Citation Nr: 0003047 Decision Date: 02/07/00 Archive Date: 02/10/00 DOCKET NO. 94-48 656 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to service connection for gastroesophageal reflux disease with duodenal ulcer, secondary to service- connected chronic bronchitis. 2. Entitlement to an increased rating for service-connected bilateral hearing loss, currently evaluated as 10 percent disabling. 3. Entitlement to a compensable rating for the service- connected residuals of an injury to the right posterior tibial nerve from September 7, 1993, and to an evaluation greater than 10 percent from September 23, 1998. 4. The propriety of the initial 10 percent rating assigned for service-connected post traumatic stress disorder (PTSD) from August 22, 1995, and entitlement to an evaluation greater than 30 percent from July 16, 1998. 5. Entitlement to a disability evaluation greater than 30 percent for service-connected chronic bronchitis from September 7, 1993 to September 25, 1998. 6. Entitlement to an earlier effective date for the 100 percent evaluation assigned for the service-connected chronic bronchitis. 7. Entitlement to permanency of the 100 percent evaluation for chronic bronchitis. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J. A. Markey, Counsel INTRODUCTION The veteran had active military service from December 1967 to December 1987. This matter came before the Board of Veterans' Appeals (hereinafter Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina. By a rating action of February 1994, the RO denied the veteran's claims for compensable evaluations for his service-connected residuals of an injury to the right posterior tibial nerve and chronic bronchitis with history of pulmonary disease, as well as his claim for an increased rating for bilateral hearing loss. A notice of disagreement with this determination was received in October 1994. A statement of the case was issued in November 1994. A substantive appeal was received in December 1994. A hearing was held at the RO in March 1995. Thereafter, by a rating action in September 1995, the RO granted service connection for PTSD, and assigned a 10 percent evaluation effective August 22, 1995. A notice of disagreement with the rating assigned for this disorder was received in October 1995. A statement of the case was issued in October 1995. A substantive appeal with respect to increased rating for PTSD was received in October 1995. Subsequently, a rating action in June 1996 denied the veteran's claim for service connection for gastroesophageal reflux disease on a secondary basis. A notice of disagreement with this denial was received in June 1996. A statement of the case was issued in July 1996. The veteran's substantive appeal was received in August 1996. Another RO hearing was held in October 1996. By a rating action in December 1996, the RO increased the evaluation for the veteran's service-connected chronic bronchitis from 0 percent to 10 percent, effective September 7, 1993. By a rating action in August 1997, the RO increased the evaluation for this disability from 10 percent to 30 percent, also effective September 7, 1993. In February 1998, the Board remanded this matter for further development and adjudication. Thereafter, in an October 1998 decision, the RO increased the evaluation for the service- connected chronic bronchitis to 100 percent disabling effective September 25, 1998. The RO also increased the evaluation for service-connected PTSD to 30 percent effective July 16, 1998. Finally, the RO increased the evaluation for the residuals of an injury to the right posterior tibial nerve to 10 percent effective September 2, 1998. The veteran perfected an appeal with regard to the effective date assigned for the 100 percent evaluation of the service- connected chronic bronchitis, claiming that this evaluation should have been effective from 1988. The Board notes that the establishment of this evaluation for the service- connected chronic bronchitis was not a full grant of benefits originally sought on appeal (i.e. for a compensable evaluation for this disability), as this evaluation was not established effective September 7, 1993 (the date of the claim). As such, the issues of an increased rating for this disability and for an earlier effective date for the 100 percent evaluation are as styled on the title page of this decision. As well, given the effective date assigned for the 10 percent evaluation for the residuals of an injury to the right posterior tibial nerve, that issue is as styled on the title page of this decision. The Board notes that the RO adjudicated the claim involving PTSD as one for an increased rating. However, the 10 percent evaluation assigned from August 1995 to July 1998 is, effectively, the initial evaluation assigned following the grant of service connection for this disorder. In light of the distinction noted by the United States Court of Appeals for Veterans Claims (Court) in the decision Fenderson v. West, 12 Vet. App. 119 (1999), the