Citation Nr: 0001932 Decision Date: 01/24/00 Archive Date: 02/02/00 DOCKET NO. 97-22 752 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Baltimore, Maryland THE ISSUES 1. Entitlement to benefits under 38 U.S.C.A. § 1151 for depression, claimed as secondary to a left brachial plexus lesion as to which compensable status has previously been established under section 1151. 2. Entitlement to a disability rating in excess of 60 percent for residuals of a left brachial plexus lesion. 3. Entitlement to a total rating based upon individual unemployability due to service-connected and otherwise compensable disabilities. REPRESENTATION Appellant represented by: Maryland Department of Veterans Affairs WITNESS AT HEARING ON APPEAL The veteran ATTORNEY FOR THE BOARD S. J. Janec, Associate Counsel INTRODUCTION The veteran had active military service from April 1959 to June 1962. This matter comes before the Board of Veterans' Appeals (Board) from a January 1997 rating decision of the Baltimore, Maryland, Regional Office (RO) of the Department of Veterans Affairs (VA) which granted compensation benefits, under 38 U.S.C.A. § 1151, for the residuals of a left brachial plexus lesion, and assigned a 60 percent disability rating. The RO also granted entitlement to special monthly compensation, under 38 U.S.C.A. § 1114(k), based upon loss of use of the left upper extremity. In February 1997, the veteran filed a Notice of Disagreement (NOD) with the January 1997 rating decision, and asserted that he was entitled to a 100 percent rating for the disability. A Statement of the Case (SOC) was issued in May 1997, and, in June 1997, the veteran filed a substantive appeal. In the appeal, he stated that he was now suffering from depression, secondary to the pain caused by the brachial plexus lesion, and that he was unable to return to gainful employment. The veteran testified at a personal hearing before a hearing officer at the RO in October 1997. In a March 1998 Supplemental Statement of the Case (SSOC), the hearing officer denied a rating in excess of 60 percent for residuals of a left brachial plexus lesion, and declined to refer the matter to the Compensation and Pension Service for consideration of an extraschedular evaluation. In a March 1998 rating decision, the RO, in pertinent part, denied compensation benefits, under 38 U.S.C.A. § 1151, for depression, claimed as secondary to the pain caused by the brachial plexus lesion; and denied entitlement to a total rating based upon individual unemployability due to compensable disabilities. Although the RO used "service connection" terminology, it is clear that the brachial plexus lesion is not service connected, but has been granted compensable status, under section 1151, "as if" that disability were service connected. Therefore, if the claimed depression were found to be a disability secondary to the brachial plexus lesion, then the depression would, similarly, be granted compensable status, under section 1151, without actually being service connected. In July 1998, the veteran's representative, on behalf of the veteran, filed an NOD pertaining to the denial of compensable status, under section 1151, for depression, and the denial as to individual unemployability. Subsequently, in October 1998, he also filed a substantive appeal pertaining to those issues. The issue of entitlement to a total rating based upon individual unemployability due to compensable disabilities is addressed in the Remand portion of this decision. FINDINGS OF FACT 1. Certain medical evidence indicates that the veteran has suffered from depression as a result of his left brachial plexus lesion, although the evidence is not clear as to whether the disorder was acute and transitory or is a chronic disability. 2. The veteran's residuals of a left brachial plexus lesion are characterized by incomplete paralysis of the median and ulnar nerves (middle radicular group), resulting in severe disability and loss of function of the left arm due to pain; complete paralysis of the nerves has not been demonstrated. CONCLUSIONS OF LAW 1. The veteran has submitted a well-grounded claim for benefits under 38 U.S.C.A. § 1151 for depression, claimed as secondary to residuals of a left brachial plexus lesion. 38 U.S.C.A. § 5107(a) (West 1991). 2. The criteria for an evaluation in excess of 60 percent for residuals of a left brachial plexus lesion, from the date of the veteran's original claim for compensation for that disability, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.7, 4.40, 4.124a, Diagnostic Codes 8511, 8515, 8516 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Factual Background A VA discharge summary from the Baltimore, Maryland, VA Medical Center (VAMC) indicates that the veteran was hospitalized at that facility from March 6, 1996, to March 15, 1996. He was admitted for end-stage osteoarthritis of the left shoulder, and a left hemiarthroplasty was performed. The surgery was complicated by an axillary artery injury, which was repaired by a left axillary brachial artery bypass. After the second procedure, the veteran was found to have neurapraxia of the brachial plexus which resolved within 72 hours, leaving him with only subjective paresthesia in the left hand. Sensation to light touch in all dermatomes was intact. He began physical therapy and was placed on pain medication. He was discharged in