Citation Nr: 0002423 Decision Date: 01/31/00 Archive Date: 02/02/00 DOCKET NO. 98-15 296 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to service connection for a right lung disorder claimed as being due to exposure to asbestos. 2. Entitlement to service connection for arteriosclerotic heart disease and coronary artery disease, status post coronary artery bypass graft with cardiomegaly. 3. Whether new and material evidence has been submitted to reopen a claim for service connection for an anxiety disorder. 4. Whether new and material evidence has been submitted to reopen a claim for service connection for hypertension. 5. Entitlement to special monthly pension. 6. Entitlement to a rating in excess of zero percent for fractured nose. 7. Entitlement to a rating in excess of zero percent for deformity of the left middle finger. 8. Entitlement to a rating of 10 percent pursuant to 38 C.F.R. § 3.324 based on multiple, noncompensable, service- connected disabilities. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD Daniel R. McGarry INTRODUCTION The veteran had active service from December 1955 to September 1957 and from August 1967 to February 1968. This matter came before the Board of Veterans' Appeals (Board) on appeal from a rating decision in which the regional office (RO) denied service connection for a right lung disorder claimed as due to exposure to asbestos, denied entitlement to special monthly pension, assigned zero percent ratings for fracture of the nose and deformity of the left middle finger, and denied a 10 percent rating pursuant to 38 C.F.R. § 3.324 based on multiple, noncompensable, serviced-connected disabilities. The veteran has also appealed the RO's denial of service connection for coronary artery disease and its determination that he has not submitted new and material evidence to reopen his claims for service connection for an anxiety disorder and hypertension. The veteran was notified by letter dated May 28, 1999, that his appeal had been certified to the Board. In the same letter, the RO advised him that he should submit any additional evidence directly to the Board within 90 days. By letter dated May 24, 1999, and received at the RO on June 2, 1999, the veteran submitted additional evidence to the RO. The RO forwarded such evidence to the Board pursuant to 38 C.F.R. § 19.37(b). Such evidence was received by the Board on September 8, 1999. In an informal hearing presentation dated in December 1999, the veteran's representative waived RO consideration of the recently submitted evidence. In March 1997, the veteran filed a claim for a total disability rating based on individual unemployability due to service-connected disabilities (TDIU), as well as a claim for pension. The claim for TDIU has not been adjudicated by the RO and is referred to the RO for appropriate action. The issues of entitlement to higher ratings for the service- connected fractured nose and deformity of the left middle finger, and entitlement to a rating of 10 percent under 38 C.F.R. § 3.324 are remanded to the RO, as discussed below. FINDINGS OF FACT 1. The record does not contain competent evidence of a nexus between a current lung disability and injury or disease during the veteran's active service. 2. The record does not contain competent evidence of a nexus between current disability due to arteriosclerotic heart disease and coronary artery disease, status post coronary artery bypass grafts, and injury or disease during the veteran's active service. 3. In an April 1974 rating decision that the veteran did not appeal, the RO denied service connection for anxiety reaction and hypertension with angina. 4. Since the RO's April 1974 rating decision, the veteran has not submitted new evidence that bears directly and substantially on the question of whether he incurred anxiety reaction or hypertension during his active military service. 5. The veteran, who was born in April 1936, is in receipt of pension based on permanent and total disability. 6. The veteran has the following nonservice-connected disabilities: arteriosclerotic heart disease, status post myocardial infarction and coronary artery bypass grafts with cardiomegaly, rated 60 percent disabling; anxiety reaction, rated 30 percent disabling; schizoid personality, rated zero percent disabling; and scar in the right lung, rated zero percent disabling. 7. The veteran has service-connected disability from deformity of the left middle finger and fracture of the nose, both rated zero percent disabling. 8. The veteran does not have any disability ratable at 100 percent. 9. The veteran is not totally blind or near totally blind. 10. The veteran is not a patient in a nursing home. 11. The veteran is not bedridden nor housebound. 12. The veteran's disabilities do not prevent him from dressing or undressing himself, keeping himself ordinarily clean and presentable, feeding himself, attending to wants of nature, or protecting himself from the hazards or dangers incident to his daily environment. CONCLUSIONS OF LAW 1. The claim of entitlement to service connection for a lung disorder is not well grounded. 