Citation Nr: 0006938 Decision Date: 03/15/00 Archive Date: 03/23/00 DOCKET NO. 96-04 235 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for residuals of burns on the face. 2. Entitlement to service connection for hearing loss. 3. Entitlement to service connection for psychiatric disorder, to include adjustment reaction and schizophrenia. 4. Entitlement to an increased evaluation for low back pain, currently evaluated as 10 percent disabling. 5. Entitlement to a compensable evaluation for low back pain prior to April 27, 1998. ATTORNEY FOR THE BOARD A. P. Simpson, Associate Counsel INTRODUCTION The appellant served on active duty from November 1983 to May 1988. This case comes before the Board of Veterans' Appeals (the Board) on appeal from a December 1989 rating decision of the Atlanta, Georgia, Department of Veterans Affairs (VA) Regional Office (RO). In that decision, the RO denied service connection for nervous disorder, burns on face, and hearing loss and continued the noncompensable evaluation for service-connected low back pain. In a July 1998 rating decision, the RO granted a 10 percent evaluation for low back pain, effective April 27, 1998. Review of the record reveals that the RO did not expressly consider referral of the case to the Chief Benefits Director or the Director, Compensation and Pension Service for the assignment of an extraschedular rating under 38 C.F.R. § 3.321(b)(1) (1999). This regulation provides that to accord justice in an exceptional case where the schedular standards are found to be inadequate, the field station is authorized to refer the case to the Chief Benefits Director or the Director, Compensation and Pension Service for assignment of an extraschedular evaluation commensurate with the average earning capacity impairment. The governing criteria for such an award 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. The United States Court of Appeals for Veterans Claims (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; however, the Board is not precluded from raising this question, and in fact is obligated to liberally read all documents and oral testimony of record and identify all potential theories of entitlement to a benefit under the law and regulations. Floyd v. Brown, 9 Vet. App. 88 (1996). The Court has further held that the Board must address referral under 38 C.F.R. § 3.321(b)(1) only where circumstances are presented which the Director of VA's Compensation and Pension Service might consider exceptional or unusual. Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Although the RO did not expressly consider 38 C.F.R. § 3.321(b)(1), the Board has reviewed the record with these mandates in mind and finds no basis for further action on this question. VAOPGCPREC. 6-96 (1996). FINDINGS OF FACT 1. Competent evidence of residuals from burns on the face is not of record. 2. Competent evidence of a current diagnosis of adjustment disorder is not of record. 3. Competent evidence of a nexus between the diagnosis of schizophrenia and service or a service-connected disability is not of record. 4. Low back pain is currently manifested by no more than slight functional impairment. 5. Prior to April 27, 1998, low back pain was manifested by no functional impairment. CONCLUSIONS OF LAW 1. The claim for service connection for residuals of burns on the face is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 2. The claim for service connection for psychiatric disorder, to include adjustment disorder and schizophrenia, is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.310(a) (1999). 3. Low back pain is no more than 10 percent disabling. 38 U.S.C.A. §§ 1155, 5107(b) (West 1991); 38 C.F.R. §§ 4.40, 4.45, 4.59; Part 4, Diagnostic Code 5292 (1999). 4. The criteria for a compensable evaluation prior to August 27, 1998, for low back pain has not been met. 38 U.S.C.A. §§ 1155, 5107(b), 5110 (West 1991 & Supp. 1999); 38 C.F.R. §§ 3.400, 4.40, 4.45, 4.59; Part 4, Diagnostic Code 5292 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Service connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1131 (West 1991). Service connection for a psychosis, such as schizophrenia, may be granted if manifest to a compensable degree within one year of separation from service. Service connection may be granted for any disease diagnosed after service when all the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (1999). In making a claim for service connection, the appellant 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) (West 1991). A well- grounded claim is a plausible claim, one which is meritorious on its own or capable of substantiation. Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). A well-grounded claim for service connection generally requires medical evidence of a current disability; evidence of incurrence or aggravation of a disease or injury in service as provided by either lay or medical evidence, as the situation dictates; and, a nexus, or link, between the inservice disease or injury and the current disability as provided by competent medical evidence. Caluza v. Brown, 7 Vet. App. 498 (1995) aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); see also 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303 (1999); Layno v. Brown, 6 Vet. App. 465 (1994); Espiritu v. Derwinski, 2 Vet. App. 492 (1992). Alternatively, the nexus between service and the current disability can be satisfied by evidence of continuity of symptomatology and medical or, in certain circumstances, lay evidence of a nexus between the present disability and the symptomatology. See Savage v. Gober, 10 Vet. App. 488, 495 (1997). Establishing direct service connection for a disability that was not clearly present in service requires the existence of a current disability and a relationship or connection between that disability and a disease contracted or an injury sustained during service. Cuevas v. Principi, 3 Vet. App. 542 (19 92); Rabideau v. Derwinski, 2 Vet. App. 141 (1992). With a "chronic disease," such as a psychosis, service connection is warranted when the disease is manifested to a compensable degree within one year following service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137 (West 1991); 38 C.F.R. §§ 3.307, 3.309(a) (1999). A well-grounded claim for secondary service connection requires evidence of a current disability as provided by a medical diagnosis, a service-connected disease or injury, and competent evidence providing a nexus between the two. Wallin v. West, 11 Vet. App. 509, 512 (1998); see also Epps v. Gober, 126 F.3d 1464 (Fed. Cir. 1997). Moreover, establishing a well-grounded claim for service connection for a particular disability requires more than an allegation that the particular disability had its onset in service. It requires evidence relevant to the requirements for service connection cited above and of sufficient weight to make the claim plausible and capable of substantiation. Tirpak v. Derwinski, 2 Vet. App. 609 (1992); see also Murphy, 1 Vet. App. at 81. The kind of evidence needed to make a claim well grounded depends upon the types of issues presented by the claim. Grottveit v. Brown, 5 Vet. App. 91, 92-93 (1993). For some factual issues, competent lay evidence may be sufficient. However, where the claim involves issues of medical fact, such as medical causation or medical diagnoses, competent medical evidence is required. Grottveit, 5 Vet. App. at 93. The appellant did not serve on active duty during a period of war, thus, entitlement to application of 38 U.S.C.A. § 1154(b) (West 1991) is not warranted. Service medical records are silent for treatment for or a diagnosis of burns or residuals of burns on the face. In June 1986, the appellant reported that she had had a recurrent rash or dry skin on the face around her mouth. The examiner stated that the skin around and under the lips was dry and scaling. The assessment was dermatitis. In July 1986 a diagnosis of mild acne vulgaris was entered. When seen in June 1987 with various pain complaints, a diagnosis of probable adjustment disorder was entered. In a subsequent June 1987 treatment report, the examiner entered an impression of reaction/adjustment disorder. In a February 1988 medical evaluation board proceeding, it was determined that the appellant had psychological factors which had influenced her physical condition and that such had been incurred in service. On her separation examination, the examiner stated that the appellant's skin was abnormal due to mild acne. The examiner also stated that psychiatric evaluation was abnormal, but did not enter a diagnosis. In an April 1991 treatment report, it was noted that the appellant had exhibited paranoid ideation and bizarre behavior during the interview. She underwent Minnesota Multiphasic Personality Inventory testing. The VA examiner stated that there was evidence of both characterological and psychotic syndrome, but that the psychodiagnostic impression was paranoid schizophrenia. In October 1991, the appellant was hospitalized at a private facility. Dr. Douglas Bess stated that the appellant had been admitted because she was delusional, paranoid, and felt like people were trying to hurt her. He also noted that she had exhibited threatening behavior toward family members. A diagnosis of paranoid delusional disorder was entered. The appellant underwent a VA psychiatric evaluation in April 1998. The appellant stated that she had had "bad nerves" since getting out of service. The VA examiner stated that the appellant's thought processes were scattered and that the appellant may have been delusional and hallucinating at the time. The VA examiner entered a diagnosis of schizophrenia, and stated that it was not related to a service-connected disability. A. Scars on face After having reviewed the evidence of record, the Board finds that the claim for service connection for residuals of burns on the face is not well grounded. See Caluza, 7 Vet. App. 498. The appellant has alleged that she sustained burns to her face in service. She is competent to allege that she burned her face, but there is no evidence of residuals from burns to her face. The service medical records reveal that she had acne on her face and had dermatitis at one time. However, no medical professional has stated that the appellant has any residuals from burns to her face. Thus, the appellant has not brought forth competent evidence of a current residuals from burns to her face. The Court has stated that "Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability," and held that "[i]n the absence of proof of a present