stable condition, and was advised to follow-up with the Orthopedic Clinic, Physical Therapy, and Vascular Surgery. VA outpatient treatment records, dated from March 1996, to October 1996, indicate that the veteran was seen for complaints of pain in the left upper extremity. In an October 1996 report, a VA physician indicated that the veteran underwent EMG testing at that time. The impression was that the findings in the left upper extremity were abnormal with respect to electromyography and nerve conduction studies. There were isolated lesions of the left axillary and left musculocutaneous nerves. There was evidence of beginning re-innervation in the deltoid and biceps muscles. There was no motor activity in the left supraspinatus muscle, but there was no evidence of denervation at rest. Nerve conduction studies in the left forearm showed evidence of an ulnar and median neuropathy, with abnormal sensory findings and slowing of motor nerve conduction in both nerves. The rest of the muscles sampled showed fairly good recruitment, at least 50-60 percent normal, without evidence of denervation. The physician concluded that, since there was some motor activity even in the most severely affected areas, a further referral to physical and/or occupational therapy might improve the function in the left upper extremity. At a VA peripheral-nerves examination in December 1996, the veteran related that he was an unemployed iron worker. He had been involved in a motor vehicle accident in 1968, and sustained a left rotator cuff injury. The pain had continued to become progressively worse and, in March 1996, he underwent surgery to have the shoulder replaced. It was reported that, during the procedure, an artery was damaged. At present, he complained of constant pain in the entire left arm. He was unable to make a fist, and felt like his hand was asleep. He also complained of paresthesia. He took pain medication and participated in physical therapy; however, the pain became too severe. He remarked that his left arm was totally useless, and he kept it in a sling. EMP nerve conduction studies, performed in October 1996, revealed problems with the left axillary and left musculocutaneous nerves, which were consistent with ulnar and median nerve neuropathy on the left. There were no abnormal findings on the right. Physical examination showed 3/5 strength in the left arm, with no atrophy or fasciculation. He was able to pinch, but had decreased sensation particularly in the ulnar part of the hand and the entire left upper arm. The diagnosis was left brachial plexus lesion. At a VA orthopedic examination in December 1996, the veteran reported that he was right-hand dominant, and had undergone a total left shoulder replacement in March 1996. The surgery was complicated by a vascular injury which required a bypass. At present, he indicated that he had only limited use of his left arm, and experienced chronic, severe pain. He stated that he was unable to perform most activities of daily living because the arm was useless, and asserted that he was also unable to work. Clinical evaluation revealed that there was diminished muscle bulk in the left shoulder region. There was a dysesthetic pain present to light touch throughout the entire extremity. The veteran was able only to minimally abduct the shoulder, and the shoulder was held at approximately 30 degrees of internal rotation. He was able only to flex his elbow and wrist minimally. Any movement generated pain. At a personal hearing before a hearing officer at the RO in October 1997, the veteran testified that his left arm often became swollen, and that he was unable to bend it. He also testified that he had virtually no movement in the left shoulder, and no grip strength in the hand. The shoulder was constantly painful, although the pain varied in severity. He wore morphine patches to help ease the pain. He stated that he was unable to do many of his normal activities of daily living, and had been unable to return to work. A report from the Mental Health Clinic at the Perry Point, Maryland, VAMC, dated in November 1997, related that the veteran was first seen in January 1997 for depression. He recounted the problems he had experienced after the left shoulder replacement surgery, and indicated that he had lost the use of his left arm. Since that time, he had become depressed and felt useless. He said he was unable to tie his shoes and no longer enjoyed the activities in which he had previously engaged. He often had ideas of suicide, but had not made any suicidal plans. He experienced insomnia and daytime restlessness. During the initial interview, he was found to be alert, well-oriented, cooperative, and coherent. He had an intact abstract reasoning capacity. Short- and long-term memory were also intact. He denied hallucinations and delusional ideas, but demonstrated a depressed mood and a flattened affect. He was diagnosed as suffering from a major depression, secondary to the loss of function in his left arm. It was noted that his treatment included sessions at the Pain Clinic, as well as antidepressant and sleeping medication. He had responded well to the therapies, and his depression had lifted. He indicated that he continued taking the antidepressants, but still experienced insomnia and woke up several times a night. An undated note from a psychologist at the Pain Clinic