Citation Nr: 0007446 Decision Date: 03/20/00 Archive Date: 03/23/00 DOCKET NO. 94-03 575 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUE 1. Entitlement to an increased rating for rheumatic heart disease, currently evaluated as 30 percent disabling. 2. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD W. R. Steyn, Associate Counsel INTRODUCTION The veteran had active military service from November 1943 to November 1945. This appeal arises before the Board of Veterans' Appeals (Board) from an October 1992 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Togus, Maine, which denied the veteran's claim seeking entitlement to an increased rating for his rheumatic heart disease from 10 percent disabling. By a rating decision of August 1994, the hearing officer at the RO granted the veteran an increased rating to 30 percent disabling for his rheumatic heart disease. The veteran continued his appeal. The veteran's claim was before the Board in January 1996, November 1996, December 1997, and October 1998 at which times it was remanded for additional development. FINDINGS OF FACT 1. The RO has obtained all relevant evidence necessary for an equitable disposition of the veteran's appeal. 2. The veteran's current cardiovascular symptoms are attributed to other nonservice-connected heart disease. CONCLUSION OF LAW The criteria for a rating in excess of 30 percent for rheumatic heart disease have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. § § 4.101, 4.104, Diagnostic Code 7000 (prior to December 11, 1997); 38 C.F.R. § 4.104, Diagnostic Code 7000, note following Diagnostic Code 7005 (effective December 11, 1997). REASONS AND BASES FOR FINDINGS AND CONCLUSION Background By a rating action of May 1947, service connection was established for rheumatic heart disease. By a decision dated December 1991, the Board granted the veteran an increased rating to 10 percent disabling for his rheumatic heart disease. VA treatment notes were added to the record in July 1992. As shown by those records, the veteran was seen in May 1992, at which time he complained of chest pain. Blood pressure readings were 150/100 and 150/110 in the right and left arms, respectively. While electrocardiogram testing revealed normal sinus rhythm, there was evidence of borderline left ventricular hypertrophy. The examiner noted that the veteran's chest pain was atypical. It was further noted that in view of such factors as elevated blood pressure, obesity, and hypertension, it was likely that the veteran would develop coronary artery disease. On consultation in June 1992, following several blood pressure screenings, it was determined that the veteran's hypertension required better control. Hospitalization records dated in July 1992 show that when the veteran was admitted for arthroscopy of his left knee, he was also evaluated by the Cardiology Service, which determined that his coronary artery disease was stable. The veteran was accorded another VA examination in September 1992, at which time he complained of shortness of breath and lightheadedness with activity. The examiner noted that the veteran's history of rheumatic fever was somewhat soft, but that apparently he had been noted to have had a murmur for years. The examiner noted that no significant valvular disease from rheumatic fever had been documented on previous echocardiograms. The veteran stated that his symptoms were an occasional palpitation, shortness of breath if he bent over, climbed a flight of stairs, or rode a bike for more than a few minutes. He stated that he became lightheaded after walking 200 feet, and claimed generalized dyspnea on exertion, but was unable to be more specific. Additionally, he reported that he experienced knife-like pain across the precordium, resulting in numbness of his hands. The veteran's blood pressure was measured at 154/74. It was observed that there was regular rhythm of the heart. However, the point of maximal impulse was not palpable. The examiner noted the presence of a II/VI ejection-type murmur, and S1 and S2 were normal. The diagnostic impression was cardiac murmur, presumably trace mitral regurgitation, with no evidence of left ventricular dilation or hypertrophy by examination. It was also noted that the mitral regurgitation was not significant , and that the veteran did not have other valvular lesions of rheumatic heart disease. In an addendum to the September 1992 examination report, the examiner acknowledged the presence of arteriosclerotic heart disease and hypertension. The examiner noted no evidence of significant rheumatic heart disease or cardiac enlargement. The veteran appeared and presented testimony at a hearing before a VA hearing officer in October 1993. During the hearing, he described the symptoms associated with his heart