disability[,] there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau, 2 Vet. App. at 143-44. Because the appellant has not submitted any evidence of current residuals that resulted from burns to her face, the Board must deny it as not well grounded. Id.; see also Caluza, 7 Vet. App. 498. Although the appellant has stated that she currently has residuals on her face from burns she sustained in service, it has not been shown that she possesses the requisite knowledge of medical principles that would permit her to render an opinion regarding matters involving medical diagnoses or medical etiology. See Espiritu, 4 Vet. App. at 494. Further, assuming that the appellant is claiming that there is a current disability as to residuals of a burn, she is a lay person, and her opinion is not competent. See Layno, 6 Vet. App. at 470. The appellant's own, unsupported opinion does not give rise to a well-grounded claim. Id. B. Psychiatric disorder After having reviewed the evidence of record, the Board finds that the claim for service connection for psychiatric disorder, to include adjustment disorder and schizophrenia, is not well grounded. See Wallin, 11 Vet. App. 509; Caluza, 7 Vet. App. 498. Service medical records reveal that the appellant was diagnosed with adjustment disorder. However, there is no post service medical evidence of a current diagnosis of adjustment disorder. Thus, the claim for service connection for adjustment disorder is not well grounded. Brammer, 3 Vet. App. at 225; Rabideau, 2 Vet. App. at 143-44. Because the appellant has not submitted any evidence of a current diagnosis of adjustment disorder, the Board must deny it as not well grounded. Id. As to the diagnosis of schizophrenia, the record does not reveal that the schizophrenia was manifested to a compensable degree within one year following her discharge from service. The first diagnosis of schizophrenia was in April 1991, which is almost three years following her discharge from service. Additionally, no medical professional has related the diagnosis to service or to a service-connected disability. In fact, when examined in April 1998, the VA examiner stated that the diagnosis of schizophrenia was not related to a service-connected disability. Thus, the appellant's claim for service connection for schizophrenia is not well grounded and is denied. See Wallin, 11 Vet. App. 509; Caluza, 7 Vet. App. 498. Although the appellant has stated that she currently has a psychiatric disorder that is due to service or a service- connected disability, it has not been shown that she possesses the requisite knowledge of medical principles that would permit her to render an opinion regarding matters involving medical diagnoses or medical etiology. See Espiritu, 4 Vet. App. at 494. The appellant's own, unsupported opinion does not give rise to a well-grounded claim. Id. The Board is aware that the service medical records revealed that a medical board determined that the appellant had a psychologic features that had influenced her physical condition; however, no medical professional has attributed a current psychiatric diagnosis to service or to those findings in service. C. General duty Although the VA does not have a statutory duty to assist a claimant in developing facts pertinent to the claim when it is determined to be not well grounded, it may be obligated under 38 U.S.C.A. § 5103(a) (West 1991) to advise a claimant of evidence needed to complete his application. This obligation depends on the particular facts of the case and the extent to which the Secretary has advised the claimant of the evidence necessary to be submitted with a VA benefits claim. Robinette v. Brown, 8 Vet. App. 69 (1995). Here, VA fulfilled its obligation under section 5103(a) by issuing a statement of the case in February 1990 and numerous supplemental statements of the case subsequently. Additionally, the Board attempted to obtain all the medical records of which the appellant had alleged the existence. In this respect, the Board is satisfied that the obligation imposed by section 5103(a) has been satisfied. See Franzen v. Brown, 9 Vet. App. 235 (1996) (VA's obligation under sec. 5103(a) to assist claimant in filing his claim pertains to relevant evidence which may exist or could be obtained). See also Epps v. Brown, 9 Vet. App. 341 (1996) (sec. 5103(a) duty attaches only where there is an incomplete application which references other known and existing evidence that pertains to the claim under consideration); Wood v. Derwinski, 1 Vet. App. 190 (1991) (VA's duty is just what it states, a duty to assist, not a duty to prove a claim). II. Increased evaluation The Board finds that the appellant has submitted evidence which is sufficient to justify a belief that her claim for an increased evaluation for low back pain is well grounded. 