38 U.S.C.A. §§ 101(16), 1110, 5107 (West 1991); 38 C.F.R. § 3.303 (1999). 2. The claim of entitlement to service connection for arteriosclerotic heart disease and coronary artery disease, status post myocardial infarction and coronary artery bypass grafts with cardiomegaly is not well grounded. 38 U.S.C.A. §§ 101(16), 1110, 5107 (West 1991); 38 C.F.R. § 3.303 (1999). 3. The RO's April 1974 rating decision that denied entitlement to service connection for anxiety reaction and hypertension is final. 38 U.S.C.A. § 7105 (West 1991); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (1999). 4. The veteran has not submitted new and material evidence to reopen the claim of entitlement to service connection for anxiety reaction and hypertension. 38 U.S.C.A. § 5108 (West 1991); 38 C.F.R. § 3.156 (1999). 5. The criteria for special monthly pension based on the need for regular aid and attendance of another person or on being housebound are not met. 38 U.S.C.A. §§ 1502, 1521, 5107 (West 1991); 38 C.F.R. §§ 3.351, 3.352(a) (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 101(16), 1110 (West 1991); 38 C.F.R. § 3.303 (1999). Also, 38 U.S.C.A. §§ 1101, 1110, 1112, and 1137 provide that where a veteran has served 90 days or more during a period of war or after December 31, 1946, and develops an organic heart disease to a degree of disability of 10 percent or more within one year of separation from such service, such disease shall be presumed to have been incurred in service. The law provides that "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." 38 U.S.C.A. § 5107(a) (West 1991). A well- grounded claim is a plausible claim which is meritorious on its own or is capable of substantiation. See Murphy v. Derwinski, Vet. App. 78, 81 (1990). The three elements of a well-grounded claim are: (1) evidence of a current disability as provided by a medical diagnosis; (2) evidence of incurrence or aggravation of a disease or injury in service as provided by either lay or medical evidence, as the situation dictates; and, (3) a nexus between the in-service disease or injury and the current disability as provided by competent medical evidence. See Caluza v. Brown, 7 Vet. App. 498 (1995); see also 38 U.S.C.A. § 1110 (West 1991); 38 C.F.R. § 3.303 (1999). Generally, competent medical evidence is required to meet each of the three elements. However, for the second element, the kind of evidence to make a claim well grounded depends upon the types of issues presented by the claim. Grottveit v. Derwinski, 5 Vet. App. 91, 92-93 (1993). For some factual issues, such as the occurrence of an injury, competent lay evidence may be sufficient. However, where the claim involves issues of medical fact, such as medical causation or medical diagnosis, competent medical evidence is required. Id. at 93. For the reasons discussed below, the Board finds that the veteran's claims of entitlement to service connection for a lung disorder and a cardiovascular disorder are not well grounded. Where a claim is not well grounded it is incomplete, and the Department of Veterans Affairs (VA) is obliged under 38 U.S.C.A. § 5103(a) to advise the claimant of the evidence needed to complete his application. Robinette v. Brown, 8 Vet. App. 69, 77-80 (1995). In this case, the RO informed the appellant of the necessary evidence in the claims form he completed, in its notices of rating decisions dated in July 1997 and August 1998, and in the statements of the case provided to the veteran in September and November 1998. The discussion below informs the veteran of the types of evidence lacking, and which he should submit for a well- grounded claim. Unlike the situation in Robinette, in this case the veteran has not advised VA of the existence of any particular evidence which, if obtained, would render his claim well grounded. A. Right Lung Disorder The veteran has asserted that a scar on his right lung was discovered by X-ray examination at the time of his separation from his second period of service. He has also asserted that he was exposed to asbestos during his first period of active service. Recently dated medical records suggest that the veteran has current disability from chronic obstructive pulmonary disease (COPD). Implied in his contentions is the assertion that he has current disability from a lung disorder which is related to his active military service. Service medical records contain no indication that the veteran incurred a lung disorder during his active military service. At the time of his medical examination for separation from his first period of service, an examiner reported that the veteran's lungs were clinically normal. A chest X-ray was negative. No diagnosis pertinent to a lung disorder was reported. At the time of his medical examination for separation from his second period of active duty service, the veteran's lungs were again described as clinically normal. A hospital summary dictated in March 1974 indicates that the veteran's chest X-ray was interpreted as being within normal limits. A January 1983 chest X-ray showed no masses or infiltrates. The veteran was hospitalized