. In November 1995 she had right foot weakness and sensitivity to touch and weather change. An injection relieved the sensitivity for two days. Another injection was given with no relief. She was still with a burning sensation which went to the back, at times with burning and redness, lasting for 1 1/2 hours. The pain came and went. She had not been able to walk since November 1995. She could not even walk without help. The VA examiner noted that the veteran had no function in the lower extremities. She had to use a wheelchair everyday. She was unable to ambulate because of a total loss of function of the lower extremities. Lower loss of extremity function was noted as permanent. The examination diagnosis shows the veteran had left foot drop secondary to spine surgery, impairment of the lower extremities secondary to herniated disc with failed back syndrome, postoperative. A May 1996 VA examination for aid and attendance/housebound status shows the veteran had left foot drop, generalized weakness in both lower extremities secondary to chronic pain exacerbation and surgery. She was noted to have been swimming and ambulating since the Fall of 1995. The examiner expected her to be ambulating again in six months. VA conducted a special neurological examination of the veteran in March 1996. Pertinent clinical findings obtained on examination show she had a hyperesthetic feeling in her right foot on the dorsum and had a local injection there. About a week later she had burning pain traveling up her right leg and involving her left leg, and she had been unable to walk since then, apparently. It was noted she had been unable to walk since November 1995. She had give-way weakness in the right leg diffusely but no atrophy or fasciculations. She was unable to feel any pressure but she could feel vibration in her right knee. In his clinical assessments the examiner noted the veteran was status post multiple back operations with failed back syndrome. She had weakness of both legs of uncertain etiology. There did not appear to be a new spinal cord injury since her last visit in August 1995, to explain why she was so weak in her legs. In a January 1997 letter on file a VA staff physician from the spinal cord injury service noted the appellant had been followed for paraplegia for two years. He also noted she had increased impairment in use of her lower extremities. The veteran provided testimony before a hearing officer at the RO in April 1997. The issue discussed was referable to impairment of rectal and anal sphincter control. VA conducted a special orthopedic examination of the veteran in August 1998. On examination she was confined to a motorized wheelchair. A brief neurologic examination pertinently demonstrated evidence of a low thoracic paraplegia without significant motor function. VA conducted a special neurologic examination of the appellant in August 1998. The examiner noted the appellant had a history of a cauda equina syndrome secondary to a fall in 1986. She initially injured her back in 1986 and then underwent several surgeries. Progressively she started having weakness and numbness in her legs. She was unable to move either leg. She developed a carpal tunnel syndrome a few years before. She had had a status post right carpal tunnel release as well as a right carpal tunnel surgery. On examination the veteran used a motorized wheelchair. Cranial nerves II-XII were normal. Motor examination revealed normal strength in both arms. She had paraplegia. Reflexes were +2 1/2 in the arms, +3 in her knees and absent in her ankles. Sensory testing revealed diminished pin in both legs with a sensory level slightly below the umbilicus. Cerebellar and the arms were normal. The legs could not be tested. The veteran was unable to walk. The examination diagnoses were right carpal tunnel syndrome and paraplegia due to cauda equina syndrome. Criteria Pursuant to 38 U.S.C.A. § 5107(a), a person who submits a claim for benefits under a law administered by the Secretary shall have the burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that the claim is well grounded. The United States Court of Appeals for Veterans Claims (Court) has held that a well grounded claim is "a plausible claim, one which is meritorious on its own or capable of substantiation. Such a claim need not be conclusive but only possible to satisfy the initial burden of § [5107(a)]." Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). The Court has also held that although a claim need not be conclusive, the statute provides that it must be accompanied by evidence that justifies a "belief by a fair and impartial individual" that the claim is plausible. Tirpak v. Derwinski, 2 Vet. App. 609, 610 (1992). The Court has held that "where the determinative issue involves medical causation or a medical diagnosis, competent medical evidence to the effect that the claim is 'plausible' or 'possible' is required." Heurer v. Brown, 7 Vet. App. 379, 384 (1995); Grottveit v. Brown, 5 Vet. App. 91, 93 (1993) (citing Murphy, at 81). The Court has held that a well grounded claim required competent evidence of a current disability (a medical diagnosis), of incurrence or aggravation of a disease or injury in service (lay or medical evidence), and of a nexus between the in-service injury or disease and the current disability (medical evidence). Epps v. Brown, 126 F.3d 1464, 1468 (Fed. Cir. 1997); Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996). In order to establish service connection for a claimed disability the facts must demonstrate that a disease or injury resulting in current disability was incurred in active military service or, if pre-existing active service, was aggravated therein. 38 U.S.C.A. § 1131 (West 1991); 38 C.F.R. § 3.303 (1999). Service connection may be granted for a disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (1999). Service connection may be granted for a disorder which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). The degree of impairment resulting from a disability is a factual determination and generally the Board's primary focus in such cases is upon the current severity of the disability. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994); Solomon v. Brown, 6 Vet. App. 396, 402 (1994). However, in Fenderson v. West, 12 Vet. App. 119 (1999), the Court held that the rule from Francisco does not apply where the appellant has expressed dissatisfaction with the assignment of an initial rating following an initial award of service connection for that disability. Rather, at the time of an initial rating, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. Where there is a question as to which of two evaluations shall be assigned, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Ratings shall be based as far as practicable, upon the average impairments of earning capacity with the additional proviso that the Secretary shall from time to time readjust this schedule of ratings in accordance with experience. To accord justice, therefore, to the exceptional case where the schedular evaluations are found to be inadequate, the Under Secretary for Benefits or the Director, Compensation and Pension Service, upon field station submission, is authorized to approve on the basis of the criteria set forth in this paragraph an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. The governing norm in these exceptional cases is: A finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1). A 10 percent evaluation may be assigned for mild incomplete paralysis of the major median nerve. A 30 percent evaluation may be assigned for moderate incomplete paralysis of the major median nerve. A 50 percent evaluation may be assigned for severe incomplete paralysis of the major median nerve. A 70 percent evaluation may be assigned for complete paralysis of the major median nerve. 38 C.F.R. § 4.124a; Diagnostic Code 8515. For a certificate of eligibility for assistance in acquiring specially adaptive housing, it is required that service- connected disabilities result in the loss or loss of use of both lower extremities such as to preclude locomotion without the aid of braces, crutches, canes, or a wheelchair; or blindness in both eyes having only light perception, plus the anatomical loss or loss of use of one lower extremity; or the loss or loss of use of one lower extremity together with residuals of organic disease or injury which so affect the functions of balance or propulsion as to preclude locomotion without the aid of braces, crutches, canes or a wheelchair; or the loss or loss of use of one lower extremity together with the loss or loss of use of one upper extremity which so affect the functions of balance and propulsion as to preclude locomotion without the aid of braces, crutches, canes or a wheelchair. 38 U.S.C.A. § 2101(a); 38 C.F.R. § 3.809. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When, after consideration of all of the evidence and material of record in an appropriate case before VA, there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b) (West 1991); 38 C.F.R. §§ 3.102, 4.3 (1999). Analysis Certificate of eligibility for assistance in acquiring specially adaptive housing Upon review of the record, the Board concludes that the veteran's claim for a certificate of eligibility for assistance in acquiring specially adaptive housing is well grounded. 