disabilities, such as chest pain and lightheadedness with activity, rapid heart beating, and chest pain, which occasionally radiated down his arms and up to his neck. In January 1994, the VA hearing officer who presided over the October 1993 hearing referred the veteran's case to the Department of Cardiology at the Manchester, New Hampshire VA Medical Center. Specifically, the hearing officer sought a response from a specialist in cardiology to the following question: In view of the March 10, 1947 examination [which revealed, among other things, blood pressure of 150/100 and 140/90, in the left and right arms, respectively, and noted diagnoses of hypertensive and coronary arteriosclerotic heart disease], is it reasonable to conclude based upon a medical analysis of the record that the veteran had hypertensive and coronary arteriosclerotic heart disease incident to service in addition to the already established rheumatic heart disease? In a memorandum dated in May 1994, a VA physician noted that the veteran suffered from hypertension and coronary artery disease, which were suggested by several elevated blood pressure readings and a positive Persantine Thallium test. The physician indicated that it was possible that hypertension may have been present in 1947, although one elevated reading did not constitute convincing evidence of such pathology. The physician further concluded that the record presented no proof of coronary artery disease in 1947. The physician concluded that the diagnosis of rheumatic heart disease remained questionable despite the cardiac murmur. He suggested a repeat cardiac output echogram with Doppler to assess valve function. He noted that this was scheduled, but that the veteran did not appear in April 1994. By a rating decision of August 1994, the RO granted the veteran an increased evaluation to 30 percent disabling for his rheumatic heart disease. VA Medical Center treatment notes from May 1996 to December 1996 were submitted. In May 1996, the veteran was seen for a reaction to Salsalate, specifically for rash on both legs. His blood pressure was 124/74. Impressions were gout and B12 deficiency. The veteran was seen again in November 1996. His blood pressure was 140/80. The veteran's LDL was very high and the examiner recommended that he go on Fluvastatin. The veteran underwent a cardiovascular examination in May 1996 from the Cardiovascular Consultants of Maine. The purpose of the cardiac evaluation was so the veteran could be seen before a planned total knee replacement. The veteran described intermittent symptoms of chest discomfort, usually relieved by Nitroglyceryin. He described the discomfort as a sharp, left-sided chest discomfort with some radiation down to the lateral chest wall. There were no prolonged episodes of discomfort. Examination showed that the veteran's pulse was 70 and regular. His blood pressure was 118/70 in the right arm. The heart rhythm was regular without murmur, rub, or gallop. There was no peripheral edema. Electrocardiogram testing showed that there was a prominent left ventricular voltage, but otherwise was within normal limits. There was no evidence of prior infarction, nor were there ST and T wave changes suggestive of ischemia or hypertrophy. Impressions were history of coronary artery disease with chest pain syndrome possibly due to ischemia and hypertension under excellent control on current antihypertensive medications. A chest x-ray report from May 1996 from the Mercy Hospital was submitted. It showed that the veteran's chest was within normal limits for someone of his age group and habitus. During the June 1996 travel Board hearing, the veteran testified that he was first advised that he suffered from hypertension in 1955 or 1956 , and that he was not informed of elevated blood pressure readings during service. He testified that he had been taking medication for his hypertension since 1955. He testified that he had had pain in his chest for 12-13 years and was taking Nitroglycerin for such pain. He testified that he retired from his job in 1979 due to a blood clot in his lung. He went on to indicate that if he walked up a flight of stairs or a half mile on flat ground that he would be short of breath. He also testified that he used a dolly to carry things around in the house and used a cart to carry groceries inside. At the time of the hearing, the veteran submitted a list of medications he was taking and waived RO review of the list. The list shows that the veteran was taking Nitroglycerin for his heart and Quinapril, Lisinopril, and Acciapril for his blood pressure. In a November 1996 decision, the Board denied the veteran's claims of entitlement to service connection for arteriosclerotic heart disease and hypertension. The Board specifically determined that there