indicated that the veteran was treated with biofeedback, and participated in sessions with the chronic pain group. He attended the sessions for several months, and his mood improved when he was prescribed the antidepressants. It was noted that he had discontinued therapy shortly after the medication was prescribed. The psychologist noted that the improvement in mood appeared related to the pain relief. The veteran was scheduled for a VA psychiatric examination in December 1997. He failed to report for the scheduled exaination. II. Analysis A. Entitlement to Benefits under 38 U.S.C.A. § 1151 on a Secondary Basis The Board will first discuss the issue of entitlement to benefits under 38 U.S.C.A. § 1151 for depression, claimed as secondary to a left brachial plexus lesion as to which compensable status has previously been established under section 1151. The threshold question to be addressed, in any claim, is whether the veteran has presented a well-grounded claim. 38 U.S.C.A. § 5107 (West 1991); Gilbert v. Derwinski, 1 Vet.App. 49 (1990). If he has not, the claim must fail and there is no further duty to assist in its development. 38 U.S.C.A. § 5107; Murphy v. Derwinski, 1 Vet.App. 78 (1990). This requirement has been reaffirmed by the United States Court of Appeals for the Federal Circuit in its decision in Epps v. Gober, 126 F.3d 1464, 1469 (Fed. Cir. 1997), cert. denied sub nom. Epps v. West, 118 S. Ct. 2348 (1998). That decision upheld the earlier decision of the United States Court of Appeals for Veterans Claims which made clear that it would be error for the Board to proceed to the merits of a claim which is not well grounded. Epps v. Brown, 9 Vet.App. 341 (1996). See Morton v. West, 12 Vet.App. 477, 480 (1999) (noting that the Federal Circuit, in Epps v. Gober, supra, "rejected the appellant's argument that the Secretary's duty to assist is not conditional upon the submission of a well-grounded claim"). See also Schroeder v. West, 12 Vet.App. 184 (1999) (en banc order). Because a grant of benefits under 38 U.S.C.A. § 1151 is analogous to a grant of service connection, the provisions of law governing the requirements to establish a well-grounded claim for service connection apply to that type of claim, as well. Like all claims, a claim for secondary service connection must be supported by "evidence sufficient to justify a belief by a fair and impartial individual that the claim is well grounded." 38 U.S.C. § 5107(a); Buckley v. West, 12 Vet.App. 76, 84 (1998). Also with regard to a claim for secondary service connection, a claimant must provide competent evidence that the secondary disability was caused by the service-connected disability. See Wallin v. West, 11 Vet.App. 509, 512 (1998); Reiber v. Brown, 7 Vet.App. 513, 516-17 (1995). The Court of Appeals for Veterans Claims has also held that, in order to establish that a claim for service connection is well grounded, there must be competent evidence of: (1) a current disability (a medical diagnosis); (2) the incurrence or aggravation of a disease or injury in service (lay or medical evidence); and (3) a nexus (that is, a connection or link) between the in-service injury or aggravation and the current disability. Competent medical evidence is required to satisfy this third prong. See Elkins v. West, 12 Vet.App. 209, 213 (1999) (en banc), citing Caluza v. Brown, 7 Vet.App. 498 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table), and Epps, supra. Although the claim need not be conclusive, the statute [38 U.S.C.A. §5107] provides that [the claim] must be accompanied by evidence" in order to be considered well grounded. Tirpak v. Derwinski, 2 Vet.App. 609, 611 (1992). In a claim of service connection, this generally means that evidence must be presented which in some fashion links the current disability to a period of military service or to an already service-connected disability. 38 U.S.C.A. §§ 1110, 1131 (West 1991); 38 C.F.R. §§ 3.303, 3.310 (1999); Rabideau v. Derwinski, 2 Vet.App. 141, 143 (1992); Montgomery v. Brown, 4 Vet.App. 343 (1993). Under applicable criteria, service connection may be granted for a disability resulting from disease or injury which was incurred in, or aggravated by, active military service or active duty for training. 38 U.S.C.A. §§ 1110, 1131 (West 1991). Disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310(a) (1999). As noted above, a claim under 38 U.S.C.A. § 1151 is analogous to a claim for service connection. In furtherance of that legal relationship, the VA General Counsel, in a precedent opinion, has concluded that disability compensation may be paid, under 38 U.S.C.A. § 1151 and 38 C.F.R. § 3.310(a), for disability which is proximately due to or the result of a disability for which compensation has been determined to be payable under section 1151. VAOPGCPREC 8-97 (Feb. 11, 1997). Evidentiary assertions by the veteran must be accepted as true for the purposes of determining whether a claim is well grounded, except where the evidentiary assertion is inherently incredible or when the fact asserted is beyond the competence of the person making the assertion. King v. Brown, 5 Vet.App. 19, 21 (1993). As noted in the Introduction, above, benefits have been awarded to the veteran pursuant to 38 U.S.C.A. § 1151, for residuals of a left brachial plexus lesion. Pursuant to the General Counsel opinion cited above, disability that is proximately due to or the result of a disease or injury for which compensation is payable under section 1151 may also be service connected. See 38 C.F.R. § 3.310(a); VAOPGCPREC 8- 97. The record indicates that the veteran has received treatment for depression, which was found to be causally related to pain which resulted from the brachial plexus lesion. Therefore, the Board finds that the veteran has submitted a well-grounded claim for benefits, under section 1151, for that disability. B. Increased Rating The Board finds the veteran's claim for an increased rating is well grounded within the meaning of 38 U.S.C.A. § 5107(a). The Court of Appeals for Veterans Claims has held that, when a veteran asserts that a service-connected disability has increased in severity, the claim for an increased rating is generally well grounded. See Jackson v. West, 12 Vet.App. 422, 428 (1999), citing Proscelle v. Derwinski, 2 Vet.App. 629 (1992). As discussed above, an award of compensation under 38 U.S.C.A. § 1151 is analogous to an award of compensation for a service-connected disability, so the veteran's claim is well grounded. Furthermore, after reviewing the record, the Board is satisfied that all relevant facts have been properly developed. No further assistance to the veteran is required to comply with the duty to assist him mandated by 38 U.S.C.A.§ 5107(a). In general, disability evaluations are assigned by applying a schedule of ratings which represent, as far as can practicably be determined, the average impairment of earning capacity. 38 U.S.C.A. § 1155. Although the regulations require that, in evaluating a given disability, the disability be viewed in relation to its whole recorded history, 38 C.F.R. §§ 4.1, 4.2, 4.41, where entitlement to compensation has already been established, and an increase in the disability rating is at issue, it is the present level of disability which is of primary concern. Francisco v. Brown, 7 Vet.App. 55 (1994). Cf. Powell v. West, 13 Vet.App. 31 (1999) (holding that earlier findings may be used if the most recent examination is inadequate). The Board recognizes that the Court of Veterans Appeals recently held that there is a distinction between an original rating and a claim for an increased rating. Thus, the rule espoused in the Francisco precedent, above, may not be applicable in the present case, because the veteran's claim for disability compensation under 38 U.S.C.A. § 1151 for residuals of a left brachial plexus lesion has remained in appellate status since he filed an NOD as to the initial decision on his original claim for that benefit. Fenderson v. West, 12 Vet.App. 119, 125-26 (1999). Under the Court's holding in the latter case, a veteran may assert that his condition at the time of his original claim was worse than it was at a later stage of his appeal, and, where the record warrants it, VA may assign "staged ratings" to reflect different levels of disability during the pendency of the claim. Although Fenderson did not involve a request for an increased rating after benefits had been awarded pursuant to 38 U.S.C.A. § 1151, the Board finds that the holding of that case is, by analogy, applicable to the facts of the present case. Accordingly, our analysis of this case takes the Fenderson decision into account. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. A little-used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity, or the like. 38 C.F.R. § 4.40 (1999). 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 required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (1999). Governing criteria provide that partial loss of use of one or more extremities from neurological lesions is rated by comparison with mild, moderate, severe, or complete paralysis of peripheral nerves. The term "incomplete paralysis" with peripheral nerve injuries indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a (1999). The most recent rating decision reflects that the veteran's residuals of a left brachial plexus lesion have been evaluated as 60 percent disabling under the provisions of Diagnostic Code (DC) 8511 of the Rating Schedule, 38 C.F.R. § 4.124a, which pertains to diseases of the peripheral nerves. Under this code, incomplete, severe paralysis of the middle radicular group of nerves in the minor upper extremity is assigned a 40 percent disability rating. Complete paralysis of the middle radicular group of the minor upper extremity warrants a 60 percent rating. This is the maximum rating available under that code. 38 C.F.R. § 4.124a, DC 8511 (1999). The veteran's disability may also be rated separately as impairment of the median and ulnar nerves. See Esteban v. Brown, 6 Vet.App. 259 (1994). Under DC 8515, a 10 percent rating is assigned for mild incomplete paralysis of the median nerve of the minor upper extremity. A 20 percent rating is assigned for moderate incomplete paralysis of the median nerve of the minor extremity; and a 40 percent rating is assigned for severe incomplete paralysis of the median nerve of the minor extremity. A 60 percent rating is warranted for complete paralysis of the median nerve of the minor extremity, exhibited by the following factors: the hand inclined to the ulnar side, index and middle fingers more extended than normally, considerable atrophy of the muscles of the thenar eminence, the thumb in the plane of the hand (ape hand); pronation incomplete and defective, absence of flexion of index finger and feeble flexion of middle finger, cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of thumb, defective opposition and abduction of the thumb, at right angles to palm; flexion of wrist weakened; pain with trophic disturbances. 38 C.F.R. § 4.124a, DC 8515. Under DC 8516, a 10 percent rating is assigned for mild, incomplete paralysis of the ulnar nerve in either the major or minor extremity. A 20 percent rating is assigned for moderate, incomplete paralysis of the ulnar nerve in the minor extremity; and a 30 percent rating is assigned for severe, incomplete paralysis of the ulnar nerve in the minor extremity. A rating of 50 percent rating is warranted for complete paralysis of the ulnar nerve of the minor extremity, exhibited by the "griffin claw" deformity due to flexor contraction of the ring and little fingers, very marked atrophy in the dorsal interspace and thenar and hypothenar eminences; loss of extension of the ring and little fingers, inability to spread the fingers (or reverse), inability to adduct the thumb; and weakened flexion of the wrist. 38 C.F.R. § 4.124a, DC 8516. Based upon a review of the record, the Board finds that the veteran's residuals of a left brachial plexus injury are most appropriately rated under DC 8511, and that an increased rating is not warranted. The veteran has been reported to be right-hand dominant; therefore, his disability involves the minor extremity. EMG studies of record, completed in October 1996, do not show that the veteran suffered complete paralysis of any nerves in the middle radicular group. In fact, while it was minimal, some motion was exhibited by the arm during recent examinations. Therefore, it would appear that the disability should be considered under the criteria pertaining to incomplete paralysis. Upon VA examinations in December 1996, the examiners concluded that the veteran had severe left arm disability as a result of the brachial plexus injury. Accordingly, the disability would properly be considered severe, incomplete paralysis, thereby warranting a 40 percent rating. However, it appears that, in considering the veteran's complaints of pain and functional loss due to pain, under 38 C.F.R. § 4.40, the rating specialists, in accordance with 38 C.F.R. § 4.7, assigned the veteran the next higher rating of 60 percent. This is the maximum rating available under that Code, and it is the Board's judgment that the 60 percent rating currently assigned best reflects the veteran's residuals of a left brachial plexus lesion. Separate ratings under DC's 8515 and 8516 would not result in a higher disability rating for the veteran. Again, as noted above, complete paralysis has not been demonstrated in either of those nerves. Therefore, even characterizing the disability as severe, incomplete paralysis of both nerves, the maximum ratings available under those codes would be 40 and 30 percent, respectively. However, in accordance with the principles for combined ratings, this would still result in a 60 percent disability rating. See 38 C.F.R. § 4.25 (1999). The Board has also considered whether 38 C.F.R. § 3.321(b)(1) might provide for an increased rating on an extraschedular basis. That regulation provides that, in exceptional cases where schedular evaluations are found to be inadequate, "an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service- connected disability or disabilities" may be assigned. The governing norm 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. See VAOPGCPREC 36-97 (Dec. 12, 1997). However, the Board finds no evidence of an exceptional disability picture in this case. The veteran has not required frequent hospitalization for his left arm disability, nor is it shown that it markedly interferes with employment beyond the degree anticipated by the schedular rating. Although the veteran has related that he has been unable to work since the surgery, it does not appear that he was working prior to the surgery. Moreover, a total rating based on individual unemployability due to service-connected and otherwise compensable disabilities would be the more proper way to address this concern, and that issue is discussed in the Remand that follows herein. In conclusion, while we appreciate the veteran's sincere belief in the merits of his claim, the actual objective findings do not support an increased rating for his disability. Consequently, the Board concludes that the preponderance of the evidence is against the claim and, therefore, a rating in excess of 60 percent for residuals of a left brachial plexus lesion is not warranted. ORDER To the extent that the veteran's claim for benefits under 38 U.S.C.A. § 1151 for depression, secondary to residuals of a left brachial plexus lesion, is well grounded, thereby giving rise to a duty to assist in its development, the appeal is granted. Entitlement to a disability rating in excess of 60 percent for residuals of a left brachial plexus lesion is denied. REMAND For the reasons briefly set forth above, the Board has found the veteran's claim for benefits under 38 U.S.C.A. § 1151 for depression, secondary to residuals of a left brachial plexus lesion, to be well grounded. However, the evidence of record is currently insufficient upon which to grant the benefits sought. In particular, it appears