BVA9502860 DOCKET NO. 94-35 891 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to service connection for immunoblastic lymphoma and Waldenstrom's Macroglobulinemia, claimed as secondary to service- connected neurodermatitis. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD L. L. Gann, Associate Counsel INTRODUCTION The veteran had verified active service in the U.S. Navy from December 1944 to August 1946, and from August 1952 to June 1954. This appeal arises from a rating action dated in April 1993 from the Los Angeles, California, Regional Office (RO) which denied entitlement to both an increased schedular disability rating for the veteran's service-connected neurodermatitis, rated as 10 percent disabling, and service connection for immunoblastic lymphoma, claimed as secondary to service-connected neurodermatitis. In May 1993, however, the RO granted entitlement to a 30 percent schedular rating for service- connected neurodermatitis, effective from July 14, 1992. In his substantive appeal, received in March 1994, the veteran indicated that the issue of entitlement to an increased schedular evaluation was no longer on appeal, and stated that his appeal is limited solely to the issue of service connection for cancer. Thus further consideration of any other issue is no longer warranted. The claims folder was received and docketed at the Board of Veterans' Appeals (Board) in September 1994, and is now ready for appellate consideration. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends that his immunoblastic lymphoma and associated advanced Waldenstrom's Macroglobulinemia (Waldenstrom's), are the direct or proximate results of his service-connected neurodermatitis condition. He relies on the opinions of his private physician, Dr. E. Ottenheimer, who has stated that medical literature notes a link between the presence of chronic neurodermatitis and the development of Waldenstrom's and immunoblastic lymphoma. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), has reviewed and considered all of the evidence and material of record in the veteran's claims file. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the preponderance of the evidence is against the veteran's claim for immunoblastic lymphoma and Waldenstrom's Macroglobulinemia, secondary to service-connected neurodermatitis. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the veteran's appeal has been obtained by the RO. 2. The veteran is service-connected for neurodermatitis at a schedular disability rating of 30 percent. 3. Immunoblastic sarcoma was first diagnosed in June 1992, approximately 38 years after service separation. Subsequent examination records also found the presence of Waldenstrom's Macroglobulinemia. 4. The veteran's treating physician, Dr. E. Ottenheimer, has stated that, according to recent medical literature, chronic neurodermatitis is associated with Waldenstrom's Macroglobulinemia, and in turn, immunoblastic lymphoma. 5. A Department of Veterans Affairs (VA) examiner who conducted an evaluation in September 1992, stated that no "clear cut cause and effect relationship" exists between neurodermatitis and lymphoma, but noted that if the veteran's skin condition had exhibited "substantial activity" for more than forty years, it "might have contributed to developing lymphoma." 6. The Chief of Hematology at a VA medical facility opined in March 1993 that the veteran's increased skin problems noted in 1991 and 1992 may be related to his development of a lymphoproliferative disorder, but that his immunoblastic lymphoma is not related to neurodermatitis. The Chief of the VA Outpatient Clinic opined that it was not possible to render a cause and effect relationship between neurodermatitis and the diagnosis of malignant lymphoma, based upon the medical record. 7. An independent medical examiner (IME) opined in December 1994 that he knew of no established relationship between chronic neurodermatitis and the development of a lymphoproliferative disorder, nor did he find any evidence in the claims folder which supported the veteran's contentions. CONCLUSION OF LAW The veteran's Waldenstrom's Macroglobulinemia and immunoblastic lymphoma were not incurred in service, and may not be presumed to have been so incurred, nor are these conditions proximately due to, or the result of, his service-connected neurodermatitis. 38 U.S.C.A. §§ 1110, 5107 (West 1991); 38 C.F.R. §§ 3.303(d), 3.310(a) (1994). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Board notes that the veteran's claim is well grounded within the meaning of 38 U.S.C.A. § 5107 (West 1991). A well grounded claim is a plausible claim, one which is meritorious on its own or capable of substantiation. Murphy v. Derwinski, 1 Vet.App. 78, 81 (1990). We are also satisfied that all relevant facts have been properly developed so that further assistance to the veteran is not required. Service connection may be established for disability resulting from personal injury or disease incurred in or aggravated by service. 