38 U.S.C.A. § 5107(a). In this regard, the veteran is essentially claiming that her service-connected disabilities are sufficiently disabling as to afford him entitlement to increased compensation benefits, in this case, with respect to obtaining specially adaptive housing. In general, an allegation of increased disability is sufficient to establish a well grounded claim. Proscelle v. Derwinski, 2 Vet. App. 629 (1992). The veteran's assertions concerning the severity of her service-connected disabilities (that are within the competence of a lay party to report) are sufficient to conclude that her claim for specially adaptive housing is well grounded. King v. Brown, 5 Vet. App. 9 (1993). The Board is also satisfied that as a result of the June 1995 remand of the case to the RO for further development and adjudicative actions, all relevant facts have been properly developed to their full extent and that VA has met its duty to assist. Godwin v. Derwinski, 1 Vet. App. 419 (1991); White v. Derwinski, 1 Vet. App. 519 (1991). The Board's review of the evidentiary record discloses that among other disabilities for which service connection has been granted, the veteran is in receipt of a 60 percent evaluation for status post surgery times three, herniated nucleus pulposus with failed back syndrome. She has also been granted special monthly compensation for loss of use of the left foot. VA examiner after VA examiner, in other words, competent medical authority, have repeatedly acknowledged her inability to walk and have attributed such inability to walk due to her service-connected loss of use of the left foot, and her service-connected back disability which has required several back surgeries. The veteran has been reported as unable to ambulate without a wheelchair. The Board notes that the most current evidence of record clearly reflects an inability of the appellant to ambulate due to loss of use of one extremity and organic disease which have so affected the functions of balance or propulsion as to preclude locomotion without the aid of a wheelchair. While there are some minor contradictions in the opinions on file, the evidentiary record is not in dispute in showing that overall the considered medical reasoning attributes the appellant's locomotion problems with need of a wheelchair to her service-connected organic disease of the back and loss of use of the left lower extremity, thereby qualifying her for a certificate of eligibility for assistance in acquiring specially adaptive housing. Service connection for a right leg disorder The Board's review of the evidentiary record discloses that despite some contradictions in the evidentiary record, the medical evidentiary record shows the appellant has an ill defined disorder of her right leg which most recently has been diagnosed as reflective of loss of function considered to be neurological in nature. Competent medical authority has linked dysfunction of the right lower extremity to a service-connected disability; namely, the back disability. The Board therefore concludes that the veteran's claim of service connection for a right leg disorder as secondary to her service-connected back disability is well grounded. The Board notes that VA medical examiners have acknowledged a growing dysfunction of the right lower extremity to the extent that she the veteran had been determined to have total loss of function in the right lower extremity. Her lower extremity impairment has been linked to her service-connected herniated disc with failed back syndrome. The evidentiary record therefore provides a favorable basis upon which to predicate a grant of entitlement to service connection for a right leg disorder as secondary to the service-connected status post surgery times three, herniated nucleus pulposus with failed back syndrome. Initial evaluation in excess of 10 percent for right carpal tunnel syndrome Initially the Board finds that the veteran's claim of entitlement to an evaluation in excess of 10 percent for her right carpal tunnel syndrome is well grounded within the meaning of 38 U.S.C.A. § 5107(a); that is, a plausible claim has been presented. Murphy v. Derwinski, 1 Vet. App. 78 (1990). In general, an allegation of increased disability is sufficient to establish a well grounded claim seeking an increased rating. Proscelle v. Derwinski, 2 Vet. App. 629 (1992). The veteran's assertions concerning the severity of her service-connected right carpal tunnel syndrome (that are within the competence of a lay party to report) are sufficient to conclude that her claim for an initial evaluation in excess of 10 percent for that disability is well grounded. King v. Brown, 5 Vet. App. 19 (1993). The Board is also satisfied that all relevant facts that have been properly developed to their full extent and that VA has met its duty to assist. Godwin v. Derwinski, 1 Vet. App. 419 (1991); White v. Derwinski, 1 Vet. App. 519 (1991). The RO has assigned a 10 percent evaluation for the appellant's right carpal tunnel syndrome under diagnostic code 8515. The current 10 percent evaluation contemplates mild incomplete paralysis of the major median nerve. The most recent special neurological examination on file revealed normal motor findings and normal strength of the major upper extremity. Earlier neurological examinations of record are nonrevealing to any significant extent as to carpal tunnel syndrome of the right upper extremity. While carpal tunnel syndrome undoubtedly constitutes some disablement of the right upper extremity, its manifestations are not shown to be more than mild in nature, consistent with the current 10 percent evaluation. In the absence of moderate incomplete paralysis required for the next higher evaluation of 30 percent, there exists no basis upon which to predicate assignment of an increased evaluation. No question has been presented as to which of two evaluations would more properly classify the severity of the appellant's right carpal tunnel syndrome. 38 C.F.R. § 4.7. In view of the denial of the claim for an initial evaluation in excess of 10 percent for right carpal tunnel syndrome, the Board finds that assignment of "staged" ratings is not for application in the veteran's case. Fenderson, supra. Although the veteran is entitled to the benefit of the doubt where the evidence is in approximate balance, the benefit of the doubt doctrine is inapplicable where, as here, the preponderance of the evidence is against the claim for an initial evaluation in excess of 10 percent for right carpal tunnel syndrome. The Court has held that the Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance. Floyd v. Brown, 9 Vet. App. 88 (1996). The Board, however, is still obligated to seek all issues that are reasonably raised from a liberal reading of documents or testimony of record and to identify all potential theories of entitlement to a benefit under the law or regulations. In Bagwell v. Brown, 9 Vet. App. 337 (1996), the Court clarified they it did not read the regulation as precluding the Board from affirming an RO conclusion that a claim does not meet the criteria for submission pursuant to 38 C.F.R. § 3.321(b)(1), or from reaching such conclusion on its own. In the veteran's case at hand, the Board notes that the RO neither provided nor discussed the criteria pursuant to assignment of an extraschedular evaluation. The Court has held that the Board must address referral under 38 C.F.R. § 3.321(b)(1) only where circumstances are presented which the VA Under Secretary for Benefits or the Director of the VA Compensation and Pension Service might consider exceptional or unusual. Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). The Board does not find the veteran's disability picture due to right carpal syndrome to be unusual or exceptional in nature as to warrant referral of her case to the Director or Under Secretary for review for consideration of extraschedular evaluation pursuant to the provisions of 38 C.F.R. § 3.321(b)(1). The current schedular criteria adequately compensate the veteran for the current nature and extent of severity of her right carpal tunnel syndrome. Having reviewed the record with these mandates in mind, the Board finds no basis for further action on this question. ORDER Entitlement to a certificate of eligibility for assistance in acquiring specially adaptive housing is granted. Entitlement to service connection for a right leg disability as secondary to service-connected status post surgery times three, herniated nucleus pulposus is granted. Entitlement to an initial evaluation in excess of 10 percent for right carpal tunnel syndrome is denied. REMAND 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. As the Board noted earlier, the RO denied entitlement to an increased (compensable) evaluation for residuals of a fracture of the right wrist in September 1998. The representative at the RO filed a notice of disagreement with the above determination in January 1999. Where there has been an initial RO adjudication of a claim and a notice of disagreement as to its denial, the claimant is entitlement to a statement of the case, and the RO's failure to issue such is a procedural defect requiring remand. Godfrey v. Brown, 7 Vet. App. 398 (1995); Manlincon v. West, 12 Vet. App. 238 (1999). Therefore, it is the decision of the Board that the issue of entitlement to an increased (compensable) evaluation for residuals of a fracture of the right wrist be remanded to the RO for further action as follows: 1. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded to the RO. Kutscherousky v. West, 12 Vet. App. 369 (1999). 2. The RO should issue a statement of the case on the issue of entitlement to an increased (compensable) evaluation for residuals of a fracture of the right wrist. The veteran should be notified of the need to file a substantive appeal (VA Form 9) if she wishes appellate review. Thereafter, the case should be returned to the Board for further appellate review, if otherwise in order. By this remand, the Board intimates no opinion as to any final outcome warranted. No action is required of the appellant until she is notified by the RO. RONALD R. BOSCH Member, Board of Veterans' Appeals