Board has re-characterized the issue as one involving the propriety of the initial evaluation assigned. Further, although the rating was increased during the pendency of the appeal to 30 percent, this constitutes less than the maximum available benefit; hence, the Board must also consider whether a higher evaluation is warranted from the date of that increase. Id.; AB v. Brown, 6 Vet. App. 35, 38 (1993); As noted in the February 1998 Board remand, the RO, in a final rating action of April 1988 denied service connection for a stomach disorder on a direct basis; however, it did not consider service connection on a secondary basis at that time. Hence, de novo consideration of that claim is warranted. Further, in November 1998, the veteran filed a notice of disagreement with that portion of the October 1998 RO decision that noted that the assigned 100 percent evaluation for chronic bronchitis was not considered permanent. A statement of the case was issued in November 1998, and a substantive appeal was received in December 1998. The Board decision on the claim for secondary service connection for the veteran's gastrointestinal disorder is set forth below. However, the claims involving increased ratings (initial or otherwise) for the service-connected bilateral hearing loss, residuals of an injury to the right posterior tibial nerve, chronic bronchitis, and PTSD, as well as the earlier effective date and permanency claims regarding the chronic bronchitis, will be addressed in the REMAND following the order portion of the decision. FINDING OF FACT The weight of the evidence demonstrates that the veteran's gastroesophageal reflux disease with duodenal ulcer is not in any way related to his service-connected chronic bronchitis. CONCLUSION OF LAW The criteria for service connection for gastroesophageal reflux disease with duodenal ulcer as secondary to service- connected chronic bronchitis are not met. 38 U.S.C.A. §§ 1110, 5107 (West 1991); 38 C.F.R. §§ 3.303, 3.310 (1999). REASONS AND BASES FOR FINDING AND CONCLUSION Service connection may be granted for disability resulting from an injury or disease that was incurred in or aggravated by active service, or for disability that is proximately due to or the result of a service-connected condition. 38 U.S.C.A. § 1110 (West 1991); 38 C.F.R. §§ 3.303(a), 3.310(a) (1999). 38 C.F.R. § 3.310(a) has been interpreted to permit service connection for the degree of impairment resulting from aggravation of a nonservice-connected disability by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). The veteran and his representative contend, in substance, that the veteran suffers from gastroesophageal reflux disease with duodenal ulcer secondary to service-connected chronic bronchitis, including due to medications taken to relieve the symptoms associated with the chronic bronchitis (as noted in the introduction, the claim of secondary service connection is separate from a previously denied claim of service connection for a stomach disorder on a direct basis). The Board notes at the outset that the veteran's claim is "well grounded," meaning his claim is at least "plausible." 38 U.S.C.A. § 5107(a) (West 1991). The Board further notes that all evidence that is pertinent to his claim has been appropriately developed and VA's "duty to assist" satisfied. See Murphy v. Derwinski, 1 Vet. App. 78, 81-82 (1990). The relevant evidence consists of VA outpatient treatment records and the reports of VA examinations, and the veteran's testimony given during a October 1996 RO hearing. In a VA outpatient treatment record dated in October 1995, Dr. K, a VA examiner who has treated the veteran at least since 1988 for various disabilities, to include bronchitis and arthritis, indicated that the veteran had developed signs of gastro-esophageal reflux with a duodenal ulcer "as adjunct to ibuprofen treatment and the condition related to asthmatic bronchitis." A VA gastrointestinal examination was accomplished in November 1995, and as a result, the veteran was diagnosed with a history of a duodenal ulcer; the examiner recommended the accomplishment of an upper endoscopy be accomplished for further detail. The veteran was also diagnosed with gastroesophageal reflux disease, and the examiner noted that the veteran might benefit from long term H2 receptor antagonists or a proton pump inhibitor if the antagonists did not fully relieve symptoms. Finally, the veteran was diagnosed with unexplained weight loss. The examiner noted that he did not have the veteran's records to review. A January 1996 outpatient treatment record noted the veteran's diagnosis of gastroesophageal reflux disease, and it was recommended that he discontinue tobacco use and NSAIDS (non-steroidal anti-inflammatory drugs). A gastroscopy was performed later that month, which showed Grade II erosive esophagitis, mild duodenitis, and a normal stomach. In a February 1996 record, Dr. K noted a diagnosis of, among other things, a duodenal ulcer. During the October 