Citation Nr: 0002642 Decision Date: 02/02/00 Archive Date: 02/10/00 DOCKET NO. 96-26 939 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Louisville, Kentucky THE ISSUES 1. Entitlement to an increased evaluation for post-traumatic stress disorder (PTSD), currently rated as 70 percent disabling and previously evaluated as 30 percent disabling. 2. Entitlement to an increased evaluation for synovitis of the left hip, secondary to a gunshot wound (GSW), currently rated as 20 percent disabling. 3. Entitlement to an increased evaluation for lumbosacral strain, currently rated as 10 percent disabling. REPRESENTATION Appellant represented by: Military Order of the Purple Heart WITNESS AT HEARINGS ON APPEAL Appellant ATTORNEY FOR THE BOARD J. W. Loeb, Counsel INTRODUCTION The veteran served on active duty from February 1964 to October 1965. This case, which at the time consisted of the certified issues of entitlement to an increased evaluation for PTSD and a total disability evaluation on the basis of unemployability, was remanded by the Board of Veterans' Appeals (Board) in June 1998 to the Department of Veterans Affairs (VA) Regional Office (RO) in Louisville, Kentucky, for additional development, to include the issuance of a statement of the case on the issues of entitlement to increased evaluations for left hip disability and lumbosacral strain. An October 1998 statement of the case was issued that denied entitlement to increased evaluations for left hip disability and lumbosacral strain, and the veteran timely appealed. A January 1999 rating decision increased the veteran's 30 percent evaluation for PTSD to 70 percent, effective August 26, 1998. The veteran testified at a personal hearing before the undersigned sitting at the RO in October 1999, at which time he submitted additional evidence in support of his claim along with a waiver of RO consideration of this evidence. The case is again before the Board for adjudication. The Board notes that the veteran's 20 percent evaluation for left hip disability has been in effect for over 20 years and is protected. Based on the Board decision below, the issue of entitlement to a total disability rating on the basis of unemployability due to service-connected disabilities is rendered moot. The issue of entitlement to an increased evaluation for lumbosacral strain will be addressed in the remand portion of this action. FINDINGS OF FACT 1. All available evidence necessary for an equitable determination of the issues on appeal, other than an increased evaluation for lumbosacral strain, has been obtained. 2. The veteran's service-connected psychiatric disability renders him demonstrably unable to obtain or retain employment. 3. The veteran's left hip disability produces no more than moderate impairment of the left hip, Muscle Group XVII; flexion of the thigh is to, at least, 110 degrees; and there is no malunion of the femur or fracture of the surgical neck of the femur with a false joint. 4. The veteran was first shown to be unable to work on October 17, 1995, due to his PTSD symptomatology, and the veteran's claim for an increased evaluation for PTSD was received in January 1996. CONCLUSIONS OF LAW 1. A 100 percent schedular rating for psychiatric disability is warranted from October 7, 1995. 38 U.S.C.A. §§ 1155, 5107(a) (West 1991); 38 C.F.R. §§ 4.7, 4.132, Diagnostic Codes 9411 (1999). 2. The criteria for an evaluation in excess of 20 percent for left hip disability have not been met. 38 U.S.C.A. §§ 1155, 5107(a) (West 1991); 38 C.F.R. §§ 4.7, 4.73, Diagnostic Codes 5252, 5255, 5317 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has found that the veteran's claims are well grounded within the meaning of 38 U.S.C.A. § 5107(a). The Board is also satisfied that all relevant facts have been properly and sufficiently developed. Accordingly, no further assistance to the veteran is required to comply with the duty to assist mandated by 38 U.S.C.A. § 5107(a). Disability evaluations are determined by the application of a schedule of ratings that is based on the average impairment of earning capacity. 38 U.S.C.A. § 1155. Separate diagnostic codes identify the various disabilities. 38 C.F.R. Part 4 (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. In accordance with 38 C.F.R. §§ 4.1, 4.2, 4.41, 4.42 (1999) and Schafrath v. Derwinski, 1 Vet.App. 589 (1991), the Board has reviewed all evidence of record pertaining to the history of the veteran's PTSD and left hip disability. The Board has found nothing in the historical record which would lead it to conclude that the current evidence of record is not adequate for rating purposes, nor has the Board found any of the historical evidence in this case to be of sufficient significance to warrant a specific discussion herein, except as noted below. Service medical records reveal that the veteran was hospitalized in May 1965 with a GSW of the left hip. It was noted that the missile had entered the left groin, missing the neurovascular bundle, transversed directly through the neck of the femur without fracturing the neck and exited through the buttock. The wound was debrided and closed. The veteran lacked approximately 10 