Citation Nr: 0006822 Decision Date: 03/14/00 Archive Date: 03/17/00 DOCKET NO. 94-09 672 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston- Salem, North Carolina THE ISSUES 1. Entitlement to service connection for Raynaud's disease. 2. Entitlement to service connection for esophagitis. 3. Entitlement to service connection for a back disorder. 4. Entitlement to an increased disability evaluation for dermatitis, currently evaluated as 30 percent disabling. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESSES AT HEARINGS ON APPEAL Veteran and wife ATTORNEY FOR THE BOARD Martin F. Dunne, Counsel INTRODUCTION The veteran served on active duty in the Armed Forces from July 1958 to June 1960. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina, which denied the benefits sought on appeal. The veteran appealed the decisions to the Board. In July 1993, the veteran and his wife testified before a hearing officer at the RO. In September 1996, he testified at a personal hearing held at the Board in Washington, D.C., before a Member of the Board who remanded the case to the RO to obtain additional evidence and readjudication of the claim. Completing the remand instructions, the RO again denied the claim and the case was returned to the Board for appellate determination. Unfortunately, the Member of the Board who conducted the veteran's September 1996 personal hearing is no longer with the Board. Since the law requires that the Board Member who conducts a hearing on an appeal must participate in any decision made on that appeal, see 38 C.F.R. § 20.707 (1999), the VA, in a letter dated in December 1999, addressed to the veteran, informed him of his right to a hearing before another Member of the Board, and requested that he provide a response as to whether such a hearing was desired. In a letter dated later in December 1999, the veteran related that did not want an additional hearing. Accordingly, the Board will adjudicate the appeal on the current record. FINDINGS OF FACT 1. There is no competent medical evidence of a nexus or link between the veteran's currently diagnosed CREST syndrome, including Raynaud's disease, and either his active duty service or his service-connected skin disorder. 2. There is no competent medical evidence of a nexus or link between the veteran's currently diagnosed CREST syndrome, including esophageal dysmotility, and either his active duty service or his service-connected skin disorder. 3. There is no competent medical evidence of a nexus or link between the veteran's low back disorder, currently diagnosed as herniated nucleus pulposus, and either his active duty service or his service-connected skin disorder. 4. In April 1974, the RO granted the veteran service connection for dermatitis of the hands, effective from November 1973, the date of receipt of his claim, and a 30 percent evaluation was assigned, effective the same date; the 30 percent evaluation has since been in effect. 5. The veteran's dermatitis is manifested by itchy hands, areas of fissuring in the tips of the fingers, and some crusting on the tips of the fingers. CONCLUSIONS OF LAW 1. The claim for service connection for Raynaud's disease is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 2. The claim for service connection for esophagitis is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 3. The claim for service connection for back disorder is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 4. The criteria for a disability evaluation in excess of 30 percent for dermatitis have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.321, 4.1-4.7, 4.27, 4.118, Diagnostic Code 7899-7806 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I Service Connection To establish service connection for a claimed disability, the facts, as shown by the evidence, must demonstrate that a particular disease or injury resulting in current disability was incurred during active service or, if preexisting active service, was aggravated therein. See 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. When a disease is first diagnosed after service, service connection may nevertheless be established by evidence demonstrating that the disease was in fact incurred during the veteran's service or by evidence that a presumption period applied. See 38 C.F.R. §§ 3.303, 3.307, 3.309; Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). Additionally, a disability which is proximately due to, or results from, another disease or injury for which service connection has been granted shall be considered a part of the original condition. See 38 C.F.R. § 3.310(a). Further, when aggravation of a disease or injury for which service connection has not been granted is proximately due to, or is the result of, a service-connected condition, the veteran shall be compensated for the degree of disability, and no more, over and above the degree of disability existing prior to the aggravation. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). The preliminary question to be answered, however, is whether the veteran has presented evidence of a well-grounded claim. A well-grounded claim is not necessarily a claim that will ultimately be deemed allowable. It is a plausible claim, properly supported with evidence. See 38 U.S.C.A. § 5107(a); Epps v. Gober, 126 F.3d 1464 (1997); Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). In the absence of evidence of a well-grounded claim, there is no duty to assist the veteran in developing the facts pertinent to the claim, and the claim must fail. See Slater v. Brown, 9 Vet. App. 240, 243 (1996); Gregory v. Brown, 8 Vet. App. 563, 568 (1996) (en banc); Grivois v. Brown, 6 Vet. App. 136, 140 (1994); Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). Three types of evidence must be presented in order for a claim for service connection to be well grounded: (1) a medical diagnosis of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between an in-service injury or disease and the current disability. Where the determinative issue involves medical causation, competent medical evidence to the effect that the claim is plausible is required. See Epps, 126 F.3d at 1468. Alternatively, a claim may be established as well grounded pursuant to the chronicity provision of 38 C.F.R. § 3.303(b). That provision is applicable where evidence, regardless of its date, shows that a veteran had a chronic condition in service, or during an applicable presumption period, and still has such condition. Such evidence must be medical unless it relates to a condition as to which, under he court's case law, lay observation is competent. If the chronicity provision is not applicable, a claim may still be well grounded or reopened on the basis of 38 C.F.R. § 3.303(b) if the condition is observed during service or any applicable presumption period, continuity of symptomatology is demonstrated thereafter, and competent evidence relates the present condition to that symptomatology. See Savage v. Gober, 10 Vet. App. 488, 498 (1997). A. Raynaud's Disease Essentially, the veteran contends that his Raynaud's disease was either incurred during his active duty service, during the one year presumptive period following his separation from active duty service, or the disease was proximately due to or the result of his service-connected dermatitis. In the veteran's case, his service medical records do not contain any complaints, findings or symptomatology associated with Raynaud's phenomenon or disease. At service entry and service separation, his upper and lower extremities, and feet were normal. Post-service, the veteran's earliest medical evidence of record is from 1970. This is a hospitalization record showing treatment at a non-VA medical facility for food poisoning. Between 1970 and August 1992, the veteran's medical evidence, consisting of private medical statements, private hospitalization records, and VA medical records, including the report of the veteran's March 1974 VA examination, do not contain complaints, symptomatology or findings pertaining to Raynaud's phenomenon or disease. The veteran's VA outpatient treatment record, dated in August 1992, is the earliest indication of possible Raynaud's phenomenon. At that time, he was complaining of pain, numbness, and pallor color in his hands and feet, which were brought on by cold. Following medical evaluation, the diagnoses were tinea of the hands and possible Raynaud's phenomenon. During the veteran's July 1993 personal hearing held before a hearing officer, the veteran testified he is experiencing numbness in his fingers; his hands cannot tolerate cold; they hurt when he put them under cold or hot water; and his feet also are now similarly affected. He further testified that, during exacerbations, parts of his hands turn purple and black and that his fingers tend to be affected longer than the palms. In an October 1995 letter, A. Bello, M.D., of Duke University Medical Center, a specialist in rheumatology/immunology, related that the veteran currently carries the diagnosis of limited scleroderma/CREST syndrome for which the physician had been following for approximately two and a half years. After a thorough review of the veteran's chart, the physician related that the veteran has had signs and symptoms that can be associated with this syndrome as early as 1973. Prior to rheumatology evaluation in May 1993, the veteran was carrying several diagnoses, including dyshidrotic eczema and chronic hand dermatitis, which only improved with high dose steroids. It was the physician's opinion that those were early manifestations of limited scleroderma. During the veteran's personal hearing before a Member of the Board in September 1996, the veteran reiterated his testimony pertaining to the current and past condition of his hands and feet. He also related that he was taking prescribed medication for his skin condition, which he claimed were having adverse effects on his system, to include weight gain and esophagitis. The veteran underwent VA dermatology examination in August 1997; specifically, to ascertain the nature, extent and characteristics of his skin condition. On examination, his hands were cold with the distal tips purple and there were areas of fissuring noted in the