38 U.S.C.A. § 1110, 1131 (West 1991). Regulations also provide that service connection may be established where all the evidence of record, including that pertinent to service, demonstrates that the veteran's current disability was incurred as a result of service. 38 C.F.R. § 3.303(d) (1994). 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) (1994). The veteran contends that his immunoblastic lymphoma and Waldenstrom's Macroglobulinemia are related to service. It is not asserted, nor does the evidence show, that these conditions were either present in service, or manifest to a compensable degree within one year of service separation. It is well- established that these disorders were not diagnosed until many decades after service. Thus a grant of service connection on direct or presumptive basis is not warranted. See 38 U.S.C.A. §§ 1101, 1110, 1112, 1113 (West 1991); 38 C.F.R. § 3.307, 3.309 (1994). The essential argument in this case, however, is that Waldenstrom's Macroglobulinemia and immunoblastic lymphoma developed secondary to the veteran's service-connected neurodermatitis. The Evidence Upon review, it appears that the veteran's original claims folder was lost, so that a new claims folder had to be reconstructed. This reconstructed file, however, contains no copies of service medical records, or any post-service records compiled prior to a VA examination report dated in January 1967. A detailed history provided by the veteran during the course of that examination is, nonetheless, helpful in our consideration of this claim. According to the veteran, his neurodermatitis first became manifest during his first period of service. He was granted service connection for this condition in 1946, and was awarded a 10 percent schedular disability evaluation, which was apparently discontinued when he commenced his second period of service in 1952. After separation from his second period of active duty, in 1954, he attempted to gain reinstatement of his disability rating, but was unsuccessful until August 1966. He noted that his skin condition first arose in his groin area, causing a rash with itching, and later spread to his thighs, back of the neck, arms, and gluteal regions. He claimed that he experienced temporary improvement of his condition, but never complete clearing with regard to the itching. The 1967 examination report found the presence of very mild lichenification on the middle of the inner thigh, in the left groin, on both buttocks, and over the scrotum, as well as a neurodermatitic reaction in the anal region. Keratotic parafollicular papules were also found on the posterior thighs, with hyperpigmented papules on the left elbow and occipital regions. The diagnosis was "neurodermatitis lichen chronicus vidal, mild." In 1972, the veteran underwent another VA examination, at which time a hyperkeratotic lichenified lesion was found on the dorsum of the right forearm, as well as erythematous and macerated lesions on areas of the left groin. The diagnosis was a lichen simplex chronicus of the forearm, and intertrigo of the left groin. The lichen simplex was considered nondisabling, and was not expected to ever become so. The left groin intertrigo was found to be chronic, with the possibility of future exacerbations. Further evidence with regard to the presence of a skin condition is not shown until December 1991, when the veteran sought treatment for rash located on his face and body, accompanied by extreme itching and scabbing. He reported that this rash could be a reaction to the drug Keflex, which had been prescribed earlier for a chronic upper respiratory infection. His skin problems did not respond to prescribed medications, and, in February 1992, he again reported the presence of a pruritic rash with itching over his entire body. The impression was neurodermatitis. VA treatment records dated in March 1992 also note a history of "pruritus" since December 1991. Punch biopsies of several excoriative areas were made, which pathologists diagnosed as pyogenic folliculitis and early cellulitis. Dr. E. Ottenheimer, a private oncologist-hematologist, conducted an evaluation in June 1992, at which time a history of neurodermatitis and diverticulitis were given. The veteran also noted that he first began to feel "poorly" in December 1991, after suffering from influenza. He was treated with Keflex, and thereafter developed a serious rash. During treatment for gastrointestinal complaints, the presence of peripheral adenopathy was found, and thereafter, a lymph node biopsy showed that he suffered from immunoblastic sarcoma. Dr. Ottenheimer performed a series of tests, including a bone marrow examination and tests for quantitative immunoglobulins. The pertinent diagnoses were immunoblastic lymphoma, stage 3 at least, Waldenstrom's Macroglobulinemia with hyperviscosity syndrome, and chronic neurodermatitis. In his discussion, Dr. Ottenheimer opined: This is a fascinating clinical presentation of a patient