degrees flexion of the left hip joint. The final hospital diagnosis in July 1965 was open fracture of the left femoral neck secondary to a GSW of the left groin. When seen in September 1965, it was noted that the veteran had had persistent, severe pain in the left hip joint with any strenuous activity. Physical examination in September 1965 revealed tenderness to deep palpation both anteriorly and posteriorly over the region of the femoral head and neck; there was some limitation of motion of the left hip with complaints of pain and tenderness at the extremes of motion in all directions. X-rays of the left hip demonstrated a circular defect in the neck of the femur. The final diagnosis was chronic synovitis of the left hip secondary to old GSW. On VA examination in October 1966, the veteran complained of mild constant distress of the left hip, which was aggravated by much walking, standing, or exertion. Physical examination revealed nontender and nonadherent entry and exit wounds of the left inguinal and lower buttock areas. There was slight tenderness to deep palpation, both anteriorly and posteriorly, over the area of the femoral head and neck. Abduction and adduction of the left hip were slightly limited. X-rays of the left hip did not show any evidence of bone or joint abnormality. The diagnosis was chronic synovitis of the left hip joint secondary to GSW. The veteran complained on VA examination in February 1971 of pain and disability in the left hip. Examination of the left thigh showed some loss of subcutaneous tissue but no loss of muscle or tendon. There was no atrophy of the thigh or leg. There was some paresthesia over the lateral aspect of the left thigh extending from the hip to the level of the knee. Motion of the left hip was normal. The diagnoses were old, healed GSW of the left hip, with no functional incapacity, mildly symptomatic, no muscle atrophy; paresthesia, lateral surface of the left thigh, due to cutaneous neurological deficit; cicatrices of the left hip, with subcutaneous tissue loss, no muscle or tendon impairment; and synovitis of the left hip, quiescent. October and November 1995 reports from a VA counseling psychologist reveal that the veteran had been selling quilts since 1994 but was not making any money; he had stopped driving a taxi in 1994 after an accident in which he injured his wrist. It was noted that although the veteran's rating for PTSD was 10 percent, his overall presentation was suggestive of possibly far more impairment, either from his PTSD or some other emotional condition. The veteran said that he had not used alcohol or drugs for over a year. The veteran reported daily flashbacks, significant difficulty sleeping, anxiety, and difficulty getting along with anyone in authority. The examiner indicated that the veteran needed to begin treatment for his PTSD symptomatology as soon as possible. The examiner noted that he was referring the veteran to the VA medical center for evaluation of his readiness to begin training as well as recommendations as to possible employment options; he did not think that the veteran could currently teach or work in a traditional business atmosphere. The prognosis for success was considered by the examiner to be unknown. The veteran subsequently refused treatment for his PTSD. On VA psychiatric examination in February 1996, the veteran complained of being increasingly isolated and of not being able to get along with anyone, as well as of insomnia, increased crying spells, combat nightmares, depression and daily flashbacks. On mental status examination, the veteran had extremely poor hygiene, was angry and irritable, had memory and concentration problems, was constantly suspicious and guarded, and had somewhat limited insight. The diagnosis was PTSD, moderate; major depressive disorder, chronic and recurrent, severe; and alcohol dependence, in remission for 17 months. On VA psychiatric examination in May 1996, the veteran said that he was unemployed and lived with his mother. He had a quilt business but was not making any money from it. He was alienated and estranged from others, including his family, and said that he did not have any friends. He also complained of being angry and anxious. It was noted that the veteran had a history of alcohol and drug abuse but had not done any alcohol or drugs for at least 10 months. On mental status examination, he was oriented and his cognitive functioning did not show any signs of deterioration. It was noted that his insight was limited and his judgment had historically been very poor. The diagnoses were alcohol abuse and dependence, in remission; polysubstance dependence, in remission; PTSD, by history; and schizoid personality disorder with paranoid personality traits. The examiner concluded that the veteran's substance abuse history coupled with his personality pathology was the principle cause of his psychiatric condition. The global assessment of functioning (GAF) level was 55-60, which was noted to be moderate. The veteran testified at an RO hearing in September 1996 that he had been fired from many jobs because he could not get along with others, that he did not have any friends, that he even