tips of the fingers. There was no active drainage from the tips of his fingers, but there was some crusting. The diagnosis was probable CREST syndrome. The examiner explained that CREST is a syndrome in which the "C" stands for calcinosis; "R" for Raynaud's; "E" for esophageal dysmotility; "S" for sclerodactyly; and "T" for telangiectasia. Further, the physician reiterated that Raynaud's phenomenon is part of the syndrome and the syndrome is a chronic condition resulting in significant disability, especially with the use of the hands. In an April 1998 addendum to the August 1997 VA examination report, the examining physician noted that, after review of the file, he agreed with Dr. Bello that the CREST syndrome began in 1973 and that the syndrome was probably not related to any of the other diagnoses that the veteran was carrying, such as eczema and dermatitis. In summation, the physician pointed out that the features of CREST syndrome include Raynaud's phenomenon, and that eczema and CREST syndrome are different entities. In analyzing the veteran's claim for service connection for Raynaud's phenomenon or disease, the Board notes that nowhere in his service medical records does it show that he had any symptomatology associated with such condition. It was not until 1992 that Raynaud's phenomenon was diagnosed. Subsequent review of the medical records and examinations by physicians specializing in dermatology, have recently offered their opinions that Raynaud's phenomenon began in 1973, which is still some thirteen years after the veteran's separation from active duty, and that Raynaud's phenomenon was not etiologically related to the veteran's service-connected dermatitis. As such, there is no competent medical evidence of a nexus between the veteran's currently diagnosed CREST syndrome, which includes Raynaud's syndrome, and the veteran's active duty service or his service-connected skin disability. While the veteran may well believe that his currently diagnosed Raynaud's disease is related to service, or in the alternative to his service-connected dermatitis, the Board would like to emphasize that it is the province of trained health care professionals to enter conclusions that require medical opinion, such as the diagnosis of a disability, or an opinion as to the etiology of that disability. As the veteran is a lay person without medical training or expertise, he is not competent to render an opinion on a medical matter (here, medical causation); hence, his contentions in this regard have no probative value. See Jones v. Brown, 7 Vet. App. 134, 137 (1994); Espiritu v. Derwinski, 2 Vet. App. 292, 294-95 (1991). A claim must be supported by evidence and sound medical principles, not just assertions. See Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992). In the absence of competent medical evidence of a nexus between currently diagnosed CREST syndrome, including Raynaud's disease, and either the veteran's active duty service or his service-connected dermatitis, the claim is not plausible and must be denied as not well grounded. B. Esophagitis In both written and oral testimony, the veteran asserted that he experiences heartburn and regurgitation, which he attributes to side effects of his medication prescribed for his service-connected dermatitis. As noted earlier in this decision, the veteran is currently diagnosed as having CREST syndrome, which includes esophageal dysmotility. In reviewing his service medical records, there is no indication that he had any complaints or symptomatology pertaining to esophagitis, including heartburn or regurgitation, while he was on active duty. Post-service, the veteran's VA outpatient treatment records show that in July 1993 he gave a six-to-eight month history of experiencing solid food dysplasia and burning sensation associated with acid regurgitation. The examiner noted that the symptoms were very suspicious for scleroderma/CREST syndrome. An UGI (upper gastrointestinal series), undertaken a couple of months earlier, revealed that the distal esophageal peristalsis was mildly delayed. There was no stricture or GE (gastroesophageal) reflux demonstrated. The report of the veteran's August 1995 endoscopy revealed suspected esophageal motor disorder, non-erosive gastritis and suspected gastric vascular lesion. As noted in Dr. Bello's October 1995 letter, the veteran is diagnosed as having CREST syndrome, which includes esophageal dysmotility. In the physician's opinion, this syndrome began as early as 1973. After examining the veteran and reviewing his records in August 1997, a VA physician also offered the medical opinion that CREST syndrome began in 1973. In the physician's addendum of April 1998, he noted that esophageal dismotility is part of CREST syndrome, but that the syndrome is a separate entity from the veteran's skin condition. In reviewing the veteran's post-service medical records, for various periods from 1970 through early 1998, it shows that his skin condition has been treated over the years with multiple medications, including Lac-Hydrin, Triamcinolone .1% cream, Prednisone, Nifedipine, Lansoprazole, Percocet, Atarax, Doxepin, Keflex, Calcium carbonate, and bacitracin ointment. However, nowhere in the record is there competent medical opinion that any of the veteran's prescribed medications or ointments have had any causal relationship with the veteran's currently diagnosed CREST syndrome, including esophagitis. Therefore, the records show that neither esophagitis or any chronic symptomatology associated with esophagitis was found during the veteran's active duty service, nor was esophagitis or symptomatology associated therewith found until many years after the veteran's separation from active duty service. Also, there is no competent medical opinion of a nexus between the veteran's currently diagnosed CREST syndrome, including esophageal dysmotility, and either the veteran's active duty service or his service-connected dermatitis. Although the veteran believes that his esophagitis was either incurred in service or that it was proximately due to or the result of his service-connected dermatitis, he is not competent to render such a nexus opinion regarding the medical etiology of his disability. See Jones, 7 Vet. App. at 137; Espiritu, 2 Vet. App. at 294-95. A claim must be supported by evidence and sound medical principles, not just assertions. See Tirpak, 2 Vet. App. at 611. C. Low Back Disorder It is the veteran's contention that the problems with his back condition stem from the medication he was taking for his service-connected dermatitis, which, he maintains, was of such quantity that it caused his blood pressure to rise and dizziness, which resulted in a fall in which he sustaind a back injury. The veteran's service medical records, including his entry and separation examination reports, consistently show that his back was normal. These records do not show any back complaints, back injury or history thereof while he was on active duty service. The veteran's private medical records reveal that he sustained a fall in January 1984. His subsequent medical records for 1984 reveal that on January 17, 1984, he reported an onset of back pain while unloading a truck of furniture at work, he fell backwards onto some concrete and sustained a back injury. He was subsequently diagnosed as having herniated nucleus pulposus, L4-5. However, nowhere in the records is there any indication other than an onset of back pain prior to the fall, that may have caused the fall. There is no competent medical opinion of a cause and effect relationship between any medication he was taking at the time and his fall. Without a medical opinion of a nexus between the veteran's current back condition and his service- connected dermatitis, or a nexus between his current back condition and his active duty service, the claim is not plausible and must be denied as not well grounded. Despite the veteran's contention that his fall in 1984 was triggered by side effects from the medication he was taking for his service-connected skin condition, his lay assertions, without supporting medical evidence, do not constitute competent evidence to well-ground the claim. For the reasons noted above, the veteran is not competent to render such a nexus opinion regarding rhe medical etiology of his disability. See Jones, Espiritu, supra. Again, the Board would emphasize that a well-grounded claim must be supported by evidence, not merely allegations. See Tirpak, supra. D. Conclusion It is the veteran's burden to submit evidence sufficient to establish a well-grounded claim, See Epps, 126 F.3d at 1464, but, in this case, the veteran simply has not met that burden in each of his claims for service connection. As the duty to assist has not been triggered by evidence of any well- grounded claim, there is no duty to assist the veteran in developing the record to support his claim for service connection for Raynaud's disease, esophagitis, or low back disorder. Id. Furthermore, the Board is aware of no circumstances that would put the VA on notice that any additional relevant evidence may exist which, if obtained, would well-ground the veteran's service connection claims. See McKnight v. Gober, 131 F.3d 1483, 1485 (Fed. Cir. 1997). Although it appears that the RO may not have specifically denied the veteran's claims for service-connection as not well grounded, "when an RO does not specifically address the question whether a claim is well grounded but rather, as here, proceeds to adjudication on the merits, there is no prejudice to the veteran solely from the omission of the well-grounded analysis." Meyer v. Brown, 9 Vet. App. 425, 432 (1996). Moreover, as the veteran has been advised of the elements necessary to submit a well-grounded claim for service connection for the claimed conditions, and the reasons why his current claims are inadequate, the duty to inform has been met. See 38 U.S.C.A. § 5103(a) (West 1991); Robinette v. Brown, 8 Vet. App. 69, 77-78 (1995). II. Increased Rating While on active duty, the veteran was treated for skin conditions, diagnosed as chronic eczema and fungus infection. Post-service, his parents and his private physician submitted statements to the effect that the veteran