with Waldenstrom's macroglobulinemia. . . . It is rarely reported that Waldenstrom's can transform into an immunoblastic sarcoma which has occurred in this case. It is also of interest that the patient's history of neurodermatitis is also compatible with the above diagnosis. The veteran was thereafter admitted to St. Bernardine Medical Center where comprehensive testing confirmed the diagnoses of immunoblastic lymphoma, with bone marrow infiltration by mature, small cell lymphocytes, as well as a hyperviscosity syndrome. Neurodermatitis was noted by history. In August 1992, Dr. Ottenheimer submitted a follow-up letter in which he stated: This letter is by way of information regarding [the veteran]. He has been seen by me in consultation for an immunoblastic lymphoma, recently diagnosed. Associated with this lymphoma is an advanced Waldenstrom's macroglobulinemia with which he presented in a hyperviscosity state. I understand from the patient's history that he has a chronic neurodermatitis which has in the literature been reported to be associated with Waldenstrom's macroglobulinemia and, in turn, immunoblastic lymphoma. The veteran then underwent VA hematologic and dermatologic examinations in September and October 1992. The VA hematologist also noted a history of neurodermatitis since service, which was intermittently active since then, although the veteran was uncertain as to the frequency or severity of his flare-ups. These skin problems again manifested in 1992. He was thereafter diagnosed with "two kinds of cancer" and underwent several cycles of chemotherapy. The examiner gave a diagnosis of lymphoma with a macroglobulin production, and stated that "a clear-cut cause and effect relationship between the lymphoma and the skin condition is not certain." He found it notable, however, that "there is some evidence that chronic stimulation of the immune system may increase the risk of lymphoproliferative disorders." He opined that "if his skin problem has had substantial activity in the last 40+ years it might have contributed to developing lymphoma." (emphasis in the original) The VA dermatologist indicated a history of a recurrent, severe, generalized, pruritic rash since 1946, which had never fully cleared. The veteran noted that since chemotherapy, his skin condition has greatly improved. Objectively, the examiner found no active dermatitis. The record was thereafter referred to Dr. A. Lichtenstein, Chief of Hematology at a VA medical facility. He opined in March 1993 that: This is a 66 [year-old] veteran with a long history of neurodermatitis diagnosed in the 1940's . . . who developed fatigue, [increasing] skin rash and adenopathy (sic) beginning of 1992. Subsequent evaluation revealed Waldenstrom's disease confirmed by bone marrow [biopsy], immunoglobulin studies and serum viscosity and immunoblastic lymphoma confirmed by node "biopsy." It is possible that the [increase] in skin problems which began in December 1991 - January 1992 may be related to his current lymphoproliferative disorder. However, the neurodermatitis which began in the 1940's is not, in any way, related to his blood cancer. Accompanying this statement is a note by Dr. M. Chalet, Chief of a VA Outpatient Clinic, who opined in March 1993 that "[o]n the bass (sic) of medical records submitted it is not possible to render a cause-and-effect relationship between the patients (sic) neurodermatitis and the diagnosis of malignant lymphoma." In response to the RO's request, Dr. Ottenheimer submitted a photocopy of four pages from a chapter entitled "Lymphocytic Lymphomas" from an unknown medical text. Dr. Ottenheimer contended that this information substantiates his opinion that the veteran's neurodermatitis was a precursor to the development of immunoblastic lymphoma. Passages subsequently highlighted by the veteran and/or his representative included the following: A slight increase in the incident of lymphomas has been noted in large series of patients with collagen vascular diseases as compared with the general population adjusted for age. This increased incidence approached 10% in patients with long- standing Sjogren's syndrome, who tend to develop diffuse aggressive lymphomas or immunoblastic sarcomas. .... Patients who are chronically immunosuppressed by drugs, particularly those who have received renal transplants, have a higher incidence of diffuse aggressive lymphomas and immunoblastic sarcomas, often in the brain. This article also included a table which listed the diseases predisposed to develop lymphomas. This list included acquired immunodeficiency syndrome (AIDS), Klinefelter's syndrome, Swiss- type agammaglobulinemia, acquired hypogammaglobulinemia, Iatrogenic immunosuppression, X-linked lymphoproliferative disorder, and Sjogren's syndrome. Neurodermatitis was not listed in this table. Private treatment records submitted from the Beaver Medical Clinic in Yucaipa, California, again note treatment in April 1993 for neurodermatitis, with a itching and