1996 RO hearing, the veteran testified that he experiences stomach pain and has to be careful regarding the types of food he eats. He noted that a new medication he was using to treat his stomach problems was somewhat helpful. In the February 1998 remand, the Board requested that, among other things, the RO contact Dr. K and request that he explain the bases for his October 1995 statement, and indicate if his conclusion was based on information, such as history, provided by the veteran or some other source (and if it was some other source, indicate what source). The RO complied with the Board request, and in a late February 1998 response, Dr. K indicated that the veteran definitely had signs of peptic ulcer disease as well as chronic bronchitis with asthma. Dr. K also noted that the veteran was treated with H2 blockers and bronchodilatation, and that he had an upper gastrointestinal series (UGI) series in 1996 (or 1990, the notation is somewhat unclear) which showed thickened duodenal folds which may be secondary to chronic peptic ulcer disease. It was noted that chronic bronchitis and asthma can aggravate peptic ulcer disease. Dr. K also made note of the January 1996 procedure and resultant diagnoses, and in concluding his response, stated that gastroesophageal reflux disease or erosive esophagitis could arise by over-using or chronic treatment with NSAIDS, and that peptic ulcer disease could be aggravated by asthma and chronic bronchitis. A VA gastrointestinal examination - for the stomach, duodenum, and peritoneal adhesions - was accomplished in May 1998, the report of which notes the veteran's self history of peptic ulcer disease diagnosed in the mid-1970s, and that during the examination the veteran denied vomiting, melena, circulatory disturbances after meals, and diarrhea. The veteran did report occasional colicky abdominal pain that resolved with medication. The examiner, who reviewed the claims file, noted the veteran's recent treatment, including the January 1996 endoscopy. Physical examination revealed that the veteran was in mild respiratory distress due to his chronic obstructive pulmonary disease, and that his abdomen was flat, soft, and nontender. Bowel sounds were normal, and no hernia was seen on examination of the hernial orifices. The examiner's impression was that the veteran suffered from peptic ulcer disease by history (per veteran), and esophagitis due to gastroesophageal reflux disease. The examiner commented that after reviewing the claims folder with particular reference to the comments made by Dr. K, it was his opinion that the veteran's gastroesophageal reflux disease, the only documented pathology seen during the last endoscopy, was not due to the NSAIDS (i.e. ibuprofen) which the veteran was taking for an arthritic condition. The examiner further noted that medications used for treating bronchitis were not known to cause gastroesophageal reflux disease. Another VA gastrointestinal examination - this one an "esophagus and hiatal hernia examination" - was also accomplished in May 1998 by the same examiner. The report of this examination notes the history documented in the other May 1998 examination, noted above. The examiner's impression was that the veteran suffers from gastroesophageal reflux disease as previously shown, and he commented that there was no evidence that the medications used in the treatment of chronic bronchitis or other medications used in treating arthritis caused gastroesophageal reflux disease. The examiner noted the veteran did not manifest clinical evidence of peptic stricture. Finally, the report of a September 1998 VA general medical examination notes that the veteran gave a history of gastrointestinal bleeding in March 1998 and that he was not sure whether he had an ulcer. He was diagnosed with a history of gastrointestinal bleeding. The Board reiterates that this claim is limited to whether gastroesophageal reflux disease with duodenal ulcer is secondary to the veteran's service-connected chronic bronchitis. In that regard, the Board points out that while the veteran's service medical records document multiple complaints and treatment of gastrointestinal difficulties, these records are not for consideration for this limited claim. It is pointed out that there is no indication in these service medical records that chronic bronchitis treated in service led to or aggravated a gastrointestinal disorder. That said, the Board concludes that, following review of the entire record, the preponderance of the evidence is against the veteran's claim of entitlement to service connection for gastroesophageal reflux disease with duodenal ulcer as secondary to service-connected chronic bronchitis. As noted above, the specialist who examined the veteran in May 1998 and reviewed the entire claims folder, was of the opinion that the veteran's gastroesophageal reflux disease was not due to his use of NSAIDS and that medications used to treat bronchitis were not known to cause gastroesophageal reflux disease. On the other hand, while Dr. K originally, in October 1995, indicated that the veteran's signs of gastroesophageal reflux with a duodenal ulcer were "adjunct to ibuprofen treatment and the condition related to asthmatic bronchitis," he most recently, in February 1998, generally stated that "chronic bronchitis and asthma can aggravate peptic ulcer disease" and that "gastroesophageal reflux disease and erosive esophagitis could arise by over-using or chronic treatment with NSAIDS." He did not specifically explain the basis (information used, history, other sources) for his prior conclusion regarding the veteran's gastroesophageal reflux disease with duodenal ulcer. The Board has assigned greater probative weight to the VA specialist's opinion that the veteran's gastroesophageal reflux disease with duodenal ulcer is, essentially, not due to his service-connected chronic bronchitis or the medication used to treat this disability (as a side note, it is noted that NSAIDS were apparently used to treat and arthritic condition, and not the service-connected chronic bronchitis). The preponderance of the evidence is against the claim that the veteran's service-connected chronic bronchitis caused or aggravate the veteran's gastroesophageal reflux disease with duodenal ulcer, and the legal criteria for service connection for this disability on a secondary basis have not been met. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine does not apply, and service connection for gastroesophageal reflux disease with duodenal ulcer as secondary to the service-connected chronic bronchitis must be denied. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for gastroesophageal reflux disease with duodenal ulcer as secondary to service-connected chronic bronchitis is denied. REMAND Initially, the Board finds that the veteran has submitted evidence that is sufficient to justify a belief that his remaining claims for higher evaluations are well grounded. See 38 U.S.C.A. § 5107(a) (West 1991); Murphy . Derwinski, 1 Vet. App. 78, 81 (1990); Proscelle v. Derwinski, 2 Vet. App. 629 (1992). Therefore, VA has a duty to assist him in the development of facts pertinent to his claims. Id. The Board also points out that a remand by the Board confers on the claimant, as a matter of law, the right to compliance with the remand order. See Stegall v. Brown, 11 Vet. App. 268 (1998). In the February 1998 remand, the Board noted that the veteran's service-connected residuals of injury to right posterior tibial nerve was evaluated by the RO utilizing 38 C.F.R. § 4.124a, Diagnostic Code 8523. It was noted that under that diagnostic code, mild, incomplete paralysis of the anterior tibial (deep peroneal) nerve, is rated noncompensable, that moderate, incomplete paralysis is rated 10 percent disabling, and that if the incomplete paralysis is severe, a 20 percent evaluation is assigned. The Board also noted that under the schedule incomplete paralysis of the posterior tibial nerve is rated under 38 C.F.R. § 4.124a, Diagnostic Code 8525, with a 10 percent rating assignable for mild or moderate incomplete paralysis, and a 20 percent rating assignable for severe incomplete paralysis. On remand, the Board requested that the veteran be scheduled for an examination of the residuals of the injury to the right posterior tibial nerve, and requested that the RO provide the examiner with the criteria of Diagnostic Code 8523 and 8525. It was also requested that the examiner state which nerve was injured and evaluate the disability in accordance with the proper code. In further adjudicating the claim, it was requested that the RO specifically state whether Diagnostic Code 8523 or 8525 is applicable and why. From a review of a September 1998 VA examination report and October 1998 rating action, it does not appear that the examiner or the RO fully complied with these respective requests. For example, the examiner appears to have identified injuries to certain nerves, but it is not appear that the injury(ies) was evaluated in accordance with the code. Furthermore, it does not appear that consideration was given to the report of a May 1998 VA examination, which appears to discuss other possible residuals of the injury to the right posterior tibial nerve. Therefore, further remand of this matter is warranted to accomplish all actions requested on remand, and for consideration of all relevant evidence of record. As regards the claim involving the rating assigned for the veteran's bronchitis, the Board notes that in the February 1998 remand, it was noted that certain portions of 38 C.F.R. Part 4 pertaining to the rating criteria for respiratory disorders had changed, effective October 7, 1996, including the criteria governing the evaluations for chronic bronchitis at 38 C.F.R. § 4.97, Diagnostic Code 6600, 6603. The Board noted that, as stated in Karnas, where the law or regulation changes after a claim has been filed or reopened, but before the administrative or judicial appeal has been concluded, the version most favorable to the claimant will apply. As such, this claim was remanded for another VA examination and RO consideration pursuant to the new and old rating schedule criteria (with consideration of Karnas). As noted in the introduction portion of this decision, by a rating action in August 1997, the RO increased the evaluation for the service-connected chronic bronchitis from 10 percent to 30 percent, effective September 7, 1993, and in an October 1998 decision, increased the evaluation for the service- connected chronic bronchitis to 100 percent disabling effective September 25, 1998. A review of a October 1998 decision reflects that only the new rating criteria was considered in evaluating the veteran's chronic bronchitis. While only considering the new criteria from September 1998 was not prejudicial to the veteran as an evaluation of 100 percent was established, consideration should have been given to both the old and new criteria for respiratory disorders for the period of time prior to September 25, 1998 (i.e. when the 30 percent evaluation was in effect). As such, the RO must again review the veteran's claim, now appropriately characterized as a claim for a disability evaluation greater than 30 percent for service-connected chronic bronchitis from September 7, 1993 to September 25, 1998. In doing so, the Board points out that the RO should take into account the effective date of the revised regulation. In other words, for any date prior to effective October 7, 1996, the RO should not apply the revised respiratory disorder rating schedule to the claim, but from that date until September 1998, the RO should apply both the old and new criteria. The claims of entitlement to an earlier effective date for the 100 percent evaluation assigned for the service-connected chronic bronchitis, and the claim of entitlement to permanency of the 100 percent evaluation for chronic bronchitis, will be held in abeyance pending the outcome of this claim. As regards the PTSD claim, in its February 1998 remand, the Board also noted that certain portions of 38 C.F.R. Part 4 pertaining to the rating criteria for psychiatric disorders, to include PTSD, had changed, effective November 7, 1996. Again citing the dictates of Karnas, the Board remanded this claim for another VA psychiatric examination and RO consideration of the claim pursuant to the new and old rating schedule criteria As noted in the introduction portion of this decision, by a rating action in October 1998, the RO increased the evaluation for the service-connected PTSD from 10 to 30 percent, effective July 16, 1998. However, a review this decision reflects that only the new rating criteria was considered in evaluating this disorder. As such, the RO must again review the veteran's claim, now appropriately characterized as a claim for an initial disability evaluation greater than 10 percent for service- connected PTSD from August 22, 1995, and for an evaluation greater than 30 percent for this disorder from July 16, 1998. See Fenderson, supra. It was also indicated in the Fenderson decision that in the case of an initial rating, separate ratings can be assigned for separate periods of time based on the facts founds, a practice known as "staged rating" (the Board notes that the RO essentially engaged in this practice in their October 1998 decision). In readjudicating this claim, the Board again points out that the RO should take into account the effective date of the revised regulation. In other words, for any date prior to effective November 7, 1996, the RO should not apply the revised psychiatric disorder rating schedule to the claim, but from date forward the RO should apply both the old and new criteria. Finally, as regards the claim for a higher evaluation for hearing loss, the Board notes that the criteria for evaluating hearing loss (and other sense organs) was revised effective June 10, 1999. Under the new criteria, when the pure tone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) are 55 decibels or more, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral. 64 Fed. Reg. 25202-25210 (codified at 38 C.F.R. § 4.86 (1999)). Because the record reflects pure tone thresholds in one ear at 55 decibels or more at all frequencies (during a June 1998 evaluation, the single such evaluation to be considered in this appeal), this change might have an impact on the evaluation of the veteran's hearing loss. The RO has not, to date, considered the veteran's claim under the former and revised applicable schedular criteria, applying the more favorable result, pursuant to Karnas. Such action is necessary, in the first instance, to avoid any prejudice to the veteran. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). Further, if the claim is again denied, the RO must provide notice to the veteran of the revised applicable schedular criteria, and afford him an opportunity to respond with argument and/or evidence. The Board would emphasize, however, that the revised criteria applies prospectively. As the only audiological evaluation pertinent to this claim took place prior to the effective date of the revisions, further audiological evaluation is warranted to determine whether the above-cited provision is, in fact, applicable to this case. In view of all of the above, these claims are REMANDED to the RO for the following action: 1. After obtaining and associating with the claims file records of all pertinent outstanding medical evaluation and/or treatment of the veteran, the claims folder, along with copies of the criteria of Diagnostic Code 8523 and 8525, should be referred to the examiner who conducted the September 1998 VA neurological examination. The RO should request that the examiner attach an addendum to this examination, evaluating, to the extent possible, the disability in accordance with the proper code. If, for any reason, that examiner is unavailable, or is unable to provide the requested information without examining the veteran, the RO should schedule the veteran to undergo evaluation of the claim in accordance with the instructions set forth herein and in its February 1998 remand. 2. The RO should schedule the veteran for a VA audiological evaluation to determine the current severity of his bilateral hearing loss. It is imperative that the examiner reviews the evidence in the claims folder, including a complete copy of this REMAND. The report of the examination should reflect consideration of the veteran's pertinent medical history and complaints. All pertinent clinical findings and tests should be performed, to include speech discrimination results, if appropriate. The examiner must set forth the rationale underlying any conclusions drawn or opinions expressed, to include, as appropriate, citation to specific evidence in the record in a typewritten report. 3. The RO should adjudicate each of the claims remaining on appeal. In evaluating the claim of entitlement to a compensable rating for the residuals of the right posterior tibial nerve injury from September 7, 1993, and to an evaluation greater than 10 percent from September 23 1998, the RO must specifically state whether Diagnostic Code 8523 is applicable, and why. The RO should also adjudicate the claims involving entitlement to a disability evaluation greater than 30 percent for service-connected chronic bronchitis from September 7, 1993 to September 25, 1998, the propriety of the initial 10 percent disability evaluation assigned for service-connected PTSD from August 22, 1995, and entitlement to an evaluation greater than 30 percent for this disorder from July 16, 1998; and entitlement to an evaluation in excess of 10 percent for bilateral hearing loss. Regarding the chronic bronchitis claim, consideration should be given to the former and revised criteria of Diagnostic Codes 6600, 6603, and the effective date of the change in regulation (i.e. prior to October 7, 1996, the old criteria should be considered, and subsequent to October 7, 1996, both the old and new should be considered, and the more favorable assigned). Regarding the PTSD claim, consideration should be given to the former and revised criteria of Diagnostic Code 9411, and the effective date of the change in regulation (i.e. prior to November 7, 1996, the old criteria should be considered, and subsequent to November 7, 1996, both the old and new should be considered, and the more favorable assigned). In addition, consideration should be given to whether "staged rating" is appropriate. Finally, regarding the bilateral hearing loss claim, consideration should be given to the criteria in effect both prior to and after June 10, 1999; if the revised criteria is deemed inapplicable, the RO should clearly explain why. Adjudication of each claim should be accomplished in light of all relevant evidence and all pertinent legal authority. All pertinent legal authority governing the claims, as well as all concerns noted in this REMAND, should be addressed. 4. If any benefit sought on appeal remains denied, the veteran and his representative should be furnished a supplemental statement of the case and a citation and discussion of the applicable laws and regulations and be afforded the opportunity to respond to that supplemental statement of the case before the claim is returned to the Board. The purpose of this REMAND is to afford due process and to accomplish additional development and adjudication, and it is not the Board's intent to imply whether the benefits requested should be granted or denied. The veteran need take no action until otherwise notified, but he may furnish additional evidence and/or argument during the appropriate time frame. See Kutscherousky v. West, 12 Vet. App. 369 (1999); Colon v. Brown, 9 Vet. App. 104, 108 (1996); Booth v. Brown, 8 Vet. App. 109 (1995); Quarles v. Derwinski, 3 Vet. App. 129, 141 (1992). This REMAND 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. JACQUELINE E. MONROE Member, Board of Veterans' Appeals