in a private hospital in June 1996 for treatment of a heart disorder. In late June 1996, he underwent a five-vessel coronary artery bypass graft. Postoperative X-rays showed some bibasilar atelectasis and pleural effusion. A November 1997 chest X-ray was described as showing residual chronic changes bilaterally, but no evidence of acute infiltrate. There was slight increased density over the left lateral chest wall, possibly indicatives of some pleural thickening. During a VA hospitalization in July 1998, the veteran complained of difficulty with breathing. It was noted that a November 1997 chest X-ray had shown slight, increased density over the left lateral chest wall. A current X-ray showed a small, questionable nodular density in the peripheral lower lung field. No corresponding abnormality was seen with a computed tomography (CT) scan of the chest. There was no pleural effusion or interstitial fibrosis. However, there was hyperexpansion of the lungs suggesting COPD. An X-ray taken in November 1998 was interpreted as showing no evidence of acute cardiopulmonary disease. A nodular opacity projected over the left costophrenic angle suggested a pleural density or a subcutaneous lesion, rather than a pulmonary nodule. The Board has reviewed the entire record and finds that it contains no competent medical evidence of a nexus between current disability from a lung disorder and a disease or injury the veteran incurred during his active military service. The veteran's assertions that he has current disability from a lung disorder as a result of exposure to asbestos during his active military service are afforded no probative weight in the absence of evidence that he has the expertise to render opinions about the etiology of his claimed lung disorder. See Espiritu v. Derwinski, 2 Vet. App. 492 (1992). In the absence of competent medical evidence that the veteran has current disability from a lung disorder that is related to a disease or injury incurred during his active military service, the Board concludes that the claim for service connection for a right lung disorder is not well grounded. B. Coronary Artery Disease Service medical records contain no indication that the veteran had a heart disorder during his active military service. A report of medical examination dated in September 1957 indicates that the veteran's heart was clinically normal. In a medical history dated in August 1967, the veteran denied a history of pain or pressure in his chest and palpitation or pounding heart. An examiner noted that the veteran's heart was clinically normal. A similar finding was reported at the time of the veteran's medical examination for separation from service in February 1968. In June 1977 a private physician reported he had treated the veteran in June 1976 for symptoms of chest pain. The reported diagnosis was probable costochondritis. The veteran was hospitalized in December 1982 with complaints of substernal chest pain. He gave a history of recurrent, angina-like pain during the preceding eight years. Examination of his heart was within normal limits. The veteran was scheduled for an electrocardiogram stress test and coronary angiography. His symptoms were diagnosed as angina pectoris. Notes of VA outpatient treatment dated in September 1983 indicate that the veteran had an episode of syncope. He also complained of occasional throbbing pain in his mid-chest. An examiner noted that the veteran was status post coronary artery bypass surgery. The veteran underwent a five-vessel coronary artery bypass graft in June 1996. A summary of a VA hospitalization in July 1998 indicates that the veteran first had bypass surgery in 1982. The medical evidence contained in the claims folder indicates that the veteran developed a heart disorder many years after his separation in February 1968 from his last period of active duty service. While the record contains evidence that the veteran has current disability from arteriosclerotic heart disease and coronary artery disease, there is no competent medical evidence of a nexus between such disability and any disease or injury he incurred during his active military service. Therefore, the Board concludes that the claim for service connection for coronary artery disease is not well grounded. II. New and Material Evidence to Reopen Claims The RO disallowed the veteran's claim of entitlement to service connection for anxiety reaction and hypertension in an April 1974 rating decision. The veteran did not appeal and the April 1974 disallowance is final. 38 U.S.C.A. § 7105 (West 1991); 38 C.F.R. § 20.302, 20.1103 (1999). The claims can be reopened only with the submission of new and material evidence. 38 U.S.C.A. § 5108 (West 1991). As defined by regulation, new and material evidence means evidence not previously submitted to the agency decisionmakers which bears directly and substantially upon the specific matter under consideration, which is neither cumulative nor redundant, and which by itself or in connection with evidence previously assembled is so significant that it must be considered in order to fairly decide the merits of the claim. 