a rash located over most of the veteran's body. During a VA dermatological examination in May 1993, the veteran also exhibited generalized patchy, erythematous, eczematous eruptions on his extremities and torso, with numerous scratch papules, excoriations, and areas of lichenification. The examiner diagnosed a generalized, severe, neurodermatitis. Upon receipt of the claims folder, the Board referred this case to an independent medical expert (IME) in the field of oncology for review of the record and an opinion on two questions posed by the Board. In December 1994, the IME ("Dr. M.") submitted his statement. In response to our first question, concerning the general medical association between neurodermatitis and the development of Waldenstrom's and/or immunoblastic lymphoma, Dr. M. noted that "I know of no established cause-and-effect relationship between chronic neurodermatitis and the eventual emergence of Waldenstrom's Macroglobulinemia and/or immunoblastic lymphoma." Our second question focused on whether the medical evidence contained in the record demonstrated a relationship between the veteran's neurodermatitis and his eventual development of both Waldenstrom's and immunoblastic lymphoma. Dr. M. stated that he found "nothing in the appellant's claims folder to establish a causal relationship between [his] long-standing neurodermatitis and his development of Waldenstrom's Macroglobulinemia and immunoblastic lymphoma." In response to the IME's statement, the veteran's representative submitted a medical article which described how immunosuppressive drug therapy in organ transplant recipients was associated with higher rates of non-Hodgkin lymphoma than in the general population, and that the risk of this cancer is related to the aggressiveness of the immunosuppressive regimen. Opeiz, Gerhard, and Robin Henderson, "Incidence of non-Hodgkin Lymphoma in Kidney and Heart Transplant Recipients," The Lancet, (date unknown). Accompanying this article is a letter from Dr. N. Spritz, Chief of the Medical Service at the New York VA Medical Center, in which he states that there is a "clear increase in risk for Non- Hodgkin's Lymphoma in renal transplant recipients." He noted that "[n]either I nor the oncology people could find a case of Waldenstrom's Macroglobulinemia per se. It is however, a relatively rare disease and it is clearly in the category of Non- Hodgins (sic) Lymphomas." Analysis According to his notice of disagreement and substantive appeal, the veteran essentially alleges that his service-connected neurodermatitis, which first arose during the 1940's, in turn resulted in the development of Waldenstrom's and immunoblastic lymphoma. Upon review of the entire record, however, we find that the preponderance of the evidence is against the veteran's claim. Although the evidence amply demonstrates that the veteran suffered from a recurrent skin condition, most often described as neurodermatitis, for many years, the positive evidence which links this condition to the eventual development of his lymphoproliferative disorders, remains wholly speculative and unsupported by any clear medical evidence. While Dr. Ottenheimer has opined that the patient's history of neurodermatitis is "compatible" with a diagnosis of Waldenstrom's and immunoblastic lymphoma, and that "literature" has shown an association between these disorders, the only supporting evidence submitted by Dr. Ottenheimer is a medical article which does not discuss the relationship between neurodermatitis and the development of lymphocytic lymphomas. The article does describe how immunosuppressive drug therapy, most notably in renal transplant patients, has produced a higher incidence of diffuse aggressive lymphomas and immunoblastic sarcomas, particularly of the brain. Increased incidences of these lymphomas have also been shown in patients with collagen vascular diseases. Neurodermatitis is not, however, listed on the accompanying table of those diseases, including collagen vascular diseases, which are predisposed to the development of lymphomas. Moreover, Dr. Ottenheimer provided no discussion, evidence, or findings which demonstrate what applicability the information contained in his submitted article has to the veteran's specific case. All other medical professionals who have offered opinions, including Drs. Chalet and Lichtenstein, the 1992 VA examiner, and the IME, could not find enough evidence to establish a cause-and- effect relationship, or specifically determined that there is no causal relationship shown between the veteran's service-connected neurodermatitis and the development of immunoblastic lymphoma. The veteran has particularly focused upon the 1992 VA hematology examiner's statement, that "chronic stimulation of the immune system" such as that found in a chronic skin disorder, may increase the risk for lymphoproliferative disorders. We note, however, that this examiner specifically qualified his statement, opining that if the veteran's skin problem