38 U.S.C.A. § 5107(a) (West 1991). That is, her assertion that her service-connected disability has worsened raises a plausible claim. See Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992). The appellant has been recently examined and his medical records have been obtained. See Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). All relevant facts on this issue have been properly developed and the duty to assist has been met. 38 U.S.C.A. § 5107(a). Service connection for low back pain was granted by means of a July 1988 rating decision and assigned a noncompensable evaluation. In a July 1998 rating decision, the RO granted a 10 percent disability evaluation for low back pain, effective April 27, 1998. In an October 1989 VA outpatient treatment report, the appellant was seen with complaints of lower back pain. The VA examiner stated that an x-ray of the left spine revealed mild levoscoliosis, but that otherwise it was negative. The assessment was chronic low back pain-mild narrowing of L5- S1. Private medical records reflect that the appellant was in an automobile accident in October 1990. She complained of neck and low back pain following the incident. In an October 1990 letter, Dr. David D. Millman stated that an x-ray of the lumbar spine revealed left scoliosis with normal appearing pedicles. The lumbar curve was diminished with L2, L3, L4 in extension malposition plus narrowing of the L5-S1 disc space. There was no abnormality demonstrated of the apophyseal joints or pars interarticularis. The final impression was hypolordosis, subluxation, discopathy, scoliosis. The appellant underwent a VA examination in December 1990. Examination of the low back revealed no pain on pressure. The VA examiner stated that there did not appear to be any spasm of the lumbar paravertebral muscles or of any malalignment of the lumbar spine. Range of motion was 90 degrees of flexion, 15 degrees of extension, 25 degrees of lateral flexion, and 28 degrees of rotation. Deep tendon reflexes were 2+. The VA examiner stated that there was no atrophy, weakness, fasciculations, or sensory loss. He stated that there were equal lengths to the extremities and equal circumference of the thighs and calves at corresponding levels. Kernig's test was negative, as was straight leg raising on the left; however, straight leg raising was positive on the right at 70 degrees. The VA examiner stated that the appellant was not wearing a back brace, that she was not using a walking aid, and that she walked with a normal gait. The diagnosis was chronic low back pain secondary to lumbar or low back strain. In a February 1991 VA outpatient treatment report, the VA examiner noted that the appellant had complained of mechanical low back pain. Examination revealed no deficit. The appellant had good range of motion of the lumbar spine. Deep tendon reflexes were 2+, and straight leg raising was negative. The VA examiner noted that the appellant was able to sit and stand without problems and that x-rays were negative. The assessment was mechanical low back pain. In April 1991, the VA examiner stated that the examination revealed negative straight leg raising, normal strength and reflexes, and no evidence of neurologic impairment. The assessment was low back pain-chronic. In a May 1991 physical therapy report, the VA physical therapist stated that the appellant was ambulatory without an assistive device. He stated that the appellant had a history of low back pain. Examination revealed that strength was normal, and that straight leg raising was negative. There was no hamstring tightness. The VA physical therapist stated that he instructed the appellant to do exercises at home. A June 1991 private medical record revealed that the appellant complained of low back pain. Physical examination revealed tenderness over the lumbar spine. Straight leg raising was positive at 45 degrees on right. Reflexes were 2-3+ and symmetrical. Lumbar spine x-ray was negative. The assessment was low back pain. An x-ray taken of the appellant's lumbar spine in April 1992 was negative. The appellant underwent a VA examination in April 1998. The appellant reported low back pain. She stated that she continued to receive pain medication, use a back brace, and undergo physical therapy, but that she had had no surgery. The appellant reported a dull pain in her low back and that she was not able to walk or run for long periods of time. She denied flare-ups of pain, weakness, fatigability, and lack of endurance. The appellant reported that she wore a back brace when she worked or drove. Upon physical examination, the VA examiner noted that the appellant had mild paravertebral lumbar tenderness in the right area. There was no muscular atrophy. The VA examiner stated that she had normal posture and stability, but that she walked with a limp. She had 90 degrees of flexion, with pain at 80 degrees and normal lateral bending and rotation. There were no gross sensory or motor deficits. Deep tendon reflexes were 2 and equal and symmetric. Straight leg raising was negative bilaterally, as was Babinski's. There was no difficulty with walking on toes or heels except for limping. The diagnosis was mechanical low back pain without signs of neuropathy or radiculopathy. An x-ray taken at that time was normal. The Board notes that the April 1998 examination report reveals that the appellant had 150 degrees of extension and was able to do 160 degrees of extension with pain. The Board finds that such range of motion cannot be accurate as to extension of the lumbar spine. Regardless, the VA examiner noted that the appellant had pain on extension. Service-connected disabilities are rated in accordance with a schedule of ratings that are based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4 (1999). An evaluation of 10 percent is warranted when limitation of motion of the lumbar spine is slight; 20 percent when limitation of motion is moderate, and 30 percent when limitation of motion is severe. 