38 C.F.R. § 3.156(a) (1999). Current case law provides for a three-step analysis when a claimant seeks to reopen a final decision based on new and material evidence. First, it must be determined whether new and material evidence has been presented under 38 C.F.R. § 3.156(a); second, if new and material evidence has been presented, it must be determined immediately upon reopening whether, based upon all the evidence and presuming its credibility, the claim as reopened is well grounded pursuant to 38 U.S.C.A. § 5107(a); and third, if the claim is well grounded, the merits of the claim must be evaluated after ensuring the duty to assist under 38 U.S.C.A. § 5107(b) has been fulfilled. See Hodge v. West, 155 F.3d 1356 (Fed. Cir. 1998) and Winters v. West, 12 Vet. App. 203 (1999) (en banc). In determining whether the evidence presented or secured since the prior final disallowance of the claim is new and material, "the credibility of the [new] evidence" is presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). The new and material evidence must be presented or secured since the time that the claim was finally disallowed on any basis, not only since the time that the claim was last disallowed on the merits. Evans v. Brown, 9 Vet. App. 273, 285 (1996). If new and material evidence has not been submitted, the Board does not need to address the merits of the claims. Sanchez v. Derwinski, 2 Vet. App. 330 (1992). When the RO denied service connection for anxiety reaction and hypertension in April 1974, the evidence in the record consisted of service medical records and records associated with the veteran's hospitalization at a VA medical facility in February 1974. The veteran's service medical records from his first period of service do not contain any indication that the veteran had complaints, diagnoses, or treatment associated with anxiety reaction or hypertension. At the time of his medical examination in September 1957, the veteran's blood pressure measured 146/84. His vascular system was described as normal. No psychiatric abnormality was reported. When the veteran enlisted in the Navy in August 1967, he denied a history of high or low blood pressure, frequent or severe headache, and dizziness or fainting spells. He also denied a history of frequent trouble sleeping, depression, excessive worry, and nervous trouble of any sort. On examination, a clinical evaluation was entirely normal. His blood pressure was 134/86. While aboard a ship in November 1967, the veteran reported to sick call complaining of a smothering feeling. He reported having trouble sleeping at night due to feeling "hemmed up." An examiner noted that the veteran had recently come aboard the ship and had few friends. As a civilian, he had been a farmer and was not used to the close confinement of shipboard life. The reported diagnosis was anxiety reaction. The veteran underwent a psychiatric evaluation in January 1968 after he "nearly passed out." The examiner, a psychiatrist, noted that the veteran had previously been examined by a general medical officer rather than a psychiatrist. The veteran complained of feeling that he would go to pieces in a crowd and the desire to isolate himself. He felt unable to control his nerves and think straight. He could not eat or sleep. Reportedly, he was hyperventilating. He denied such symptoms during his previous enlistment. The examiner commented that the veteran was reacting to enforced interpersonal contacts. During the examination, he answered questions relevantly and coherently. He presented no signs or symptoms of neurosis, psychosis, or organic brain damage. The psychiatrist reported a diagnosis of schizoid personality, manifested by a marked intolerance of close relationships with others, social withdrawal, seclusiveness, and unsociability. The examiner recommended that the veteran be given an administrative discharge from service. No psychiatric abnormality was noted at the time of the veteran's February 1968 medical examination for separation from service. At that time, the veteran's blood pressure was 136/90. His vascular system was described as normal. The veteran was hospitalized in February 1974 with a chief complaint of numbness from his waist down. He had recently been treated for alcoholism. A physical examination was essentially negative. Neurological examination showed that reflexes were hypoactive, but not pathological. Laboratory tests were within normal limits. The veteran's mental status was described as oriented, steady, and mentally clear. He was friendly and cooperative and not psychotic. A cardiovascular examination was negative other than a finding of a heart rate of 100. The reported diagnosis was nonpsychotic organic brain syndrome due to alcohol. In denying service connection for anxiety reaction, the RO reasoned that the veteran did not incur a neuropsychiatric disorder during a period of active service and that the personality disorder diagnosed in service was a constitutional or developmental abnormality and not a disability for which service connection could be granted. The rating board denied