isolated himself from his mother, and that prior VA treatment for PTSD had been counterproductive. On VA psychiatric examination in October 1997, conducted by the same physician who saw the veteran in May 1996, the veteran said that he had been drug and alcohol free for over 2 years. He lived with his mother and was involved with an unsuccessful quilt business. He noted feelings of alienation, estrangement, and anger. The diagnoses and GAF level were the same as in May 1996 and the examiner reiterated his conclusion that the veteran's symptoms were diagnostic of significant personality pathology with schizoid personality features with paranoia. The examiner also noted that the veteran continued to show a pervasive pattern of detachment from social relationships, with no desire for any kind of close relationship; he was suspicious of the motive of others and almost always chose solitary activities. On VA general medical examination in October 1997, the veteran complained of synovitis and daily left hip pain, as well as of morning stiffness of the left leg. He said that his left hip was aggravated by increased activity. Physical examination revealed left hip abduction from 0-30 degrees with tenderness at 30 degrees and flexion from 0-110 degrees with tenderness at 110 degrees. There was no spasm or muscle atrophy and muscle strength in the lower extremities was 5/5 and equal. Deep tendon reflexes were 2+ and equal, bilaterally. The diagnosis was chronic synovitis of the left hip, status post GSW with decreased range of motion and tenderness. The examiner doubted if the veteran could stand or walk for extended periods of time without increased pain in the left hip and noted that there was some functional impairment of the left hip that could restrict him somewhat in daily activities. There was no weakened movement, excess fatigability, incoordination, or flare-ups. The veteran did have pain on movement. The veteran's testimony at a video conference hearing with a member of the Board in April 1998 was similar to his testimony at his RO hearing in September 1996. On VA psychiatric examination in August 1998, the veteran noted daily nightmares and flashbacks of combat, hypervigilance, depression, attacks of rage, and lack of social interaction. On mental status examination, the veteran's speech was relevant and logical and he was not considered to have any cognitive problems. His mood was depressed. The examiner concluded that the veteran's symptoms were consistent with PTSD, and chronic PTSD was diagnosed. Additional diagnoses were alcohol dependence and drug abuse, currently in remission. GAF was 43. The veteran indicated on VA psychiatric evaluation by a social worker in November 1998 that he had been sober for approximately 4 years. He said that he did not have any friends. On mental status examination, the veteran was described as somewhat disheveled and of dressing somewhat bizarrely. There was a long-term memory deficit and his mood was depressed. It was noted that the veteran had a great deal of difficulty establishing interpersonal relationships. The examiner concluded that the veteran's poor interpersonal skills, intolerance of authority, intermittent angry outbursts, and somewhat bizarre personal appearance and presentation would prevent him from being able to function in most traditional job settings. In his current homebased business, the veteran's symptomatology limited his ability to deal with the public and would appear to lower his earnings potential to some degree. According to a private medical report dated in June 1999, the veteran complained of intermittent problems with pain in the left hip, which radiated into the left foot, that seemed to grow worse each year. On physical examination, there was left leg pain on straight leg raising at 50 degrees which radiated down the leg; reflexes were very decreased bilaterally. Motor strength showed some weakness of ankle plantar flexion on the left. X-rays of the pelvis showed a defect within the left femoral neck. The examiner concluded that the veteran had low back pain and lumbago, in general, with some degree of lumbar radicular pain, especially on the left. On VA orthopedic examination of the left hip in September 1999, the veteran complained of severe left hip pain with weakness, stiffness, swelling, heat, redness, locking, fatigability, and lack of endurance. The veteran said that he walked with a limp and used a cane as needed. Physical examination revealed full range of motion of the left hip with complaints of pain and grimacing with all movements. There was objective evidence of pain to palpation of the left hip. Muscle strength was 4/5 in the left leg with questionable effort. Sensation was intact. The veteran walked with a limp. There was no objective evidence of painful motion with tenderness to palpation of the left hip. There was also no objective evidence of edema, effusion, instability, weakness, redness, heat, abnormal movement or guarding of movement. No unusual shoe wear pattern was found. The diagnosis was left hip pain, status post GSW and surgery. The veteran testified at a personal hearing before the undersigned sitting at the RO in October 1999 that he had a lot of trouble dealing with other people; that he had no social life; that he had crying spells, nightmares, depression, anger, and frustration; and that he had pain and stiffness in his left hip. The Board notes that effective November 7, 1996, VA revised the criteria for diagnosing and evaluating psychiatric disabilities. 61 Fed. Reg. 52695 (1996). In Karnas v. Derwinski, 1 Vet.App. 308, 312-13 (1991), the United States Court of Appeals for Veterans Claims held that where the law or regulation changes after a claim has been filed or reopened but before the administrative or judicial appeal process has been concluded, the version most favorable to the appellant applies unless Congress provided otherwise or permitted the Secretary of Veterans Affairs to do otherwise and the Secretary did so. The Board has found the old criteria to be more favorable to the veteran. Therefore, the Board will decide the veteran's appeal under the criteria in effect prior to November 7, 1996. Under 38 C.F.R. § 4.132, Diagnostic Code 9411, a 100 percent rating is warranted if the attitudes of all contacts except the veteran's most intimate are so adversely affected as to result in virtual isolation in the community; the veteran has totally incapacitating psychoneurotic symptoms bordering on gross repudiation of reality with disturbed thought or behavioral processes associated with almost all daily activities such as fantasy, confusion, panic and explosions of aggressive energy resulting in profound retreat from mature behavior; or he is demonstrably unable to obtain or retain employment due to the disability. The Board notes that each of the three criteria for a 100 percent rating is an independent basis for granting a 100 percent rating. See Johnson v. Brown, 7 Vet.App. 95 (1994). A 70 percent rating is warranted when the ability to establish and maintain effective or favorable relationships with people is severely impaired and the service-connected psychoneurotic symptoms are of such severity and persistence that there is severe impairment in the ability to obtain or retain employment. The evidence on file reveals that the veteran has had problems with multiple psychiatric symptomatology, especially insomnia, depression, anger, and nightmares and flashbacks of combat, and that the veteran had been isolated from others for many years. Problems involving an inability to get along with others are shown essentially throughout the appeal period. The veteran has lost a number of jobs over the years because of his constant anger and inability to get along with others. He has complained of being isolated from everyone, including his family, and of not having any friends. Although he is living with his mother, he is even isolated from her. Even though he conducts a business selling quilts out of his house, he is not making any money at it and it cannot be considered gainful employment. Although one VA examiner concluded that the veteran's symptomatology was due to a personality disorder, all other examiners have found the veteran to have active PTSD. It was noted by the VA examiner in October 1995 that the veteran had PTSD and did not appear to be able to teach or work in a traditional business atmosphere, and the veteran's GAF score in August 1998 was 43. The August 1998 examiner attributed all of the veteran's psychiatric impairment to the service-connected disability. The Board finds that the evidence establishes that the disability is so severe that it renders the veteran demonstrably unemployable. Consequently, an evaluation of 100 percent is warranted for PTSD. 38 C.F.R. § 4.7. The effective date of an award of increased disability compensation is the earliest date that it is factually ascertainable that an increase in disability had occurred, if a claim is received within one year thereof. Otherwise, it is the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C.A. § 5110 (West 1991); 38 C.F.R. § 3.400(o)(1) (1999). A report of VA examination or hospitalization may be accepted as an informal claim for an increased evaluation. 38 C.F.R. § 3.157 (1999). Since there is evidence of the veteran's isolation and problems with others beginning during his October 17, 1995, evaluation, and the veteran subsequently filed a claim for an increased evaluation for PTSD in January 1996, within a year of the examination essentially showing unemployability, the effective date of the increased evaluation of 100 percent for PTSD is October 17, 1995, the date of examination. The veteran is currently assigned a 20 percent evaluation for his left hip disability under the provisions of Diagnostic Code 5317. According to this code, a 20 percent evaluation is assigned for moderate residual impairment of Muscle Group XVII, pelvic girdle group 2 involving the gluteus maximus, gluteus medius and gluteus minimus, which includes such movements as extension of the hip, abduction of the thigh, and elevation of the opposite side of the pelvis. A 40 percent evaluation is assigned for moderately severe residual impairment of this muscle group. A 20 percent evaluation is warranted when flexion of the thigh is limited to 30 degrees; a 30 percent evaluation is assigned when flexion of the thigh is limited to 20 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5252. A 20 percent evaluation is also warranted when there is limitation of abduction of the thigh, with motion lost beyond 10 degrees, which is the maximum rating assigned under this code. 38 C.F.R. § 4.71a, Diagnostic Code 5253. A 20 percent evaluation is warranted for malunion of the femur with moderate knee or hip disability; a 30 percent evaluation is assigned for malunion of the femur with marked knee or hip disability; and a 60 percent evaluation is warranted for fracture of the surgical neck of the femur with a false joint. 