has suffered from a skin condition on his hands more or less constantly since his separation from service. At the time of his March 1974 VA examination he stated that he experienced burning an itching sensation in his hands; they would crack and peel; he would experience swelling of his hands and bursting of the skin; his fingernails would become loose and come off; and there would be occasional bleeding of his hands on pressure. Examination revealed no swelling of the hands but there was a dry, hard, rough, scaling with cracking or fissuring on the palm and palmar surfaces of the fingers, bilaterally. The diagnoses included dermatitis of the hands. In April 1974, the RO granted the veteran service connection for dermatitis of the hands, effective from November 1973, the date of receipt of his claim, and a 30 percent evaluation was assigned, effective the same date. The 30 percent evaluation has since been in effect. The veteran's VA outpatient treatment reports for 1973 through 1992 show that he was being seen for dermatitis of the hands. In late 1973, he was diagnosed as having hand eczema and Prednisone was prescribed. In 1975, he was experiencing flare-ups of his skin condition approximately once a week. By 1979, this skin condition was affecting his feet. Aristocort was prescribed for his hands. Subsequent medical reports note complaints and findings reflective of itching hands and cracking skin. In July 1991, the veteran filed his claim for an increased evaluation for his dermatitis. The veteran's VA outpatient treatment reports for December 1991 to September 1992 are of record. These show that in August 1992 he was diagnosed with tinea and that Raynaud's phenomenon was suspected. During the veteran's July 1993 hearing before a hearing officer, the veteran testified that he is unable to make a fist without causing the skin on his hands to crack. He related that his fingernails would come off and that during exacerbations his fingers would discolor. He complained that his hands constantly itched and swelled. In his October 1995 letter, Dr. Bello noted that the veteran carries the diagnosis of scleroderma/CREST syndrome, for which the physician has been following for approximately two and a half years. After a thorough review of the veteran's chart, the physician offered that the veteran has had signs and symptoms that can be associated with CREST syndrome as early as 1973. Prior to evaluation by rheumatology in May 1993, the veteran was carrying several diagnoses, including dyshidrotic eczema and chronic hand dermatitis, which only improved with high dose steroids. In the physician's opinion, these conditions in fact were early manifestations of the veteran's limited scleroderma. The veteran's VA outpatient treatment records for 1993 to 1996 show treatment for complaints of skin disease on his hands. The report dated in February 1996 found no current ulcers on his hands and no inflammation. There was edema. During his personal hearing before a Member of the Board, in September 1996, the veteran related that the skin on his hands went through a cycle of flaking, drying, bursting open and bleeding. During these exacerbations, he would wear gloves. Medically, he rubs Cortisone on his hands several times a day and takes oral medication. The report of the veteran's August 1997 examination notes that he described his skin problems as development of diffuse rash with dry skin on his extremities, as well as his fingers turning purple and development of infection on the tips of his fingers. He stated that he has daily outbreaks and is unable to sleep at night. He has been using topical antibiotics, as well as oral antibiotics that help with the treatment. The veteran stated that his disease is worse in the winter. On examination, the veteran's hands were cold, with the distal tips the color of purple and there were areas of fissuring in the tips of the fingers. There was no active drainage from the tips of the fingers; however, there was some crusting. Color photographs of the veteran's hands and feet accompanied the examination report. The diagnosis was probable CREST syndrome. In an April 1998 addendum to this VA examination report, the examining physician further noted that he agreed with Dr. Bello's opinion that the probable onset of this syndrome was as early as 1973 and that this syndrome and eczema are different entities. In August 1997, the VA received medical records and findings by the Social Security Administration, which show that the veteran was awarded disability benefits, effective from January 1984. Those records further show that the award of disability benefits was based on the veteran's back disorder. As a preliminary matter, the Board finds that the veteran's increased rating claim for dermatitis is well grounded within the meaning of 38 U.S.C.A. § 5107(a). A mere allegation that a service-connected disability has become more severe is sufficient to establish a well-grounded claim for an increased rating. See Caffrey v. Brown, 6 Vet. App. 377, 391 (1994); Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992). The Board is satisfied that all relevant facts have been properly developed and that no further assistance to the veteran is required in order to comply with the duty to assist on this issue. Id. VA utilizes a rating schedule as a guide in the evaluation of disabilities resulting from all types of diseases and injuries encountered as a result of or incident to military service. The disability evaluations are determined by comparing a veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities. The percentage ratings represent, as far as can practicably be determined, the average impairment in earning capacity resulting from such diseases and injuries and their residual conditions in civil occupations. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1, Part 4. It is thus essential, both in the examination and in the evaluation of disability, that each disability be reviewed in relation to its history. See 38 C.F.R. § 4.41. However, where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. See 38 C.F.R. § 4.3. In the veteran's case, he is service-connected for dermatitis, which is rated under Diagnostic Code 7899-7806 as eczema and provides that a noncompensable evaluation is warranted for eczema if there is slight, if any, exfoliation, exudation or itching, and if the eczema is on a nonexposed surface or small area. A 10 percent evaluation is warranted for eczema with exfoliation, exudation or itching, if an exposed surface or extensive area is involved. A 30 percent evaluation is warranted if there is exudation or constant itching, extensive lesions, or marked disfigurement. For a 50 percent evaluation, there must be ulceration or extensive exfoliation or crusting, and systemic or nervous manifestations, or be considered exceptionally repugnant. See 38 C.F.R. §§ 4.27, 4.118. The veteran's medical records from 1993 to 1996 reflect treatment for CREST syndrome. The veteran has not established entitlement to service connection for CREST syndrome. The results of the veteran's August 1997 VA dermatology examination, conducted specifically to ascertain the nature, extent and characteristics of his skin disorder, diagnosed CREST syndrome. Other than CREST syndrome, there was no indication of any other skin condition, to include eczema. Furthermore, the examiner, in an addendum to the examination report, stated that CREST syndrome is probably not related to the diagnosis of eczema or dermatitis, for which the veteran is service connected, and that eczema and CREST syndrome are different entities. In the veteran's case, his service-connected eczema has been rated 30 percent disabling for over 20 years. As such, the 30 percent evaluation is protected and cannot be reduced. See 38 U.S.C.A. § 110; 38 C.F.R. § 3.951. In the absence of greater disability, such as complete or exceptional repugnant deformity of one side of the face or marked or repugnant bilateral disfigurement, third degree burn scars in an area or areas exceeding one square foot, nervous manifestations, ulceration or extensive exfoliation or crusting, and systemic or nervous manifestations, or eczema that is exceptionally repugnant, the Board finds that more than the veteran's 30 percent evaluation for dermatitis is not warranted. There is no medical evidence of scaring on the veteran's head, face, or neck productive of marked and unsightly deformity of his eyelids, lips, or auricles; any burn scars; or superficial, tender, or painful scars on objective demonstration which would warrant higher evaluations under Diagnostic Codes 7800 to 7806. The above determination is based on application of pertinent provisions of the VA's Schedule for Rating Disabilities. Additionally, the Board finds that there is no indication that the schedular criteria are inadequate to evaluate the veteran's service-connected skin disability. Although the veteran has been receiving Social Security disability benefits, the records show that the award of those benefits is based on his nonservice-connected back disorder, not on his service-connected dermatitis. The veteran has neither presented evidence nor is there competent medical opinion to the effect that the veteran's dermatitis has caused marked interference with employment (i.e., beyond that contemplated in the assigned evaluation), necessitated frequent periods of hospitalization, or that his dermatitis otherwise has rendered impracticable the application of the regular schedular standards. In the absence of evidence of such factors, the Board is not required to remand this mater to the RO for the procedural actions outlined in 38 C.F.R. § 3.321(b)(1). See Bagwell v. Brown, 9 Vet. App. 337, 338-9 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). ORDER In the absence of evidence of a well-grounded claim, service connection for Raynaud's disease is denied. In the absence of evidence of a well-grounded claim, service connection for esophagitis is denied. In the absence of evidence of a well-grounded claim, service connection for a back disorder is denied. A disability evaluation in excess of 30 percent for dermatitis is denied. LAWRENCE M. SULLIVAN Member, Board of Veterans' Appeals