service connection for hypertension because the evidence in the record did not show that the veteran incurred hypertension during his active service. The evidence which has been received since the April 1974 rating decision that denied service connection for anxiety reaction and hypertension consists of copies of service medical records previously considered by VA decisionmakers, reports of VA hospital and outpatient treatment, records of private hospital treatment, statement from several private physicians, and statements from two of the veteran's former employers. Except for the copies of the service medical records which had been previously considered, all of such evidence is new in the sense that it had not been previously considered by agency decisionmakers. In a statement dated in May 1977, a private physician reported that he had treated the veteran during the preceding several years for hypertension. Another physician's secretary reported that the veteran had been hospitalized in November 1964 with a diagnosis of angina. A VA hospital summary dated in April 1977 contains a diagnosis of history of high blood pressure. A physician noted that the veteran was told he must take blood pressure medication for the remainder of his life. Subsequently dated records of VA and private medical treatment show that the veteran was prescribed medication for high blood pressure and nervousness. The most recently dated evidence in the claims folder is a VA hospital summary made in August 1999. The report contains diagnoses of generalized anxiety disorder, dysthymia, and hypertension. The Board has carefully reviewed all the evidence received since the RO's April 1974 rating decision. Much of such evidence is new and tends to show that the veteran has current disability from an anxiety disorder and hypertension. However, none of the new evidence refers to the veteran's service and all such evidence was made many years after his separation from his last period of active service. The new evidence is not material, as it does not bear directly and substantially on the question of whether the veteran incurred an anxiety disorder or hypertension during his active military service. Therefore, the Board concludes that the claims for service connection for anxiety reaction and hypertension are not reopened. III. Special Monthly Pension The July 1997 rating decision granted entitlement to a pension based on permanent and total disability due to nonservice-connected disabilities and denied special monthly pension benefits. Pension benefits are payable at a special, higher rate (with a higher minimum income limit) if a claimant is a patient in a nursing home, helpless or blind, or so nearly helpless or blind as to need or require the regular aid and attendance of another person, or otherwise establishes the factual need for the regular aid and attendance of another person. 38 U.S.C.A. § 1502(b); 38 C.F.R. § 3.351. Determinations as to need for aid and attendance must be based on actual requirements of personal assistance from others. In making such determinations, considerations is given to such conditions as: Inability of claimant to dress or undress himself or to keep himself ordinarily clean and presentable; frequent need of adjustment of any special prosthetic or orthopedic appliance which by reason of the particular disability cannot be done without aid (not including adjustment of appliances that normal persons would be unable to adjust without aid); an inability to feed himself through loss of coordination of the upper extremities or through extreme weakness; an inability to attend to wants of nature; or incapacity, physical or mental, which requires care or assistance on a regular basis to protect the claimant from the hazards or dangers incident to his daily environment. "Bedridden" will be a proper basis for the determination and is defined as that condition that, through its essential character, actually requires that the claimant remain in bed. It is not required that all of the disabling conditions enumerated above be found to exist before a favorable rating may be made. The particular personal functions that a claimant is unable to perform should be considered in connection with his condition as a whole. It is only necessary that the evidence establishes that the claimant is so helpless as to need regular aid and attendance, not that there be a constant need. 38 C.F.R. § 3.352. The United States Court of Veterans Appeals (now the U.S. Court of Appeals for Veterans Claims, herein after referred to as the Court), in discussing 38 C.F.R. § 3.352(a), noted (1) it is mandatory for VA to consider the enumerated factors within the regulation; (2) eligibility requires that at least one of the enumerated factors be present; and (3) the "particular personal function" refers to the enumerated factors. Turco v. Brown, 9 Vet. App. 222 (1996). In the case of a veteran entitled to a pension who does not qualify for increased pension based on the need of regular aid and attendance, an increase in the pension rate is authorized where the veteran has certain additional severe disabilities or is permanently housebound. The requirements for this increase are met where, in addition to having a single permanent disability rated or ratable as 100 percent under the regular schedular evaluation, without resort to individual unemployability, the veteran: (1) has additional disability or disabilities independently ratable at 60 percent or more, separate and distinct from the permanent disability rated as 100 percent disabling and involving different anatomical segments or bodily systems, or (2) is "permanently housebound" by reason of disability or disabilities. 