38 C.F.R. Part 4, Diagnostic Code 5292 (1999). Under Diagnostic Code 5295, lumbosacral strain is assigned a noncompensable evaluation when there are slight, subjective symptoms only. 38 C.F.R. Part 4, Diagnostic Code 5295 (1999). A 10 percent evaluation is warranted when it is manifested by characteristic pain on motion. Id. A 20 percent evaluation is warranted if there is muscle spasm on extreme forward bending, unilateral loss of lateral spine motion in a standing position. Id. A 40 percent evaluation requires severe lumbosacral strain manifested by listing of the whole spine to the opposite side, a positive Goldthwait's sign, marked limitation of forward bending in a standing position, loss of lateral motion with osteoarthritis changes, or narrowing or irregularity of the joint space. Id. I. Evaluation in excess of 10 percent for low back pain After having reviewed the evidence, the Board concludes that the preponderance of the evidence is against an evaluation in excess of 10 percent. The appellant's low back pain is no more than slightly disabling. See 38 C.F.R. Part 4, Diagnostic Code 5292. At the time of the April 1998 examination, the VA examiner stated that the appellant had mild paravertebral lumbar tenderness in the right area. At 80 degrees of flexion, pain started and she was able to go to 90 degrees. Extension of the lumbar spine caused pain. Thus, as to evaluations under Diagnostic Codes 5292 and 5295, the preponderance of the evidence shows that the appellant has no more than slight limitation of motion or that the appellant has characteristic pain on motion. See 38 C.F.R. Part 4, Diagnostic Codes 5292, 5295. As stated above, flexion was 80 degrees without pain and 90 degrees with pain and extension caused pain. The Board finds that such clinical findings are indicative of no more than a 10 percent evaluation. See id. Higher evaluations under Diagnostic Codes 5292 or 5295 are not warranted. The appellant's range of motion has not been shown to be any more than slight. See 38 C.F.R. Part 4, Diagnostic Code 5292. In the April 1998 examination report, the VA examiner stated that at 80 degrees of flexion, pain was shown. She had pain on extension as well. However, lateral bending and rotation were normal. Additionally, there has been no evidence of muscle spasm on extreme forward bending or loss of lateral spine motion. See 38 C.F.R. Part 4, Diagnostic Code 5295. Based on the record, the appellant's low back pain is no more than 10 percent disabling. See 38 C.F.R. Part 4, Diagnostic Codes 5292, 5295. Additionally, an increased evaluation may be based on either actual limitation of motion or the functional equivalent of limitation of motion due to less or more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995) (discussing 38 C.F.R. §§ 4.40, 4.45). At the time of the April 1998 examination, at 80 degrees of flexion, pain occurred. Extension of the lumbar spine caused pain. The VA examiner stated that the appellant had normal lateral bending and rotation. The appellant denied flare-ups of pain, weakness, fatigability, and lack of endurance. See 38 C.F.R. §§ 4.40, 4.45. The Board finds that such functional impairment is indicative of no more than mild or slight functional impairment due to pain or any other factor and thus no more than a 10 percent evaluation is warranted. The evidence of record establishes that the actual limitation of motion and the functional equivalent of limitation of motion are identical and are no more than mild or slight. The appellant is competent to report her symptoms; however, to the extent that she has described that her pain is worse than the 10 percent evaluation contemplates, the medical findings do not support her contentions. The Board attaches greater probative weight to the clinical findings of a skilled, unbiased professional than to the appellant's statements, even if sworn, in support of a claim for monetary benefits. Taking the appellant's contentions into account and the medical findings, an evaluation in excess of 10 percent is not warranted. To this extent, the preponderance of the evidence is against her claim and there is no doubt to be resolved. 38 U.S.C.A. § 5107(b) (West 1991). II. Evaluation in excess of 0 percent prior to April 27, 1998, for low back pain When the RO granted a 10 percent evaluation for low back pain, it granted an effective date of April 27, 1998, the date of a VA examination, which the RO stated was the date that an increase in the appellant's low back pain was factually ascertainable. After careful review of the medical evidence, the Board finds that the preponderance of the evidence is against a compensable evaluation prior to April 27, 1998, for low back pain. Despite the complaints of pain, the objective evidence during the relevant time period shows no findings of impairment. In December 1990, there was no pain on pressure of the lumbar spine. Additionally, there was no spasm of the lumbar paravertebral muscles. The VA examiner stated that there was no atrophy, weakness, fasciculations, or sensory loss. She had 90 degrees of flexion. In February 1991, the