that the veteran's depression may have been acute and transitory in nature, and has been resolved. In the November 1997 VA treatment record, it was noted that the veteran's suicidal ideation had disappeared, and his depression had lifted. However, it is also noted that he continued to take antidepressants and occasionally had insomnia. As the Court of Appeals for Veterans Claims has noted, "in the absence of proof of a present disability, there can be no valid claim." Brammer v. Derwinski, 3 Vet.App. 223, 225 (1992). Based upon the evidence of record, the Board cannot conclusively determine whether the veteran, in fact, currently has chronic depression. The RO attempted to address this concern, and scheduled the veteran for a psychiatric examination. However, he failed to report. When entitlement to a benefit cannot be established or confirmed without a current VA examination or reexamination, and a claimant, without showing good cause, fails to report for such examination, and the examination was scheduled in conjunction with an original compensation claim, the claim shall be adjudicated based on the evidence of record. 38 C.F.R. § 3.655(b) (1999); see also 38 C.F.R. § 3.158 (1999). The veteran is hereby advised that, while VA does have a duty to assist him in the development of his claim, that duty is not limitless. His cooperation in responding to requests for information and reporting for scheduled examinations is required. We wish to emphasize that "[t]he duty to assist in the development and adjudication of a claim is not a one- way street." Wamhoff v. Brown, 8 Vet.App. 517, 522 (1996). "If a veteran wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the putative evidence." Wood v. Derwinski, 1 Vet.App. 190, 193 (1991). See also Olson v. Principi, 3 Vet.App. 480, 483 (1992). In view of the foregoing, it will be necessary to have the RO undergo the requested development and adjudication in connection with the veteran's claim for benefits under 38 U.S.C.A. § 1151 for depression, claimed as secondary to residuals of a left brachial plexus lesion, before a final order is entered by the Board regarding the claim for a total disability rating. See Henderson v. West, 12 Vet.App. 11 (1998), citing Harris v. Derwinski, 1 Vet.App. 180 (1991), for the proposition that, where a decision on one issue would have a "significant impact" upon another, and that impact in turn could render any review of the decision on the other claim meaningless and a waste of appellate resources, the two claims are inextricably intertwined. In the event the section 1151 claim were to be resolved in favor of the veteran, it could have a significant impact upon the total- rating claim which is currently on appeal. In view of the foregoing, the case is REMANDED to the RO, in pertinent part, for the following development: 1. The RO should obtain copies of any recent records of VA or non-VA treatment for the claimed depression, as well as any other service-connected and/or otherwise compensable disabilities, that have not already been associated with the veteran's claims file. 2. The veteran should be scheduled for a VA psychiatric examination to ascertain the chronicity and/or severity of his depression. The examiner is requested to provide a current diagnosis, and to note for the record whether the depression which initially was reported to have resulted from the loss of use of the veteran's arm is chronic and continuing, or may be considered to be acute and now resolved. If the disorder is found to be chronic, the examiner should provide an opinion as to the degree of social and industrial impairment caused by the depression, and assign a numerical code on the Global Assessment of Functioning (GAF) scale, provided in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). The examination report should reflect review of all pertinent material in the claims folder and include a complete rationale for all opinions expressed. 3. The veteran should also be scheduled for a VA examination by an appropriate physician to ascertain the degree to which his left arm disorder interferes with his ability to engage in substantially gainful employment. After the examination and a review of the record, the examiner should express an opinion as to whether the veteran is precluded from gainful employment due solely to his service-connected or otherwise compensable disabilities. A complete rationale for the opinion expressed should be provided. 4. When the above development has been completed, and all evidence obtained has been associated with the file, the claim for benefits under 38 U.S.C.A. § 1151 for depression, secondary to residuals of a left brachial plexus lesion, and the claim for a total rating based on individual unemployability due to service-connected and otherwise compensable disabilities, should be readjudicated by the RO. If either decision remains adverse to the veteran, he and his representative should be furnished with a Supplemental Statement of the Case and afforded a reasonable opportunity to respond. 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 veteran need take no action unless otherwise notified; however, he is advised that he has the right to submit additional evidence and argument on the matter that has been 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. ANDREW J. MULLEN Member, Board of Veterans' Appeals