38 U.S.C.A. §§ 1502(c), 1521(e); 38 C.F.R. § 3.351(d). In this case, the veteran has the following nonservice- connected disabilities: arteriosclerotic heart disease, status post myocardial infarction and coronary artery bypass grafts with cardiomegaly, rated 60 percent disabling, and anxiety reaction, rated 30 percent disabling. In addition, the following nonservice-connected disabilities have been rated zero percent disabling: schizoid personality and scar in the right lung. The veteran also has service-connected disability from deformity of the left middle finger and fracture of the nose, both rated zero percent disabling. The evidence of record does not demonstrate, and the veteran has not contended, that he is a patient in a nursing home. He has not asserted, nor does it appear from the medical evidence, that he is totally blind or near totally blind. When examined while hospitalized in July 1998, his eyes were normal other than requiring use of glasses. No eye disorder was reported in a hospital summary dated in August 1999. The record contains no indication that the veteran wears any prosthetic or orthopedic appliances. The evidence also indicates that he is not bedridden, unable to walk unassisted, or unable to dress or undress himself. In a report dated in February 1997, a physician who examined the veteran noted that the veteran had no pathology affecting his upper extremities, lower extremities, or spine. The physician reported that the veteran was able to feed himself and to attend to the wants of nature without requiring aid. The only reported limitations in activity involved inability to drive an automobile due to angina, and inability to shop and have social interaction due to anxiety. The same physician reported that the veteran did not require aid to protect himself from the hazards or dangers incident to his daily environment. During the July 1998 hospitalization, a physical examination was essentially normal, with the exception of the need for eyeglasses, deafness in the right ear, and broken nose from trauma. Treatment notes indicate that the veteran was alert and oriented, and independent in performance of activities of daily living. He walked with a steady gait. He denied suicidal and homicidal ideation. Similar findings were reported while the veteran was hospitalized in December 1998. When hospitalized in August 1999 for treatment of general anxiety and dysthymia, a physical examination was within normal limits except for decreased hearing in both ears and left knee crepitus with limitation of motion. At the time of his discharge from the hospital, an examiner reported a score on a scale of overall functioning (GAF) indicative of serious neuropsychiatric symptoms such as suicidal or homicidal ideation, and serious impairment of social and occupational functioning. In general, the most recently dated medical evidence contained in the claims folder does not show that any of the veteran's disabilities render him in need of regular aid and attendance. On the basis of the recent and detailed information contained in the summaries of recent VA hospitalizations, the Board finds that the veteran does not lack the capacity to protect himself in his environment. Considering the entire record, the Board concludes that the preponderance of the evidence shows that the veteran does not need regular assistance to protect himself from daily hazards. The veteran has not asserted, nor does the evidence in the record indicate that he is bedridden. The Board concludes that the veteran is not, in fact, bedridden. Concerning whether the veteran is entitled to special monthly pension based on housebound status, the Board notes that the veteran does not have a single disability rated as 100 percent disabling. Nor does it appear from the record that he is in fact housebound. Accordingly, the Board concludes that special monthly compensation by reason of being housebound is not warranted. In the Remand part of this decision, the Board has instructed the RO to request a VA examinations to evaluate his disability from a disorder of the left middle finger and fractured nose. However, the Board notes that the highest schedular rating assignable for each of such disorders is 10 percent. Assuming, without deciding, that the veteran's disability from such disorders could warrant assignment of the highest schedular rating of 10 percent, such ratings would not support entitlement to special monthly pension benefits. Further, it is not apparent from the medical evidence that