VA examiner stated that the appellant had good range of motion in her lumbar spine. There was no deficit found. Reflexes were 2+, and straight leg raising was negative. Similar findings were made in April 1991 and May 1991. In June 1991, physical examination revealed tenderness over the lumbar spine. Straight leg raising was positive on the right at 45 degrees. In April 1992, an x-ray of the lumbar spine was negative. Thus, prior to the April 1998 examination, the clinical findings revealed normal findings. The Board finds that the appellant's low back pain was no more than 0 percent disabling prior to April 27, 1998. Additionally, an increased evaluation may be based on either actual limitation of motion or the functional equivalent of limitation of motion due to less or more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca, 8 Vet. App. 202 (discussing 38 C.F.R. §§ 4.40, 4.45). The medical evidence prior to the April 1998 VA examination does not reveal any clinical findings that would warrant an evaluation in excess of 0 percent. There was no atrophy, weakness, fasciculations, or sensory loss in December 1990. See 38 C.F.R. §§ 4.40, 4.45. Straight leg raising was consistently negative. Strength was reported to be normal. The Board finds that such evidence is indicative of no functional impairment due to pain or any other factor and thus no more than a 0 percent evaluation is warranted prior to April 1998. The Board is aware that there is a large gap of time where there are no medical records; specifically, 1992 to 1998. The RO attempted to get as many medical records that the appellant stated had existed. Prior to April 1998, there was no showing of slight limitation of motion or characteristic pain on motion. See 38 C.F.R. Part 4, Diagnostic Codes 5292, 5295. Although the VA examiner reported in the June 1991 treatment report that the appellant had tenderness over the lumbar spine, the record was silent as to pain on motion of the lumbar spine. See 38 C.F.R. Part 4, Diagnostic Code 5295. The Board finds that the clinical findings in the April 1998 examination report that the appellant had pain on range of motion and limited motion established a factually ascertainable fact as to when the appellant's low back pain worsened from noncompensable to 10 percent. See 38 C.F.R. Part 4, Diagnostic Codes 5292, 5295. The Board finds that an evaluation in excess of 0 percent was not factually ascertainable until April 27, 1998. Prior to such date, the preponderance of the evidence showed no more than a noncompensable lumbar spine disability. Thus, the RO was proper in granting a 10 percent evaluation, effective April 27, 1998, as that was the date that an increased evaluation was factually ascertainable. See 38 U.S.C.A. § 5110; 38 C.F.R. § 3.400. Prior to that date, there was no objective medical evidence which established an evaluation in excess of 0 percent for low back pain. See 38 C.F.R. Part 4, Diagnostic Codes 5292, 5295. The preponderance of the evidence is against the appellant's claim for an evaluation in excess of 0 percent prior to April 27, 1998, for low back pain, and an increased evaluation is not warranted. 38 U.S.C.A. § 5107(b). ORDER Service connection for residuals of burns on the face is denied. Service connection for psychiatric disorder, to include adjustment disorder and schizophrenia, is denied. An increased evaluation for low back pain is denied. A compensable evaluation prior to April 27, 1998, for low back pain is denied. REMAND The record reflects that the appellant was scheduled for a VA audiological evaluation in November 1998, to which she did not report. There is a document in the file that reveals that the appellant was sent a notice of the scheduled VA examination; however, the date on which the notice to report was sent is not included. The document bears a date in January 1999, a date which post dates the scheduled examination. The Board finds that a determination of whether the appellant's failure to show up constituted "good cause" must be made. Accordingly, the case is hereby REMANDED to the RO for the following action: The RO is to make a determination if the appellant's failure to show for the VA examination scheduled on November 30, 1998, constituted "good cause." The RO should contact the facility that sent the letter of notification of the scheduled examination to the appellant to find out when that letter was sent. The RO should then issue the appellant a letter, which allows her adequate time to establish "good cause." The determination should be associated with the claims file. If the determination is that the appellant showed good cause, then the audiological evaluation should be rescheduled. Regardless, the RO must comply with 38 C.F.R. § 3.655 (1999). If, however, the determination is that the appellant did not show "good cause," then the RO should issue a supplemental statement of the case with its reasons and bases for such determination. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded to the regional office. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 1999) (Historical and Statutory Notes). In addition, VBA's Adjudication Procedure Manual, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44-8.45 and 38.02-38.03. NANCY I. PHILLIPS Member, Board of Veterans' Appeals