was no medical evidence of record to support the veteran's claim that his arteriosclerotic heart disease and hypertension were attributable to service or were proximately related to his service-connected rheumatic heart disease. Copies of VA medical center treatment records were submitted from 1986 to 1997. In September 1993, an impression was provided of angina with exertion. In October 1993, it was noted that the veteran had angina, but that it was relieved with rest. A VA echocardiogram from February 1997 showed that the left atrium was moderately dilated, the left ventricle wall thickness was concentrically increased, and there was mild mitral annular calcification. It was also concluded that there was normal left ventricular systolic function and that there was left ventricular diastolic abnormal relaxation pattern. The veteran underwent a VA stress test in February 1997, but the test was stopped due to right knee pain and shortness of breath. The conclusion was that the exercise capacity was limited by right knee pain. A VA x-ray report of the veteran's chest from March 1997 concluded that there were multiple areas of reversibility involving the myocardium, including portions of the lateral, inferior, and anterior walls, as well as the septum and apex. There was also a fixed defect in the inferior wall which might have been secondary to a prior infarct or diaphragmatic attenuation. The veteran underwent a VA echocardiogram in June 1997. An examiner interpreted the examination to show that the left ventricle was dilated. Moderate left valve dysfunction was seen. Lateral hypokinesis was noted. Estimated ejection fraction was 35 to 40 percent. The left atrium was moderately dilated. The aortic root was normal in size. No valvular abnormalities were see. The examiner noted that this was not the picture of rheumatic heart disease. The veteran underwent a VA examination in June 1997. The veteran complained of pain in the sternal area, sharp like a knife, which was relieved by Nitroglycerin sublingually. He stated that sometimes the pressure or pain in the sternal area went to the left precordial area or to the left side of his chest and at times produced numbness in his left arm. He had shortness of breath on exertion, with one flight of stairs, or 200 feet of walking would produce dyspnea. The veteran did not have nocturnal episodes of dyspnea. He stated that he had edema of the ankles at times. The veteran was taking Lasix, Diltiazem, Quinapril, Colchicine, Indomethacin, Fluvastatin, and Omeprazole. Examination showed that the veteran was in no acute distress. He showed no dyspnea, as he was sitting and talking. There was no cyanosis. Regarding the heart, it was difficult to locate the apex because of the chest wall. The cardiac sounds were a little bit distant, but there was a soft, grade two systolic murmur heard at the apex as well as at the base of the heart. The veteran said that the heart rhythm was "NSR". There was no ankle edema and the peripheral pulses were normal. His blood pressure was 160/85. Impressions were hypertensive cardiovascular disease with coronary artery disease with status-post myocardial infarction, by history and rheumatic heart disease with mitral regurgitation, by history. The examiner noted an echocardiogram done in August 1990 that showed a trace of mitral regurgitation, no mitral stenosis, and no dilated left ventricular. The examiner further opined that with all of the findings at the time of the examination, that the veteran's disabilities were more related to his coronary artery disease and hypertension than his rheumatic heart disease. The veteran underwent a VA examination in January 1998. The veteran described episodic, central to left sided chest discomfort as well as exertional dyspnea. The veteran described a history of rheumatic fever at age 18, but did not have known valvular heart disease secondary to this. The veteran underwent a Persantine cardiolite scan which showed multiple areas of reversible ischemic disease consistent with coronary insufficiency. An EKG test showed normal sinus rhythm with normal axis and no ischemic ST or T-wave abnormality and no evidence of prior myocardial infarction. An echocardiogram showed concentric left ventricular hypertrophy with well preserved left ventricular systolic performance. The examiner's impression was recurrent exertional chest discomfort with exertional dyspnea. The examiner stated that in light of this and findings of reversible ischemia on his exercise cardiolite scan, the veteran needed to be evaluated more completely with a cardiac catheterization. The veteran underwent a VA x-ray in January 1998. The x-ray report noted that the veteran had mild cardiomegaly, but, otherwise no radiographic evidence of acute cardiopulmonary disease. A