the disability associated with the veteran's left middle finger and nose disorders, either separately, or in combination with his other disabilities, result in his need for aid and attendance, or render him bedridden or housebound. Therefore, the Board finds that a decision on the veteran's eligibility for special monthly pension is not inextricably intertwined with decisions on his claims for higher ratings for fractured nose and deformity of the left middle finger. ORDER Service connection is denied for a right lung disorder and arteriosclerotic heart disease and coronary artery disease, status post coronary artery bypass surgery with cardiomegaly. The claims for service connection for anxiety reaction and hypertension are not reopened. Special monthly pension benefits based on the need for regular aid and attendance of another person or by reason of being housebound are denied. REMAND In his notice of disagreement filed in February 1998, the veteran indicated that he disagreed with the RO's assignment of a zero percent rating for deformity of the left middle finger. Therefore, the RO is required to provide the veteran a statement of the case which addresses that issue. Manlincon v. West, 12 Vet. App. 238 (1999) (When an NOD is filed, the Board should remand, rather than refer, the issue to the RO for the issuance of a SOC). The veteran was granted service connection for fracture of the nose by the RO's July 1997 rating decision. The associated disability was rated as zero percent disabling pursuant to Diagnostic Code 6502. Under that diagnostic code, disability associated with traumatic deviation of the nasal septum is rated based on the degree of obstruction of the nasal passages. However, the record is devoid of any recent clinical findings upon which the Board can review the degree of such obstruction. In order to properly rate the veteran's disability from residuals of fracture of the nose, a thorough and contemporaneous medical examination must be conducted. See Green v. Derwinski, 1 Vet. App. 121 (1991). The veteran's claim for a 10 percent rating pursuant to 38 C.F.R. § 3.324 based on multiple, noncompensable, service- connected disabilities is inextricable intertwined with his claim for higher ratings for his service-connected disabilities. A grant of a compensable rating for either the nasal or the finger disability would preclude the assignment of a rating under 38 C.F.R. § 3.324. Therefore, the Board must defer a decision on such claim pending the RO's readjudcation of the claims for higher ratings for the veteran's service-connected disabilities. Pursuant to this remand, the RO will be scheduling VA examinations. The veteran is hereby notified that it is his responsibility to report for the examinations and to cooperate in the development of the claim, and that the consequences of failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158 and 3.655 (1999). To ensure that 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 action: 1. The RO should provide the veteran and his representative a SOC that conforms with the requirements of 38 U.S.C.A. § 7105(d)(1) (West 1991), in particular, one that provides the veteran the law and regulations pertaining to its July 1997 rating decision in which it assigned a zero percent rating for deformity of the left middle finger, a discussion of how such laws and regulations affect the RO's decision, and a summary of the reasons for such decision. The veteran and his representative must be given an opportunity to respond to the SOC. 2. The veteran should be afforded VA examinations to assess his current disability from service-connected fracture of the nose and from deformity of the left middle finger. All indicated tests and diagnostic studies must be performed. The nose examination report should include notation of the presence or absence of obstruction of nasal passages and the degree of such obstruction, if any. The finger examination report should include the degree of limitation of motion, if any, due to the veteran's left middle finger disorder and/or the presence of painful or tender scar. The claims folder should be made available and be reviewed by the examiner(s). 3. After the development requested above has been completed to the extent possible, the RO should again review the record and readjudicate the claims for higher ratings for fracture of the nose and deformity of the left middle finger, and for a rating under 38 C.F.R. § 3.324. 4. If any benefit sought on appeal remains denied, the appellant and his representative should be furnished a supplemental statement of the case addressing the issues of entitlement to a higher rating for fracture of the nose and entitlement to a 10 percent rating under 38 C.F.R. § 3.324, and, if the veteran files a timely substantive appeal, on the issue of entitlement to a higher rating for deformity of the left middle finger. The veteran and his represent should be 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 unless otherwise notified. 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. MARY GALLAGHER Member, Board of Veterans' Appeals