had substantial activity in the last 40+ years, it might have contributed to developing lymphoma. The evidence does not demonstrate, however, that the service- connected skin disorder was substantially active for 40+ years prior to his development of lymphoma. The 1967 VA examination report found his skin eruption to be "very mild," and by the veteran's own admission, this disorder demonstrated recurrent improvement. The 1972 VA examination indicated that his lesions were limited to his right forearm and left groin area, and the lichenified lesions on his arm were considered "nondisabling." Further evidence of a skin eruption was not shown until December 1991, just a few months prior to the diagnosis of immunoblastic lymphoma, when the veteran reported the onset of chronic, extensive pruritic lesions, after using the drug Keflex. He also subsequently reported in several treatment records that these severe symptoms were not present until December 1991. The veteran argues that his consistent 10% schedular rating for neurodermatitis from service separation to the present specifically demonstrates that his skin condition was substantially active for more than 40 years. As discussed previously, however, the evidence presented does not indicate that the veteran's skin disability was more than mild in degree prior to the 1991 exacerbation, at which time the RO granted an increased schedular rating (to 30 percent) for the manifestations of neurodermatitis. Thus, prior to 1991, the evidence does not establish that his skin condition displayed "substantial activity." This conclusion is also supported by the report of Dr. Lichtenstein. Upon review of the claims folder, he found that the increase in skin problems which began in 1991-1992 were possibly related to the development of a lymphoproliferative disorder. He concluded, however, that the veteran's chronic neurodermatitis is not "in any way" related to his blood cancer. Therefore, according to Dr. Lichtenstein's statement, the veteran's severe skin exacerbation may have been a clinical manifestation of an underlying disorder, but this clinical manifestation is not in any way the cause for the underlying disorder. This statement is wholly consistent with the record presented, which indicates that the veteran's severe skin exacerbations became manifest at the same time that he first began to "feel poorly" after suffering from influenza. Shortly thereafter, the diagnosis of immunoblastic lymphoma was made. Like Dr. Lichtenstein, the IME also finds no evidence to support the allegation that service-connected neurodermatitis bears any relationship to the development of either Waldenstrom's or immunoblastic lymphoma. The veteran's representative takes issue with the IME's findings, inasmuch as he failed to provide a discussion of the facts and medical principals involved in his opinions, as well as the rationale for the opinions which he expressed. We do acknowledge that the IME's typewritten report is brief in form, but we also note that the opinions expressed are wholly unequivocal. He has stated that, based upon his own knowledge, he simply knows "of no established cause-and-effect relationship between chronic neurodermatitis and the eventual emergence of either [Waldenstrom's] and/or immunoblastic lymphoma." As the IME is both an expert in the field of oncology, as well as a medical professor at a large teaching university, with knowledge of recent developments in this area, his explicit negative response is, in itself, probative. The veteran's national service representative also disputes the questions posed by the Board to the IME, and avers that the veteran's arguments have been "misinterpreted." He states that the essential contention does not center on whether there is a "direct causal" connection between Waldenstrom's and/or immunoblastic lymphoma and the veteran's service-connected neurodermatitis, but whether his immune system was significantly suppressed over the course of many years by drugs taken to control his neurodermatitis, thus making him susceptible to other diseases. Upon review of the pertinent documents submitted by the veteran and his local service representative, however, the national representative's argument rings false. In his original claim for service connection, received in August 1992, the veteran stated that he requested to "be re-evalueated (sic) for my service connected disability. For an increase for my skin condition and infection of my blood causing cancer." His notice of disagreement noted that his oncologist, Dr. Ottenheimer, believed that neurodermatitis can lead to the cancer that he has, "due to an overstimulation of the immune system." His substantive appeal argues that service-connection for his lymphoma and Waldenstrom's is warranted because his oncologist had opined that these conditions had been caused by the "skin fungus" which he contracted during World War II. In April 1994, the veteran's local service representative also submitted a VA Form 