38 C.F.R. § 4.71a, Diagnostic Code 5255. Under the provisions of 38 C.F.R. § 4.56, a moderate muscle disability is found when there has been through and through or deep penetrating wounds of short track from a single bullet, small shell or shrapnel fragment, without the explosive effect of a high velocity missile, residuals of debridement, or prolonged infection. Such wounds require service department record or other evidence of inservice treatment for the wound and a record of consistent complaints of one or more of the cardinal signs and symptoms of muscle disability noted in this section, such as loss of power or weakness. Objective findings include an entrance scar indicating short track of missile through muscle tissue, some loss of deep fascia or muscle substance or impairment of muscle tonus and loss of power or lowered threshold of fatigue when compared with the sound side. Moderately severe muscle disability is found where there has been through and through or deep penetrating wounds by a high velocity missile of small size or large missile of low velocity with debridement or prolonged infection. Such wounds require prolonged hospitalization. Objective findings include positive evidence of marked or moderately severe loss of strength and endurance of the muscle groups involved. Although it is contended that the veteran's service-connected GSW residuals of Muscle Group XVII are more than 20 percent disabling, the Board finds that the evidence of record does not support this contention. To warrant an increased evaluation for moderately severe impairment of Muscle Group XVII of the left hip due to GSW, there needs to be marked or moderately severe loss of strength and endurance of this muscle group. The evidence does not show this degree of loss of strength, since there is no evidence of muscle atrophy and muscle strength was, at least, 4/5 on the examinations on file. Moreover, the 4/5 on examination in September 1999 was with questionable effort. Additionally, there is no indication on file that the veteran's GSW of the left hip has required prolonged hospitalization. Motion of the left hip in September 1999 was normal in all directions. Consequently, since motion of the left hip does not warrant even a 20 percent evaluation under the rating schedule and the clinical evidence does not show more than moderate residual impairment of the left hip, an evaluation in excess of 20 percent is not warranted for the veteran's service- connected residuals of a GSW of Muscle Group XVII under either Diagnostic Code 5252 or Diagnostic Code 5317. Since there is no evidence of malunion of the femur or of fracture of the surgical neck of the femur with a false joint, an increased evaluation is not warranted under Diagnostic Code 5255. Based on the above discussion, the evidence shows that the disability picture for the veteran's service-connected GSW residuals does not more nearly approximate the criteria for an increased evaluation under any of the possibly applicable diagnostic codes. 38 C.F.R. § 4.7. It was noted on VA examination in October 1997 that there was some functional impairment of the left hip that could restrict the veteran somewhat in daily activities; but there was no weakened movement, excess fatigability, incoordination, or flare-ups. Additionally, there was no objective evidence of painful motion of the left hip, or edema, weakness, instability, or abnormal movement on VA examination in September 1999. Therefore, the Board sees no basis for assigning a higher evaluation for the disability under the provisions of 38 C.F.R. § 4.40 (1999), which refer to disability due to lack of normal endurance and provide for a rating to be based on functional loss due to pain. Additionally, since the clinical evidence on file does not show significant weakness, fatigability, or incoordination of the left hip due to the service-connected disability at issue, the provisions of 38 C.F.R. § 4.45 (1999), which involve these manifestations of disability of a joint, do not provide a basis for assigning a higher evaluation for this disability. DeLuca v. Brown, 8 Vet.App. 202 (1995). ORDER Subject to the provisions governing the payment of monetary benefits, a 100 percent disability rating for psychiatric disability is granted, effective October 17, 1995. An evaluation in excess of 20 percent for left hip disability, secondary to GSW, is denied. REMAND With respect to the issue of entitlement to an increased evaluation for lumbosacral strain, the Board notes that MRI and VA examination findings in 1999 show that the veteran has degenerative disc disease (DDD) of the lumbar spine and that range of motion of the low back was worse in September 1999 than on examination in October 1997. However, it is unclear whether the loss of motion is due to service-connected or nonservice-connected disability, to include whether the veteran's DDD is etiologically related to his service- connected lumbosacral strain. Additionally, there is some confusion in the record as to the severity of the veteran's low back disability because it was noted at one point on VA examination of the low back in September 1999 that there was no pain to palpation and no muscle spasms, while it was later reported on this examination that "[t]here is objective evidence of painful motion, spasm, weakness or tenderness." Because of the above, the Board finds that additional development is required prior to final disposition of the issue of entitlement to an increased evaluation for service- connected lumbosacral strain. Therefore, this issue is REMANDED to the RO for the following actions: 1. The RO should contact the veteran and request that he identify the complete names, addresses and approximate dates of treatment for all health care providers, including VA, who have treated him for lumbosacral disability since September 1999. With any necessary authorization from the veteran, the RO should attempt to obtain and associate with the claims file any records identified by the veteran which have not been previously obtained. 2. Thereafter, the veteran should be examined by a physician with appropriate expertise to determine the current nature and severity of the veteran's lumbosacral strain and the extent and etiology of his DDD of the lumbar spine. The claims file, including a copy of this REMAND, must be made available to the examiner for review and the examiner should indicate that the file has been reviewed. Any indicated tests or studies, including X-rays, should be conducted, and all findings should be reported in detail. The examiner should describe all symptomatology specifically due to the veteran's service-connected back disability. To the extent possible the manifestations of lumbosacral strain should be distinguished from those of DDD of the lumbar spine. Tests of joint movement against varying resistance should be performed. The extent of any incoordination, weakened movement and excess fatigability of the spine should also be described by the examiner. The examiner should be requested to identify any objective evidence of pain associated with the disability. The specific excursions of motion accompanied by pain should be identified. To the extent possible the examiner should provide an assessment concerning the degree of severity of any pain present. The examiner should also express an opinion concerning whether there would be additional limits on functional ability on repeated use or during flare-ups (if the veteran describes flare-ups), and, to the extent possible, provide an assessment of the functional impairment on repeated use or during flare-ups. The examiner should determine whether it is at least as likely as not that the veteran's DDD of the lumbar spine is etiologically related to service, was caused by his service-connected lumbosacral strain, or was chronically worsened as a result of his lumbosacral strain. The rationale for each opinion expressed should also be provided. 3. Thereafter, the RO should review the claims file and ensure that all developmental actions, including the medical examination and requested opinions, have been conducted and completed in full. The RO should then undertake any other indicated development and should adjudicate the raised issue of entitlement to service connection for DDD of the lumbar spine, to include on a secondary basis. The RO should then readjudicate the issue of entitlement to an increased evaluation for low back disability, to include consideration of 38 C.F.R. §§ 4.7, 4.40, and 4.45, and whether the case should be forwarded to the Director of the VA Compensation and Pension Service for extra-schedular consideration. 4. If the benefit sought on appeal is not granted to the veteran's satisfaction, or if a timely notice of disagreement is received with respect to any other matter, the RO should issue a supplemental statement of the case for all issues in appellate status and provide the veteran and his representative an opportunity to respond. The veteran should be advised of the requirements to perfect an appeal with respect to any new issue. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. All issues properly in appellate status should be returned to the Board at the same time. By this REMAND, the Board intimates no opinion as to any final outcome warranted. No action is required of the veteran until he is otherwise notified by the RO. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded to the regional office. Kutscherousky v. West, 12 Vet. App. 369 (1999). This case must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board 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. SHANE A. DURKIN Member, Board of Veterans' Appeals