VA chest x-ray was taken in June 1998. The report showed minimal cardiomegaly with prominence of the left ventricle of the heart, but with the rest of the chest being negative. It was noted that there had been little change from January 1998. The veteran underwent a VA examination in December 1998. The examiner referred to his original dictation dated June 1998. He stated that he had reviewed the veteran's claims file. He stated that as best he could determine, the veteran had an enlarged heart. He stated that the left ventricle by scratch percussion appeared to be at the anterior axillary line. He stated that the veteran was somewhat difficult to examine given his obese body habitus. It was noted that the veteran had extreme shortness of breath with walking approximately two blocks. It was noted that the veteran's blood pressure currently was in control with medications, and did not have any arrhythmias. It was noted that the veteran had significant dyspnea, and developed ankle edema as the day went on. The examiner noted that the veteran was able to tend to his house work, and that it took him approximately 45 minutes to make his bed. He stated that he would not find this veteran capable of any type of meaningful employment. He stated that as best he could tell after speaking with the veteran, his workload would be somewhere in the neighborhood of 2 METs and perhaps even less. It was noted that the veteran had a echocardiogram done approximately one year prior, and also had a Cardiolite test done. The examiner stated that the results of that echocardiogram showed that the left ventricle was dilated with moderate LV dysfunction with some hypokinesis noted in the inferolateral area, and an ejection fraction estimated at 35-40 percent, and the left atrium being moderately dilated. No valvular abnormalities were noted. The examiner noted that the feeling on the echocardiogram was that this was not related to rheumatic heart disease. The examiner noted that on examination the veteran continued to have near holosystolic murmur that was located in the aortic area and was also audible in the apex. The veteran reported that his symptoms were stable, and that he had not had any congestive heart failure symptoms. The examiner commented that after reviewing the chart, he was not able to find significant or any valvular lesions consistent with the veteran's history of rheumatic heart disease. The examiner noted that the veteran reportedly had some mitral regurgitations, but that this was not reported on the latest echo. The examiner noted that the veteran was markedly obese, and that that fact might have interfered with the ability to fully visualize all the valves. The examiner commented that even with that fact being taken into account, that one would expect doppler examination to show some degree of regurgitation. The examiner's impression was that the veteran's symptoms and problems were much more likely to be related to his ischemia and his coronary artery disease than they were to any rheumatic heart disease. The examiner commented that the veteran had had a stress thallium test which showed evidence of reversible ischemia. It was noted that the veteran had been offered a cardiac catheterization, but refused the offer. The veteran stated that at this point his symptoms were stable, and he was doing well on medication. Analysis The veteran's claim for increased compensation is "well grounded" within the meaning of 38 U.S.C.A. § 5107(a) (West 1991). The United States Court of Veterans Appeals (Court) has held that, when a veteran claims a service-connected disability has increased in severity, the claim is well grounded. Proscelle v. Derwinski, 2 Vet.App. 629 (1992). The Court has also stated that where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet.App. 55 (1994). The veteran is currently rated as 30 percent disabled for his service-connected rheumatic heart disease. He is not service-connected for any of his other cardiac problems. In order for a rating higher than 30 percent to be assigned, the symptomatology of the rheumatic heart disease would have to meet the diagnostic criteria of 38 C.F.R. § 4.104, Code 7000. The veteran has had examinations and been rated under both sets of applicable rating criteria for cardiovascular disabilities. He has been rated under the new general rating formula for cardiovascular disorders, effective December 11, 1997, and under the old general rating formula for cardiovascular disorder, in effect prior to December 11, 1997. His disability was determined to be 30 percent disabling under both sets of diagnostic criteria. Therefore, the RO has considered all of the criteria applicable to the veteran's claim. Karnas v. Derwinski, 1 Vet.App. 308, 313 (1991). Under the old diagnostic criteria for diseases of the heart, Diagnostic Code 7000 instructs that the veteran would receive a 30 percent evaluation for inactive rheumatic heart disease from the termination of an established service episode of rheumatic fever, or its subsequent recurrence, with cardiac manifestations, during the episode or recurrence, for three years, or diastolic murmur with characteristic EKG manifestations or definitely enlarged heart. A 60 percent evaluation is assigned to inactive rheumatic heart disease manifest by definite enlargement of the heart; severe dyspnea on exertion, elevation of systolic blood pressure, or such arrhythmias as paroxysmal auricular fibrillation or flutter or paroxysmal tachycardia; and more than light manual labor was precluded. He would receive a 100 percent evaluation if his inactive rheumatic heart caused definite enlargement of the heart confirmed by roentgenogram and clinically; dyspnea on slight exertion; rales, pretibial pitting at the end of the day or other definite signs of beginning congestive failure; and more than sedentary employment was precluded. The veteran would also receive a 100 percent disability rating if he had active rheumatic heart disease with ascertainable cardiac manifestation for a period of 6 months. 38 C.F.R. § 4.104, Diagnostic Code 7000 (prior to December 11, 1997). Under the old diagnostic criteria for diseases of the heart, the subsequent progress of rheumatic heart disease, and the effect of superimposed arteriosclerotic or hypertensive changes cannot usually be satisfactorily disassociated or separated so as to permit differential service connection. 38 C.F.R. § 4.101 ( prior to December 11, 1997). Under the new diagnostic criteria for diseases of the heart, Diagnostic Code 7000 instructs that a 30 percent rating is assigned where there is valvular heart disease (documented by findings on physical examination and either echocardiogram, Doppler echocardiogram, or cardiac catheterization), resulting in a workload of greeter than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; there is evidence of cardiac hypertrophy or dilatation on electro-cardiogram, echocardiogram, or X-ray. A 60 percent rating is assigned where there is valvular heart disease resulting in more than one episode of acute congestive heart failure in the past year, or: workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 100 percent rating is assigned when there is valvular heart disease resulting in chronic congestive heart failure, or; workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent. A 100 percent rating can also be assigned during active infection with valvular heart damage and for three months following cessation of therapy for the active infection. 38 C.F.R. § 4.104, Diagnostic Code 7000 (effective December 11, 1997). NOTE (2) under Diseases of the Heart instructs that one MET (metabolic equivalent) is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 millimeters per kilogram of body weight per minute. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination of METs by exercise testing cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. 38 C.F.R. § 4.104 (effective December 11, 1997). If nonservice-connected arteriosclerotic heart disease is superimposed on service-connected valvular or other non- arteriosclerotic heart disease, a medical opinion as to which condition is causing the current signs and symptoms shall be requested. 38 C.F.R. § 4.104, note following Diagnostic Code 7005 (effective December 11, 1997). In examining the veteran's claim for an increased rating for rheumatic heart disease, the medical evidence shows that the veteran has a great deal of cardiovascular symptoms. The evidence from 1992 to the present shows that the veteran has had dyspnea and angina. A VA x-ray report from January 1998 noted mild cardiomegaly, and at the veteran's December 1998 VA examination, the examiner commented that as best he could determine, the veteran had an enlarged heart. When the veteran underwent a VA echocardiogram in June 1997, the estimated ejection fraction was only 35 to 40 percent. At the veteran's December 1998 VA examination, the examiner estimated that the veteran's workload would be somewhere in the neighborhood of only 2 METs or less. The question that must be resolved is whether the veteran's symptoms are attributable to his rheumatic heart disease, or to his nonservice-connected cardiovascular disorders, such as coronary artery disease, ischemia, and hypertension. At the veteran's June 1997 VA examination, the examiner opined that with all of the findings at the time of the examination, the veteran's disabilities were more related to his coronary artery disease and hypertension than to his rheumatic heart disease. It could be argued that such opinion is not definitive enough pursuant to 38 C.F.R. § 4.101 (regulation in effect prior to December 11, 1997, which notes that the effect of superimposed arteriosclerotic or hypertensive changes cannot usually be satisfactorily disassociated from rheumatic heart disease, so as to permit differential service connection), or pursuant to the note following Diagnostic Code 7005 of 38 C.F.R. § 4.104 (regulation in effect December 11, 1997, which notes that a medical opinion is needed when a nonservice-connected arteriosclerotic heart disease is superimposed on service- connected valvular or other non-arteriosclerotic heart disease). However, at the veteran's December 1998 VA examination, the examiner stated (after reviewing the veteran's claims file) that the veteran's symptoms and problems were much more likely to be related to his ischemia and coronary artery disease than they were to any rheumatic heart disease. As noted above, the veteran clearly has a number of manifestations of heart disease. However, these have been clearly attributed to the veteran's non-service connected cardiovascular disorders than to any rheumatic heart disease by the December 1998 examiner. Without a contrary medical opinion, the preponderance of the evidence is against an increased rating from service connected rheumatic heart disease. This case does not present such an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b). There have been no frequent periods of hospitalization for the veteran's rheumatic heart disease, and the evidence does not show marked interference with employment due solely to the rheumatic heart disease beyond the industrial impairment acknowledged by the schedular rating. Accordingly, under the criteria of Diagnostic Code 7000, effective December 11, 1997, and under the criteria of Diagnostic Code 7000, effective prior to December 11, 1997, and the provisions of 38 C.F.R. § 4.7, a rating higher than 30 percent is not warranted. In reaching the determination, consideration has been given to the provisions of 38 C.F.R. Parts 3 and 4, whether or not they were raised by the veteran, as required by Schafrath v. Derwinski, 1 Vet.App. 589 (1991). Specifically, the RO ordered special examinations to determine the extent of the veteran's rheumatic heart disease. The Board did not base its decision solely on a single VA examination as one of the major factors for consideration in this case. Therefore, the RO and the Board have considered all the provisions of Parts 3 and 4 that would reasonably apply in this case. In summary, the Board finds that the veteran has not met the criteria, under either the new or old schedular criteria, for an increased rating from 30 percent disabling for rheumatic heart disease. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not applicable, and the increased rating claim must be denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet.App. 49 (1990). ORDER An increased rating for rheumatic heart disease from 30 percent is denied. REMAND The law requires full compliance with all orders in this remand. Stegall v. West, 11 Vet. App. 268 (1998). Although the instructions in this remand should be carried out in a logical chronological sequence, no instruction in this remand may be given a lower order of priority in terms of the necessity of carrying out the instruction completely. Regarding the issue of entitlement to a TDIU, this issue was referred to the RO by the Board in October 1998. In a February 1999 supplemental statement of the case, the RO addressed the issue of a TDIU for the first time. The letter to the veteran informing him of this decision was mailed to the veteran on March 1, 1999. In the veteran's representative's March 1, 2000, written brief presentation, the appellant's representative expressed disagreement with the RO's February 1999 decision. The written brief presentation is construed as a timely NOD regarding the issue of a total rating. Accordingly, the Board is required to remand this issue to the RO for issuance of a statement of the case (SOC). See Manlicon v. West, 12 Vet. App. 238 (1999) As such, the issue of a TDIU should be REMANDED to the RO for the following action: The RO should issue a statement of the case concerning the issue of a TDIU. If, and only if, the veteran completes his appeal by filing a timely substantive appeal on the aforementioned issue should this claim be returned to the Board. See 38 U.S.C.A. § 7104(a) (West 1991). The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded to the regional office. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 1999) (Historical and Statutory Notes). In addition, VBA's Adjudication Procedure Manual, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44- 8.45 and 38.02-38.03. G. H. SHUFELT Member, Board of Veterans' Appeals