1-646 which again noted Dr. Ottenheimer's findings, as well as the findings of the 1992 VA examiner with regard to possible stimulation of the immune system caused by substantially active chronic skin disorders and their effect upon the risk for lymphoproliferative disorders. We note that within none of these submissions is there any argument proffered by the veteran regarding the development of lymphoma resulting from the use of immunosuppressive drugs for his neurodermatitis. In fact, the exact opposite argument is made in both the Notice of Disagreement and the VA Form 1-646, where both the veteran and his local service representative argue that the stimulation of his immune system resulting from neurodermatitis ultimately caused the development of his Waldenstrom's and immunoblastic lymphoma. Thus we find that the national service representative's statements do not reflect the facts contained in the claims folder. The veteran has, indeed, argued on numerous occasions that his current lymphoma and Waldenstrom's are the direct result of service-connected neurodermatitis. Thus the questions posed by the Board to the IME were not inappropriate, and in fact, responded to the threshold arguments proffered by the veteran. See Austin v. Brown, 6 Vet.App. 547, 553 (1994). Moreover, we note that further development with regard to the effect of immunosuppressive drugs used for neurodermatitis is not required in this case, inasmuch as this claim is not well- grounded. As stated before, a well-grounded claim is a plausible claim, one which is meritorious on its own or capable of substantiation. See Murphy v. Derwinski, 1 Vet.App. at 81. A well-grounded claim also requires more than just mere allegations that the veteran's service, or an incident which occurred therein, resulted in illness, injury, or death. The appellant must submit supporting evidence that would justify the belief that the claim is plausible. See Tirpak v. Derwinski, 2 Vet.App. 609 (1992); Grivois v. Brown, 6 Vet.App. 136 (1994). The evidence submitted by the appellant's representative in support of these allegations, however, consists of a medical article describing how immunosuppressive drug therapy in organ transplant recipients has been associated with higher rates of non-Hodgkin's lymphoma than in the general population, and an accompanying letter from Dr. Spritz of the New York VA Medical Center. Neither of these reports, however, is sufficient to justify the belief by a fair and impartial individual that the representative's allegations are plausible. Not only has the veteran not undergone an organ transplant, but there is also no medical evidence which substantiates the representative's statement that the veteran was placed on a long-term, aggressive regimen of immunosuppressive drugs for many years to combat his skin disorder. There is evidence that he was placed on various medications, including cortisone, for varying periods of time to treat exacerbations of his skin condition, but there is no record that he was ever consistently treated with the combinations of drugs used to combat organ rejection in renal transplants which were noted in the cited article. Although Dr. Spritz does note that Waldenstrom's is in the category of non-Hodgkin's Lymphoma, this subject is discussed wholly in relationship to the development of these lymphomas in renal transplant patients. At no time does he even discuss the relationship of neurodermatitis, immunosuppressive drugs, and the development of non-Hodgkin's Lymphomas. Thus his letter, and the accompanying article may be very informative, but of little relevance to the representative's allegations. Thus the representative has not proffered any pertinent evidence which demonstrates that his allegations are plausible with regard to the facts of this case. His contentions are, therefore, not well-grounded, and no duty to assist in the further development of these assertions is required. 38 U.S.C.A. § 5107(a) (West 1991). We conclude, therefore, that service connection for immunoblastic lymphoma and Waldenstrom's Macroglobulinemia, secondary to service-connected neurodermatitis, is not warranted. We find that opinions of the numerous VA physicians and the IME sufficiently outweigh the unsupported statements of the veteran and Dr. Ottenheimer. Although the veteran argues that the benefit of the doubt should be given to his claim, we note that doctrine applies only when a relative balance of both positive and negative evidence has been presented, which is not found in this case. 38 U.S.C.A. §§ 1110, 5107 (West 1991); 38 C.F.R. §§ 3.303(d), 3.310(a) (1994). ORDER Entitlement to service connection for Waldenstrom's globulinemia and immunoblastic lymphoma, secondary to service-connected neurodermatitis, is denied. JACK W. BLASINGAME Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. (CONTINUED ON NEXT PAGE) NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402 (1988). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals.