Citation Nr: 0004631 Decision Date: 02/23/00 Archive Date: 02/28/00 DOCKET NO. 96-32 343 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUES 1. Service connection for hypertension secondary to service- connected major depressive disorder. 2. Whether new and material evidence has been submitted to reopen the claim for service connection for hypertension. 3. Entitlement to an increased disability evaluation for major depressive disorder, currently evaluated as 70 percent disabling. 4. Entitlement to an increased disability evaluation for non-displaced radial styloid fracture of the right wrist, currently evaluated as 10 percent disabling. 5. Entitlement to a compensable disability evaluation for scar of the scalp. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD C.A. Skow, Counsel INTRODUCTION The appellant served on active duty from September 1979 to November 1988. This matter came before the Board of Veterans' Appeals (the Board) on appeal from a July 1994 and June 1997 rating decision of the New Orleans, Louisiana, Department of Veterans Affairs Regional Office (VARO). The record does not show that VARO considered referral of this case to the Chief Benefits Director or the Director, Compensation and Pension Service, for the assignment of an extraschedular rating under 38 C.F.R. § 3.321(b)(1) (1999). The United States Court of Appeals for Veterans Claims (Court) has recently held that the Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance; however, the Board is not precluded from considering whether referral to the appropriate first-line official is required. The Board is still obligated to seek out all issues that are reasonably raised from a liberal reading of documents or testimony of record and to identify all potential theories of entitlement to a benefit under the law and regulations. Floyd v. Brown, 9 Vet.App. 88 (1996). Moreover, the Court has also held that the Board must address referral under 38 C.F.R. § 3.321(b)(1) only when circumstances are present which the Director of VA's Compensation and Pension Service might consider exceptional or unusual. Shipwash v. Brown, 8 Vet.App. 218, 227 (1995). Having reviewed the record with these holdings in mind, the Board finds no basis for action on the question of the assignment of an extraschedular rating. A claimant is entitled to a hearing if he so desire. See 38 C.F.R. § 20.700(a). The Board observes that the appellant has had two hearing before a hearing officer at VARO and that he has effectively withdrawn his request for a hearing before a member of the Board at the regional office. As such, the VA has fully complied with its due process requirements, and a disposition of the case at this time would not prejudice the appellant. Bernard v. Brown, 4 Vet.App. 384 (1993). FINDINGS OF FACT 1. Competent medical evidence has not been presented showing a nexus, or link, between hypertension and either the appellant's period of service or his service-connected psychiatric disability. 2. The Board denied the appellant's claim for service- connection for hypertension in November 1990. No appeal was filed and that decision became final. Evidence submitted since that decision is not cumulative or redundant, and bears substantially and directly on the matter in dispute with respect to reopening the claim. 3. The appellant's service-connected psychiatric disability is currently manifested by depression, occasional auditory hallucinations, paranoia, suspiciousness diminished concentration, pathologically high levels of anger, poor self-esteem, and suicidal and homicidal ideation without a plan; he is demonstrably unable to obtain or retain employment due to the severity of his psychoneurotic symptoms according to a statement from J.M. Weisler, M.D., dated September 1998. 4. The appellant's service-connected scar on the scalp is currently manifested by subjective complaints of irritation and itching, there is no objective medical evidence for any functional loss associated with the scalp scar, or that the scar is superficial and poorly nourished with repeated ulceration, or that the scar is superficial, tender and painful. CONCLUSIONS OF LAW 1. New and material evidence sufficient to reopen the claim to service connection for hypertension has been presented. 38 U.S.C.A. § 5108 (West 1991 & Supp. 1999); 38 C.F.R. § 3.156(a) (1999). 2. A well grounded claim for service connection for hypertension on both a direct and secondary basis has not been presented. 38 U.S.C.A. §§ 1101, 1131, 5107 (West 1991 & Supp. 1999); 38 C.F.R. §§ 3.302, 3.310(a) (1999). 3. The schedular criteria for a 100 percent rating for major depression are met. 38 U.S.C.A. §§ 1155, 5107 (West 1991 & Supp. 1999); 38 C.F.R. § 3.321, Part 4, Diagnostic Code 9434 (1999) and 9405 (1995). 4. The schedular criteria for a compensable rating for laceration scar of scalp are not met. 38 U.S.C.A. §§ 1155, 5107 (West 1991 & Supp. 1999); 38 C.F.R. § 3.321, Part 4, Diagnostic Code 7805 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Claims to Reopen The Board denied the appellant's claim for service connection for hypertension in November 1990. That decision is final. We note that a final rating determination is not subject to revision upon the same factual basis. 38 U.S.C.A. § 7104 (West 1991), 38 C.F.R. § 20.1100. Under pertinent law and regulations, as interpreted by the Court, the Board may reopen and review a claim which has been previously denied only if new and material evidence is submitted by or on behalf of the appellant. 38 U.S.C.A. § 5108 (West 1991); 38 C.F.R. § 3.156(a); Manio v. Derwinski, 1 Vet.App. 140 (1991). The credibility of the new evidence is presumed. Justus v. Principi, 3 Vet.App. 510, 513 (1992). The Court has held that the provisions of 38 U.S.C.A. § 5108 (West 1991) require a review of all evidence submitted by the claimant since the last final denial of a claim in order to determine whether a claim must be reopened and adjudicated on the merits. Glynn v. Brown, 6 Vet.App. 523, 529 (1994); see also Evans v. Brown, 9 Vet.App. 273, 285 (1996). According to 38 C.F.R. § 3.156(a)(1999), "New and material evidence" means evidence not previously submitted to agency decision makers which bears directly and substantially upon the specific matter under consideration, which is neither cumulative nor redundant and which, by itself or in connection with the evidence previously assembled, is so significant that it must be considered in order to fairly decide the merits of the case. The well groundedness requirement shall not apply with regard to reopening disallowed claims and revising prior final determinations. Jones v. Brown, 7 Vet. App. 134 (1994). While this appeal was pending, the United States Court of Appeals for the Federal Circuit rendered its decision in Hodge v. West, 155 F.3d 1356 (Fed. Cir. 1998). In Hodge, the Federal Circuit changed the law as it pertains to the submission of new and material evidence and offered guidance as to how the Court should review such determinations made by the Board. First, the Federal Circuit invalidated the test adopted by the Court in Colvin v. Derwinski, i.e., that evidence was new and material sufficiently to reopen a claim if the evidence, when considered with the other evidence, would raise a reasonable possibility of changing the outcome. 1 Vet.App. 171, 174 (1991). The Federal Circuit proceeded to adopt the standard set forth in 38 C.F.R. § 3.156(a) (1997) as the appropriate standard for determining whether new and material evidence had been submitted. Second, as a result of Hodge and the Federal Circuit's recitation that the determination of whether new evidence is sufficiently material is a "fact-specific determination," "a deferential standard of review of these decisions under 38 U.S.C. § 7261(a) becomes the proper one." Fossie v. West, __ Vet.App. __, __, No. 96-1695, slip op. at 5 (October 30, 1998). Hodge provides for a reopening standard which calls for judgments as to whether new evidence (1) bears directly or substantially on the specific matter, and (2) is so significant that it must be considered to fairly decide the merits of the claim. Evidence considered by the Board in its November 1990 decision included service medical records, which reflect numerous blood pressure reading within the normal range with a few borderline readings, but no diagnosis for essential hypertension. Also, the Board considered private treatment reports date April 1986 that show diastolic blood pressure readings between 84 and 108 shortly after the appellant was involved in an accident. Report of separation examination dated November 1988 was negative for hypertension. The Board further considered sworn testimony from a personal hearing in January 1990, wherein the appellant indicated that he had hypertension since service discharge. The Board in November 1990 denied service connection for hypertension based on a careful review and weighing of the evidence of record at that time because, ultimately, it concluded that competent medical evidence had not been submitted showing hypertension in service or to a compensable degree within the initial post separation year. The evidence received by the VA since the April 1992 Board decision consists of VA outpatient treatment records dated since October 1995 showing a diagnosis for hypertension and the appellant's sworn testimony that he had hypertension in and since service. After reviewing the most recent evidentiary submissions, the Board finds that the evidence is both new and material to the issue of service connection for hypertension. New evidence is that which is not merely cumulative of other evidence on the record. Colvin v. Derwinski, 1 Vet.App. 171, 174 (1991) citing Williams v. Sullivan, 905 F.2d 214, 216 (8th Cir. 1990). Material evidence is that which is relevant and probative of the issue at hand. Colvin, supra., citing Chaney v. Schweiker, 659 F.2d 676, 679 (5th Cir. 1981). The most recent evidentiary submissions now show a diagnosis for hypertension, an element of the claim that was not previously shown on consideration of the claim by the Board in November 1990. As such, the Board finds that the evidence most recently submitted is new because it is not cumulative or redundant of the evidence considered in the November 1990 Board decision. Moreover, the Board finds that the treatment records showing hypertension bear directly and substantially (to use the Secretary's wording) on the issue in dispute, which is whether or not the appellant has hypertension related to service. Having resolved the question of whether new and material evidence has been submitted to reopen the claim for service connection for hypertension (direct basis), the next question is whether the appellant has submitted a well grounded claim. This question is addressed in the following section of this decision. II. Claims for Service Connection Service connection may be granted, when the facts, as shown by the evidence, establish that a particular injury or disease resulting in chronic disability was incurred in service, or, if pre-existing service, was aggravated therein. 38 U.S.C.A. § 1110 (West 1991); 38 C.F.R. § 3.303. In the case of any disease diagnosed after discharge, service connection may be granted when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection is presumed if a veteran manifests a chronic disease, such as hypertension, to a degree of at least 10 percent within one year after separation from service. 38 U.S.C.A. § 1112 (West 1991); 38 C.F.R. §§ 3.307, 3.309. Service connection may also be granted for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Furthermore, in Allen v. Brown, 7 Vet.App. 439 (1994) (en banc), the Court held that, where service connection is sought on a secondary basis, service connection could be granted for disability which is not only proximately due to or the result of a service-connected condition, but could also be granted where a service-connected disability had aggravated a nonservice- connected disability, with compensation being paid for the amount of disability which exceed "the degree of disability existing prior to the aggravation." However, the threshold question to be answered in all cases is whether the appellant's claim is well grounded; that is, whether it is plausible, meritorious on its own, or otherwise capable of substantiation. Murphy v. Derwinski, 1 Vet.App. 78 (1990); Epps v. Gober, 126 F. 3d 1464 (1997), adopting the definition in Epps v. Brown, 9 Vet. App. 341, 344 (1996). If a particular claim is not well grounded, then the appeal fails and there is no further duty to assist in developing facts pertinent to the claim since such development would be futile. 38 U.S.C.A § 5107(a) (West 1991 & Supp. 1999). Furthermore, a claim that is not well grounded precludes the Board from reaching the merits of a claim. Boeck v. Brown, 6 Vet. App. 14, 17 (1993). To establish a plausible claim, a veteran must present medical evidence of a current disability; medical evidence, or, in certain circumstances, lay evidence, of in-service incurrence or aggravation of a disease or injury; and medical evidence of a nexus or link between the claimed in-service disease or injury and the present disease or injury. Epps v. Gober, 126 F.3d 1464 (1997); Caluza v. Brown, 7 Vet. App. 498, 506 (1995). Alternatively, a claim may be well grounded based on application of the rule for chronicity and continuity of symptomatology, set forth in 38 C.F.R. § 3.303(b). Savage v. Gober, 10 Vet. App. 489, 495-98 (1997). An appellant has, by statute, the duty to submit evidence that a claim is well grounded. 38 U.S.C.A. 5107(a). Where such evidence is not submitted, the claim is not well grounded, and the initial burden placed on the appellant is not met. See Tirpak v. Derwinski, 2 Vet. App. 609 (1992). Evidentiary assertions by the appellant must be accepted as true for the purposes of determining whether a claim is well grounded, except where the evidentiary assertion is inherently incredible. See King v. Brown, 5 Vet.App. 19 (1993). A. Service Connection on a Direct Basis A review of the record reflects that the appellant's service medical records are negative for a diagnosis of hypertension. A diagnosis for hypertension is first shown on VA outpatient treatment records dated since October 1995, many years after discharge. There is no evidence of record showing a nexus, or link, between the current findings for hypertension and the appellant's period service. Although the appellant presented sworn testimony in December 1997 to the effect that he had elevated blood pressure readings in service and that he though he was possibly diagnosed with hypertension at that time, he is not competent to offer opinions on medical diagnosis or causation as a layperson, and the Board may not accept unsupported lay speculation with regard to medical issues. See Espiritu v. Derwinski, 2 Vet.App. 482 (1992); Moray v. Brown, 5 Vet.App. 211 (1993). Moreover, lay assertions of medical causation or medical diagnosis cannot constitute evidence to render a claim well grounded. Lathan v. Brown, 7 Vet.App. 359, 365 (1995); Grottveitt v. Brown, 5 Vet. App. 91, 93 (1993); Tirpak supra. at 611. Therefore, the Board finds that a well grounded claim for service connection for hypertension on a direct basis has not been submitted. We note that the appellant is not prejudiced by the Board's action on the question of service connection for hypertension without remand to VARO as no possible benefit could flow to the appellant as the claim is not well grounded as a matter of law. See also Winters v. West, 12 Vet.App. 203 (1999). Under 38 U.S.C.A. § 5103(a), the VA is obligated to advise claimants of the evidence necessary to complete his application. Robinette v. Brown, 8 Vet.App. 69 (1995). VARO successfully completed this obligation and the Board's discussion above informs the appellant of the requirements for the completion of his application for the claim for service connection. B. Service Connection on a Secondary Basis At his personal hearing in December 1997, the appellant raised the issue of entitlement to service connection for hypertension secondary to service-connected major depression. His representative argued that secondary service connection was established because a VA outpatient treatment record dated August 1996 reflects hypertension and contemporaneous VA psychiatric treatment records show "the veteran's depressive situation was at one of its major peaks." VA outpatient treatment records dated October 1995 to June 1998 are positive for hypertension and psychiatric disability. However, these records do not address the etiology of hypertension. Additionally, these records, including those pertaining to psychiatric treatment, do not show aggravation of hypertension by the appellant's service- connected psychiatric disability. The Board finds that a well grounded claim for service connection for hypertension secondary to major depression has not been presented in this case because competent medical evidence has not been presented showing a nexus, or link, between the current medical findings for hypertension and the appellant's service-connected psychiatric disability. The Board acknowledges the appellant's belief that a causal relationship exists between the development of hypertension and his service-connected major depression. However, as a layperson, the appellant is not competent to offer opinions on medical causation and the Board may not accept unsupported lay speculation with regard to medical issues. See Espiritu supra. at 482; Moray supra. Moreover, lay assertions of medical causation cannot constitute evidence to render a claim well grounded. Lathan supra. at 365; Grottveitt supra. at 93; Tirpak supra. at 611. We note that under 38 U.S.C.A. § 5103(a) the VA is obligated to advise claimants of the evidence necessary to complete his application. Robinette v. Brown, 8 Vet.App. 69 (1995). VARO successfully completed this obligation in its May 1998 supplemental statement of the case. Likewise, the Board's discussion above informs the appellant of the requirements for the completion of his application for the claim for service connection. III. Claims for Increase A. Background By a rating decision dated May 1989, service connection was established for dysthymia (10%), laceration of the scalp (0%), and nondisplaced radial styloid fracture of the right wrist (0%). In February 1991, a VA psychiatric examination was conducted. The appellant complained of nightmares related to his involuntary killing of a person. He was diagnosed with dysthymia, with mild to moderate emotional impairment. In August 1993, the appellant requested an increased rating for scars, limited arm motion, conditions of the skeletal system, and other disorders. In September 1993, a VA skin examination was conducted. The appellant complained of a rash on his faced, diagnosed as seborrheic dermatitis. There were no complaints concerning his service-connected laceration scar of the scalp. Also, in September 1993, a VA psychiatric examination was conducted. The appellant, age 33, reported that he had been married for the past 10 years and that he worked for the U.S. Postal Service since 1989 as a letter machine operator. He reported drinking alcohol, but denied being an alcoholic. He reported taking medication for anxiety. He complained of poor self-esteem, some anxiety, and depression. He denied suicidal and homicidal ideation. He expressed no joy in hobbies or other interests. Objectively, he was well- developed, well-nourished, alert, and oriented, with intact attention and concentration. His mood was depressed and his affect was sad, somewhat tearful at times. There was no evidence of psychosis. Intelligence was average. Memory, insight, and judgment were intact. The diagnoses were dysthymia, major depression (recurrent), and rule out alcohol abuse. By a rating decision dated May 1994, an increased rating was denied for depression, laceration of the scalp, and residuals of right wrist fracture. In July 1994, VA outpatient treatment records dated August 1989 to May 1994 were received. Those records dated from 1993 were essentially silent for complaints of depression, scar of the scalp, and residual of right wrist fracture. In July 1993, it was noted that there was decreased depression. These records mostly pertain to shoulder and sinus problems. In October 1994, a copy of a "Notice of Proposed Removal" dated October 1994 from the U.S. Postal Service was submitted by the appellant. This notice reflects that the appellant had been convicted of one count of illegal use of a weapon and three counts of aggravated assault. The appellant argued in his defense that the incident that gave rise to the convictions involved a domestic dispute that "got out of hand." Sentence was suspended and the appellant was placed on probation. While it was noted that the appellant was under medication for depression and that he had regular psychiatric treatment twice a month, the appellant's removal from work was recommended. This letter was followed-up by a "Letter of Decision" dated March 1995, wherein the recommendation to remove the appellant from his position was accepted. In August 1995, a personal hearing was conducted. The appellant testified that his service-connected depression, scar of the scalp, and right wrist disabilities were more severe than currently rated. It was reported that he was removed from the U.S. Postal Service because of an altercation prompted by his nervous disorder. The appellant reported feeling depressed and taking Elavil for those symptoms. He complained of work problems and family problems. Also, the appellant indicated that his scalp felt irritated and that hair would not grow on the scar. When questioned about his service-connected wrist, the appellant complained mostly about his shoulder. Regarding the wrist, he alleged poor grip and strength. He also reported pain and that it did not move as well as it once had. In January 1996, a VA skin examination was conducted. Objective findings were negative for any visible scar on the head. Also, in January 1996, a VA wrist examination was conducted. Objective findings were positive for decreased strength of the right hand. There was 70 degrees of dorsiflexion, 80 degrees of palmar flexion, 20 degrees of radial deviation, and 44 degrees of ulnar deviation. All the fingers had normal function. Strength and dexterity were normal. In January 1996, a VA psychiatric examination was conducted. The appellant complained of depression, loss of appetite, sleep problems, psychomotor agitation, poor self-esteem, and diminished ability to concentrate. He further complained of psychotic symptoms, such as, auditory hallucinations, paranoia, and delusions. He lastly reported post traumatic stress disorder-type symptoms related to a 1987 motor vehicle accident and the accidental killing of a person, and excessive checking behavior. Socially, the appellant stated that he was married and lived with his wife and their 2 children. The appellant reported that he worked for the U.S. Postal Service, but that his supervisor had made life unbearable for the past year. Mental status examination reflects that the appellant was disheveled and inappropriately groomed, with a tearful demeanor. Intellectual functioning was low-average. He displayed severe depressive symptoms, pathologically high levels of anger, and significant emotional stress. He seemed to harbor intense feelings of inferiority and insecurity, typically associated with a diagnosis of psychotic disorder. The diagnosis was major depression, with psychotic features, and sub-threshold post traumatic stress disorder symptoms. A Global Assessment of Functioning Scale score of 40 (current and highest in past year) was assigned. In December 1996, VA outpatient treatment notes dated October 1995 to December 1996 were received. In November 1995, the appellant reported that he felt unfairly treated at work. He reported doing well in school and needing a re-supply of Elavil. He failed to reported for treatment in February 1996 and, in September 1996, it was noted that psychotherapy was trying to help the appellant react less paranoid. In February 1997, a VA psychiatric examination was conducted. The appellant complained that "I hate the f-ing post office. I don't get no breaks. They denied a change in my schedule. I don't sleep. I don't rest. I think people are at the door sometimes. I hear footsteps. I feel pressure when I have to go to work. I've been depressed." On mental status examination, the appellant was preoccupied with his job and feelings of unfair treatment, almost paranoid to the extent of delusional. He was hard to focus, and rambled about irrelevant information. Also, he was preoccupied with being a "real man." He reported auditory hallucinations. He denied suicidal thoughts, but he had homicidal thoughts toward people at work. Significant paranoia was noted. Mood was dysphoric. Concentration and attention were mildly impaired. Memory was intact. History of an attempted murder charge, changed to aggravated assault, in 1994 was noted, along with the appellant's release/suspension from his job for about a year after the charge. Intelligence was average, insight was fair, and judgment was poor. Paranoia and volatile temper were found. The diagnosis was major depression, recurrent, with psychotic features. A GAF score of 60 was assigned. In December 1997, a second personal hearing was conducted. The appellant again testified that his service-connected depression, scar of the scalp, and right wrist disabilities were more severe than reflected by the current ratings. He argued that his scalp scar was easily irritated, itchy, sore and tender. He stated that he comes close to scratching it until it bleeds. He stated that he treats the condition with over-the-counter medications, such as Vaseline and shampoo. Regarding his wrist, the appellant reported symptoms of poor strength and occasional pain, along with poor grip. In December 1997, VA outpatient treatment notes dated November 1996 to June 1998 were received. In November 1997, the appellant was seen for anxiety and depression related to an altercation with his supervisor. He was tearful and angry throughout the interview. The impression was rule out reactive psychosis. Treatment notes further show problems with psychosis and schizophrenia. The appellant submitted copies of notices for "Off Duty Status" dated April 1998 related to the charge of "Conduct Unbecoming of a Postal Employee, i.e., Veiled Threat to a Postal Employee" and "Notice of Proposed Placement on Enforced Leave" dated August 1998 related to the charge of "Failure to Meet Medical Requirements of Position, i.e., Not Fit for Duty." In an October 1998 statement, the appellant's wife reported that the appellant seemed to lack energy. She noted that he had attended school, and that he would engage in a variety of activities after school, including yard work, car work, going to the movies or out to dinner or visiting friends. However, currently, he was depressed with a poor appetite and crying spells. A VA memorandum dated September 1998 from J.M. Weisler, M.D., Chief, Ambulatory Mental Health, reflects that the appellant was a long-term patient for psychosis, with well-controlled symptoms until several months ago when he began to show symptoms of paranoia, depression, and severe mental disorganization. He was noted to be unable to perform any vocational duties at this time. In January 1999, a VA examination was conducted. The appellant complained of right wrist pain and bilateral shoulder pain. Most of his complaints were related to the shoulder. Objectively, wrist dorsiflexion was 62 degrees, palmar flexion was 58 degrees, radial deviation was 18 degrees, and ulnar deviation was 30 degrees. There was tenderness over the radial aspect on palpation. No laxity or effusion was noted. The diagnosis was status post fracture of the right wrist. In April 1999, a VA psychiatric examination was conducted. The appellant was clean and neat in appearance, alert and oriented, with goal-directed thought processes. Speech was normal in rate. Mood was dysthymic and his affect was full range and appropriate to the content of his speech. Judgment and insight were intact. He reported suicidal ideation without a plan and homicidal ideation towards his former employers without a plan. He convincingly stated that he was not a threat towards himself or others at this time. The impression was major depressive episode, partially responsive to treatment, and personality disorder not otherwise specified. GAF scores of 45, current, and 55, in the past year, were assigned. By a rating decision dated May 1999, a 70 percent disability evaluation for dysthymia, and a 10 percent disability evaluation was for the right wrist disability, was assigned, each effective from August 5, 1993. A compensable rating for laceration of the scalp was denied. B. Analysis The appellant contends that the evaluations assigned his service-connected depression and scar of the scalp do not reflect adequately the severity of his psychiatric and skin symptomatology. He asserts that the evaluations should be increased. As a preliminary matter, the Board finds that the appellant's claims for increase are "well grounded" within the meaning of 38 U.S.C.A. § 5107(a). A claim that a service-connected condition has become more severe is well grounded where the claimant asserts that a higher rating is justified due to an increase in severity. See Caffrey v. Brown, 6 Vet. App. 377, 381 (1994); Proscelle v. Derwinski, 2 Vet. App. 629, 631-632 (1992). Once a claimant has presented a well grounded claim, the VA has a duty to assist the claimant in developing facts that are pertinent to the claim. See 38 U.S.C.A. § 5107(a). The Board finds that all relevant facts have been properly developed, and that all evidence necessary for equitable resolution of the issue on appeal has been obtained. Disability evaluations are determined by comparing the veteran's current symptomatology with the criteria set forth in the Schedule for Rating Disabilities (rating schedule). 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. In making its determination, the Board analyzes the extent to which a service-connected disability adversely affects a veteran's ability to function under the ordinary conditions of daily life, and bases the assigned rating, as far as practicable, on the average impairment of earning capacity in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 410. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. See 38 C.F.R. § 4.3. Where entitlement to compensation has already been established and an increase in disability rating is at issue, the present level of disability is of primary concern. While the entire recorded history of a disability is to be reviewed by the rating specialist, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). 1. Psychiatric Disability By regulatory amendment effective November 7, 1996, substantive changes were made to the schedular criteria for evaluating psychiatric disorders, as defined in 38 C.F.R. §§ 4.125-4.132. See 61 Fed. Reg. 52695-52702 (1996). Where the law or regulations governing a claim change while the claim is pending, the version most favorable to the claimant applies, absent congressional intent to the contrary. See Karnas v Derwinski, 1 Vet. App. 308, 312-313 (1991). Accordingly, the Board is generally required to review both the pre- and post-November 7, 1996 rating criteria to determine the proper evaluation for major depression. Under the pre-November 1996 law, a 70 percent evaluation for major depression was warranted where the ability to establish and maintain effective or favorable relationships with people was severely impaired, and the psychoneurotic symptoms were of such severity and persistence that there was severe impairment in the ability to obtain or retain employment. 38 C.F.R. § 4.132, Diagnostic Code 9405. A 100 percent evaluation was warranted where the attitudes of all contacts except the most intimate are so adversely affected as to result in virtual isolation in the community. A 100 percent rating required total incapacitating psychoneurotic symptoms bordering on gross repudiation of reality and disturbed thought or behavioral process associated with almost all daily activities, such a fantasy, confusion, panic, and explosions of aggressive energy resulting in a profound retreat from mature behavior. The veteran must have been demonstrably unable to obtain or retain employment. Id. In Johnson v. Brown, 7 Vet. App. 95, 99, (1994), the Court held that the evaluative factors listed as criteria for a 100 percent rating for psychoneurotic disorder (under the old standard) represent three independent criteria. The Court further instructed that should the Board determine that any one of the three independent criteria has been met, then a 100 percent rating should be assigned. The new schedular criteria provide a 100 percent disability evaluation where there is objective evidence of total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9434 (formerly § 4.132, Diagnostic Code 9405) (as revised, effective November 7, 1996 ). A 70 percent disability evaluation is provided where there is objective evidence of occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or worklike setting); inability to establish and maintain effective relationships. Id. The evidence of record shows that the appellant's mental state has been in decline between September 1993 and April 1999, with worsening depression and the onset of psychotic symptoms that includes auditory hallucinations, paranoia, and suspiciousness. Psychiatric examinations in January 1996 and February 1997 further showed symptoms of diminished concentration, pathologically high levels of anger, and poor self-esteem. At the February 1997 psychiatric examination, the appellant was preoccupies with his job and feelings of unfair treatment; he was paranoid almost to the extent of delusional with an inability to focus and ramblings about irrelevant information. However, his concentration and attention were characterized as only mildly impaired, his memory was intact, his intelligence was average, and his insight was fair. A GAF score of 40 was assigned in January 1996, which reflects the presence of impaired reality testing or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood. See Quick Reference to the Diagnostic Criteria from DSM-IV at 47 (1994). A GAF score of 60 was assigned in February 1997, which reflects the presence of moderate symptoms or moderate difficulty in social, occupational, or school functioning. Id. The evidence of record also demonstrates significant work- related problems resulting in the appellant's removal from the his job and that the appellant has been convicted of aggravated assault stemming from a domestic dispute. The most recent psychiatric finding of record on VA psychiatric examination dated April 1999 reflect that the appellant was appropriately groomed, alert, oriented, and goal-directed in his thought processes with normal speech, and intact judgment, insight and memory. Objective findings were significant for a dysthymic mood and suicidal and homicidal ideation, without a plan. The impression was major depressive episode, partially responsive to treatment, and personality disorder not otherwise specified. A GAF score of 45 was assigned, which reflects the presence of "serious symptoms (e.g. suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious symptoms in social, occupational, or school functioning e.g., no friends, unable to keep a job)." See Quick Reference to the Diagnostic Criteria from DSM-IV at 47 (1994) While the evidence of record does not show a previous history of hospitalization for psychiatric disability, the appellant has received long-term VA outpatient psychiatric therapy. Additionally, the appellant's package of psychiatric symptoms (i.e. volatility, pathological anger, insecurity, poor self- esteem, dysthymic mood, etc.) have increasingly interfered with his employment as evinced the mental status findings on VA psychiatric examinations between 1996 and 1999, and the copies of letters prepared by his employer that document his removal from duty on two separate occasions, lastly because of a veiled threat to his supervisor. The increasing severity of the appellant's psychiatric symptoms supported by the September 1998 VA Memorandum from Dr. Weisler, wherein the Chief of Ambulatory Mental Health indicated that the appellant's symptoms were fairly well-controlled until recently when several months earlier he began to display psychotic symptoms that did not respond to treatment and made him unable to perform any vocational duties. Based on the above, the Board finds that the criteria for a 100 percent rating under both the old and new schedular criteria are met in light of the substantial evidence demonstrating that the appellant is unable to retain employment due to the severity of his psychiatric symptoms. 2. Scar of Scalp The VA Schedule for Rating Disabilities provides, under diagnostic code 7800, that scars of the head, face or neck are rated as follows: 0 percent rating for slightly disfiguring scars; 10 percent rating for moderately disfiguring scars; 30 percent rating for severely disfiguring scars, especially if producing a marked and unsightly deformity of the eyelids, lips, or auricles; and 50 percent rating for completely or exceptionally repugnant deformity of one side of the face of marked or repugnant bilateral disfigurement. 38 C.F.R. § 4.118. A 10 percent rating is available under diagnostic code 7803 where there are superficial and poorly nourished scars with repeated ulceration. Id. Superficial, tender and painful scars, on objective demonstration, are rated as 10 percent under diagnostic code 7804. Id. The appellant's scar of the scalp is currently evaluation as 0 percent disabling pursuant to diagnostic code 7805, which provides that the scar is rated on limitation of function of the affected part. Id. A review of the record discloses no complaints regarding the scalp scar on VA skin examination in September 1993, and reported of VA skin examination dated January 1996 was entirely negative for any visible scar on the head. Although the appellant testified that his scar was irritating, due to itching, and that he sometime feels as though he will itch the scar to the point of bleeding, the objective medical evidence of record fails to demonstrate any functional loss associated with the scalp scar. Additionally, the objective evidence of record fails to demonstrate disfigurement due to scar or that the scar is superficial and poorly nourished with repeated ulceration or that the scar is superficial, tender and painful. Therefore, the Board finds that the criteria for a compensable rating are not met. The Board notes that the provision of 38 C.F.R. § 3.102 is not for application in this case as there is not an approximate balance of the positive and negative evidence, which does not satisfactorily prove or disprove the claim, for the reasons discussed above. ORDER To the extent of the findings that new and material evidence has been presented to reopen the claim for service connection for hypertension, the benefit sought on appeal is granted. Service connection for hypertension is denied. Service connection for hypertension secondary to service- connected major depression is denied. A 100 percent rating for major depression is granted. A compensable rating for scar of the scalp is denied. REMAND Sworn testimony from the appellant reflects complaints of right wrist pain and functional impairment, which was not considered on recent VA examination of the right wrist. A VA examination concerning orthopedic disability should contain an opinion concerning the effect of pain upon a veteran's functional abilities, as is required by 38 C.F.R. §§ 4.40, 4.45, and DeLuca v. Brown, 8 Vet.App. 202 (1995), and address the rating criteria in relation to the veteran's symptoms. See Johnson v. Brown, 9 Vet.App. 7 (1996). Therefore, remand is necessary. 1. The appellant should be scheduled for a VA orthopedic examination to fully evaluate the service-connected right wrist disability. The claims folder must be reviewed prior to the examination along with a copy of this remand. All appropriate tests deemed necessary should be conducted and all clinical findings should be reported in detail. Specifically, for each wrist, the examiner should fully describe the degree of limitation of motion. Any limitation of motion must be confirmed by clinical findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. The inability to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance should be described, and the degree of functional loss due to pain should also be indicated. 38 C.F.R. § 4.40. It should be indicated whether there is more or less movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. A complete rationale for all opinions expressed must be provided. 2. The appellant has the right to submit additional evidence and argument on the matter or matters that the Board has remanded to the regional office. Kutscherousky v. West, 12 Vet. App. 369 (1999). 3. After the development requested above has been completed, VARO should again review the record. If any benefit sought on appeal, for which a notice of disagreement has been filed, remains denied, the appellant and his representative should be furnished a supplemental statement of the case and given the opportunity to respond thereto. Thereafter, the case should be returned to the Board, if in order. The Board intimates no opinion as to the ultimate outcome of this case. The appellant need take no action unless otherwise notified. This claim must be afforded expeditious treatment by VARO. 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 (known as the United States Court of Veterans Appeals prior to March 1, 1999) 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. 1998) (Historical and Statutory Notes). In addition, VBA's Adjudication Procedure Manual, M21-1, Part IV, directs the VAROs 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. C.P. RUSSELL Member, Board of Veterans' Appeals