Citation NR: 9632464 Decision Date: 11/19/96 Archive Date: 12/02/96 DOCKET NO. 91-19 496 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUES 1. Entitlement to service connection for hemorrhoids. 2. Entitlement to an evaluation in excess of 20 percent disabling for lumbosacral strain. 3. Entitlement to a compensable evaluation for a ganglion of the right wrist. 4. Entitlement to an extension of temporary total evaluations based on hospitalization and/or convalescence, under the provisions of 38 C.F.R. §§ 4.29, 4.30 (1995), following periods of hospitalization from September to October 1989 and in January 1990. 5. Entitlement to a total disability rating for compensation on the basis of individual unemployability. REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL Appellant and his wife ATTORNEY FOR THE BOARD Jeffrey J. Schueler, Associate Counsel INTRODUCTION The veteran served on active duty from September 1961 to September 1963, and from April 1965 to January 1972. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a November 1990 rating decision of the Department of Veterans Affairs (VA) Los Angeles, California, Regional Office (RO). That determination denied the veteran’s claims of entitlement to an evaluation in excess of 20 percent for a lumbosacral strain, entitlement to an extension of a temporary total evaluation under either 38 C.F.R. § 4.29 or § 4.30 following a January 1990 hospitalization, and entitlement to total disability evaluation based on unemployability. The veteran appealed. In October 1991, the Board remanded the case. The Board referred to the veteran’s substantive appeal raising the issue of service connection for hemorrhoids and concluded that that issue was inextricably intertwined with those issues appealed. In December 1992, the Board again remanded the case for consideration to include entitlement to: service connection for hemorrhoids; an evaluation in excess of 20 percent disabling for lumbosacral strain; a compensable evaluation for a ganglion of the right wrist; temporary total evaluations based on hospitalization and/or convalescence related to periods of hospitalizations in 1989 and in 1990; a total disability rating for compensation on the basis of individual unemployability; and a clothing allowance. After development action by the RO, the case is again before the Board for appellate consideration. At the October 1991 remand the veteran was represented by Disabled American Veterans, and at the December 1991 remand by Veterans of Foreign Wars of the United States. In April 1994, the record shows a letter from a private attorney claiming the represent the veteran in his appeal. However, a copy of a VA Form 21-22, Appointment of Veterans Service Organization as Claimant’s Representative, is of record showing that the veteran appointed The American Legion as his accredited representative in September 1994. Also of record is a copy of a VA Form 21-22, received in October 1996, showing appointment of The American Legion as the accredited representative in June 1992. A specific claim for VA benefits may be prosecuted at any one time by only one recognized organization, attorney, or agent. 38 C.F.R. § 20.601. In light of the facts that the September 1994 appointment was made after the date of the April 1994 letter from the private attorney, and that no subsequent communication has been received from the private attorney, The American Legion must be considered the veteran’s authorized representative. Following the issuance of a supplemental statement of the case in August 1995, additional evidence was submitted in April and October 1996 concerning the issues on appeal. This additional evidence was accompanied by statements, signed by the veteran, waiving initial RO consideration. See 38 C.F.R. § 20.1304(c). In November 1994, the RO granted the veteran a temporary total rating under 38 C.F.R. § 4.30 for surgery on his back that necessitated more than one month convalescence. The veteran filed a notice of disagreement requesting an extension of the total disability rating and a statement of the case was issued in August 1995. However, the record does not contain a substantive appeal as to this issue. “An appeal consists of a timely filed Notice of Disagreement in writing and, after a Statement of the Case has been furnished, a timely filed Substantive Appeal.” 38 C.F.R. § 20.200 (emphasis added). Since the veteran’s and his representative’s statements filed subsequent to the August 1995 statement of the case do not refer to a claim for an extension of § 4.30 benefits, that issue is not developed for appellate review and the Board does not have jurisdiction. The veteran’s representative, in an October 1996 statement, noted the “failure of the [RO] to certify the veteran’s appeal upon its return to the Board, in accordance with the accepted provisions of VA Adjudication Procedure Manual, M21- 1 . . . .” The representative argued that the VA was not free to ignore the provisions of the M21-1 since such provisions are the equivalent of regulations, and requested that the Board address this “procedural abnormality.” As noted above, an appeal consists of a timely filed notice of disagreement in writing and, after a statement of the case has been furnished, a timely filed substantive appeal. 38 C.F.R. § 20.200. As demonstrated in the October 1991 and December 1992 remands, these requirements have been met for the issues on appeal. The representative’s discussion of M21-1 has no bearing on the appellate jurisdiction of the Board. In an April 1995 determination, the RO established entitlement to an annual clothing allowance effective August 1, 1994. As such, since this represents a grant of the benefit sought on appeal, that issue is no longer for appellate consideration. Though the veteran, in an August 1995 statement, requested an earlier effective date for assigning a clothing allowance, that matter has not been developed for appellate review and is referred to the RO for consideration. The issues of entitlement to an evaluation in excess of 20 percent for lumbosacral strain and entitlement to a total disability rating for compensation on the basis of individual unemployability are addressed in the Remand section of this decision. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends initially that he was treated for hemorrhoids during service in 1962 and that he continues to require treatment for hemorrhoids today. He asserts that the symptomatology demonstrated currently is related to that first noted in service. In addition, the veteran maintains that his service-connected right wrist disability warrants a compensable evaluation. The veteran further argues that following his September to October 1989 and January 1990 hospitalizations, he required convalescence for which additional compensations is due under 38 C.F.R. § 4.29 and/or § 4.30. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991 & Supp. 1996), has reviewed and considered all of the evidence and material of record in the veteran's claims file. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board: that the veteran has not met the initial burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that his claim for service connection for hemorrhoids is well grounded; that the preponderance of the evidence is against the claim of entitlement to a compensable evaluation for ganglion of the right wrist; and that the evidence supports entitlement to three month extensions of temporary total evaluations under the provisions of 38 C.F.R. § 4.29, following the periods of hospitalization, from September to October 1989 and in January 1990. FINDINGS OF FACT 1. No competent evidence has been submitted that links the post-service findings of hemorrhoids to service. 2. With respect to the issues of entitlement to a compensable evaluation for a ganglion of the right wrist and temporary total evaluations based on hospitalization and/or convalescence related to periods of hospitalizations in 1989 and in 1990, all available relevant evidence necessary for an equitable disposition of the veteran’s appeal has been obtained by the RO insofar as possible. 3. The veteran’s ganglion of the right wrist does not result in more than slight dysfunction and is not manifested by superficial scars, poorly nourished with repeated ulcerations or tender and painful scarring on objective demonstration. 4. The evidence reflects that a period of convalescence was required for three months following the veteran’s September to October 1989 hospitalization. 5. The evidence reflects that a period of convalescence was required for three months following the veteran’s January 1990 hospitalization. CONCLUSIONS OF LAW 1. The claim for service connection for hemorrhoids is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 2. The criteria for a compensable evaluation for ganglion of the right wrist are not met. 38 U.S.C.A. §§ 1155, 5107(a) (West 1991); 38 C.F.R. §§ 4.2, 4.10, 4.40, 4.71, 4.71a, 4.118, Diagnostic Codes 5215, 7803, 7804 (1995). 3. The criteria for three month extensions of temporary total evaluations under the provisions of 38 C.F.R. § 4.29, following periods of hospitalization from September to October 1989 and in January 1990, are met. 38 U.S.C.A. §§ 1155, 5107(a) (West 1991); 38 C.F.R. §§ 4.29, 4.30 (1995). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Hemorrhoids Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by wartime service. 38 U.S.C.A. § 1110 (West 1991); 38 C.F.R. § 3.303 (1995). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (1995). The threshold question that must be resolved with regard to a claim is whether the veteran has presented evidence of a well-grounded claim. See 38 U.S.C.A. § 5107(a) (West 1991); Murphy v. Derwinski, 1 Vet.App. 78, 81 (1990). A well- grounded claim is a plausible claim that is meritorious on its own or capable of substantiation. See Murphy, 1 Vet.App. at 81. An allegation of a disorder that is service connected is not sufficient; the veteran must submit evidence in support of a claim that would “justify a belief by a fair and impartial individual that the claim is plausible.” See 38 U.S.C.A. § 5107(a); Tirpak v. Derwinski, 2 Vet.App. 609, 611 (1992). The quality and quantity of the evidence required to meet this statutory burden of necessity will depend upon the issue presented by the claim. Grottveit v. Brown, 5 Vet.App. 91, 92-93 (1993). In order for a claim to be well grounded, there must be competent evidence of a current disability (a medical diagnosis); of incurrence or aggravation of a disease or injury in service (lay or medical evidence); and of a nexus between the in-service injury or disease and the current disability (medical evidence). Caluza v. Brown, 7 Vet.App. 498 (1995). Where the determinant issue involves a question of medical diagnosis or medical causation, competent medical evidence to the effect that the claim is plausible or possible is required to establish a well-grounded claim. Grottveit v. Brown, 5 Vet.App. 91, 93 (1993). Lay assertions of medical causation cannot constitute evidence to render a claim well grounded under 38 U.S.C.A. § 5107(a) (West 1991); if no cognizable evidence is submitted to support a claim, the claim cannot be well grounded. Id. The September 1961 service entrance medical examination report showed a normal anus and rectum clinical evaluation. Review of the service medical records shows a notation of “hemorrhoid” in a January 1962 service clinical record. When the veteran separated from his first period of service, a July 1963 service separation medical examination report showed a normal anus and rectum clinical evaluation. The veteran did note that he had had piles about six months previously with “no trouble since.” When the veteran reentered the service, the April 1965 service entrance medical examination report showed a normal anus and rectum clinical evaluation, and the veteran reported that he had not had piles or rectal disease. The October 1971 service medical board examination report also noted a normal anus and rectum clinical evaluation. The veteran reported that he had or had had piles or rectal disease, and it is noted that this referred to occasional hemorrhoids. In an October 1988 VA clinical record, it was noted as past medical history that the veteran had a hemorrhoidectomy. The records of January 1990 and April 1991 VA hospitalizations show notations of past surgical history including a hemorrhoidectomy in 1982. In a February 1992 VA examination report, internal and external hemorrhoids were diagnosed. The examiner described extreme tenderness in all parts of the anal canal and that internal hemorrhoids were palpable and were possibly one half inch in diameter. The examiner noted that the veteran first had bleeding hemorrhoids in 1962 for which he was treated with anal suppositories and Sitz baths. The examiner continued that in 1977 the veteran was told that there were also anal fissures, and that in 1981 the veteran was hospitalized for surgical removal of three hemorrhoids as “large as golf balls;” the veteran was told that three or four smaller hemorrhoids were not removed. The hemorrhoids have been prolapsing since that surgery and also before the surgery. In addition the examiner reported that the veteran had severe pain when prolapse occurred two to three times per month, such that he has to go to bed for up to three days. In a later February 1992 VA clinical record, sigmoidoscopy revealed severe internal hemorrhoids and a polyp. In an August 1992 personal hearing, the veteran testified that he first developed hemorrhoids in 1962 in service and that he had a hemorrhoidectomy in 1982. He stated that after the 1962 removal of hemorrhoids he could still feel something, and that he has had recurring treatment since that time. He noted that use of Preparation H was not effective. Review of the service medical records shows that the first element of a well grounded claim has been satisfied; a January 1962 service clinical record shows a notation of “hemorrhoid.” And clearly the February 1992 VA examination report and February 1992 VA clinical record shows evidence of current severe hemorrhoids. See Caluza, 7 Vet.App. at 506 (well grounded claim requires competent evidence of a current disability and of incurrence or aggravation of a disease or injury in service). In this case, however, there is no competent evidence of record to support the contention that there is a relationship between the veteran’s active service and his current disability. Id. When the veteran separated from his first period of service, the July 1963 service separation medical examination report showed a normal anus and rectum clinical evaluation. The veteran did note that he had had piles about six months previously with “no trouble since.” When the veteran reentered the service, the April 1965 service entrance medical examination report showed a normal anus and rectum clinical evaluation, and the veteran reported that he had not had piles or rectal disease. The October 1971 service medical board examination report also noted a normal anus and rectum clinical evaluation, although reference was made to occasional hemorrhoids. The evidence appears to show that the veteran underwent a hemorrhoidectomy in 1982, as the veteran has described in various statements; however, no evidence has been submitted concerning that surgery, despite the RO’s January 1993 letter to the veteran specifically requesting such information and the various statement and supplemental statements of the case providing the veteran with notice of the nature of the decisions and the evidence considered. A document significant to the veteran’s claim is the February 1992 VA examination report, wherein the examiner noted that the veteran first had bleeding hemorrhoids in 1962, that in 1977 the veteran was told that there were also anal fissures, and that in 1982 the veteran was hospitalized for surgical removal of three hemorrhoids as “large as golf balls.” The examiner did not cite specific clinical records clearly recording history as recalled by the veteran. Moreover, the examiner never discussed whether the current symptomatology was related to that in service or in 1977 or 1982. The evidence must include competent medical evidence of a nexus between the in-service injury or disease and the current disability. Id. The evidence of record, establishing only a current disorder and symptomatology in service, simply does not establish such a link. The Board recognizes the veteran’s August 1992 personal hearing testimony to the effect that the veteran first developed hemorrhoids in 1962 and had a hemorrhoidectomy in 1982. However, the veteran’s testimony contending a relationship between current hemorrhoids and symptomatology in service does not constitute expert testimony so as to establish a link from that current disorder to service. Because the evidence does not establish such a nexus, the claim is not well grounded. Because the claim is not well grounded, the VA is under no duty to assist the veteran in further development of the claim. 38 U.S.C.A. § 5107(a); Murphy v. Derwinski, 1 Vet.App. 78 (1990). Although where claims are not well grounded the VA does not have a statutory duty to assist the claimant in developing facts pertinent to the claim, the VA may be obligated under 38 U.S.C.A. § 5103(a) to advise a claimant of evidence needed to complete the application. This obligation depends upon the particular facts of the case and the extent to which the VA has advised the claimant of the evidence necessary to be submitted with a VA benefits claims. Robinette v. Brown, 8 Vet.App. 69 (1995) In this case, the RO fulfilled its obligation under § 5103(a) in the January 1993 VA letter to the veteran requesting that he furnish all postservice treatment records concerning hemorrhoids, and in various statements and supplemental statements of the case in which the appellant was informed that the reason for the denial of the claim was the lack of evidence establishing a nexus between his current hemorrhoid disorder and service. Furthermore, by this decision, the Board is informing the appellant of the evidence which is lacking and that is necessary to make the claim well- grounded. II. Duty to Assist As to the issues of entitlement to a compensable evaluation for a ganglion of the right wrist and temporary total evaluations based on hospitalization and/or convalescence related to periods of hospitalizations in 1989 and in 1990, the Board finds initially that the appellant's claims are well-grounded within the meaning of 38 U.S.C.A. § 5107(a); that is, the claims are not inherently implausible. The Board also finds that the VA has satisfied its statutory obligation to assist the veteran in the development of facts pertinent to the claims. 38 U.S.C.A. § 5107(a). In October 1991 and December 1992, the Board remanded these claims to the RO for additional evidentiary development. That mandated development has been accomplished to the extent possible. On appellate review, the Board sees no areas in which further development may be fruitful with respect to these issues. III. Increased Rating for a Right Wrist Disability Historically, service medical records reveal a ganglion of the right wrist, the veteran’s major wrist, which was removed in July 1963. VA examination in May 1979 showed a one and a half inch scar on the volar aspect of the right wrist. Service connection was granted in a July 1979 rating decision for residuals of a ganglion of the right wrist, assigned a noncompensable evaluation. Following an October 1981 VA examination report showing no current neurological deficit, the Board, a September 1982 decision, denied a claim for a compensable evaluation for the disability. Disability evaluations are determined by the application of a schedule of ratings based on average impairment in earning capacity. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. Part 4 (1995). In evaluating claims for increased ratings, the Board must evaluate the veteran’s condition with a critical eye towards the lack of usefulness of the body or system in question to self support. 38 C.F.R. § 4.10 (1995). 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. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet.App. 55 (1995). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity or the like. 38 C.F.R. § 4.40 (1995). In a May 1991 VA x-ray report, the impression was mild degenerative changes at the first carpo-metacarpal and second and questionably third metacarpophalangeal joints, and there are degenerative changes with some element of subluxation (“gamekeeper’s thumb”) at the first metacarpophalangeal articulation. In a December 1991 VA examination report, it was noted as past medical history that the veteran had secondary weakness associated with the removal of the right wrist ganglion. Examination revealed motor strength 5-/5 at right wrist extension and 4+/5 at right wrist flexion. The assessment was right wrist weakness secondary to ganglion of the right wrist. In a February 1993 VA examination report, it was noted that the veteran wore a splint on his right wrist which did not show much wear and tear and looked like it was seldom worn. The veteran indicated that he injured the right wrist in service resulting in surgery in 1963 and again in 1976 for arthritis, at which time some plastic was inserted into the joint. There was a transverse scar, soft and pliable, one and a quarter inch long following the flexion crease of the right wrist. Tapping on the transverse carpal ligament caused no discomfort on either side. Range of motion measurements for the right wrist were as follows: dorsiflexion 45 degrees; palmar flexion 60 degrees; ulnar deviation 35 degrees; and radial deviation 25 degrees. The impression was residuals of fracture of the right wrist and status following insertion of wrist bone, right, artificial. The diagnosis was mild spurring of the wrists bilaterally. In a February 1993 VA x-ray report, the impression was mild degenerative changes of the bones of the wrist, including mild sclerosis of the articular surfaces of the carpal bones with small localized well circumscribed areas of bone demonstration involving the capitate bone. The joint spaces, however, were not grossly narrowed and the rest of the visualized structure were not remarkable. The veteran’s disability is currently assigned a noncompensable evaluation analogously under Diagnostic Code 5215 for limitation of motion of the wrist. Using Diagnostic Code 5215, the disability may be assigned a 10 percent evaluation for either the major or minor wrist where the evidence shows dorsiflexion less than 15 degrees or palmar flexion limited in line with forearm. See 38 C.F.R. §§ 4.20, 4.71a. In every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. As noted in the February 1993 VA examination report, dorsiflexion was measured at 45 degrees, far more than the “less than 15 degrees” required for a 10 percent evaluation under Diagnostic Code 5215. That examination also noted that palmar flexion was measured at 60 degrees, which does not correspond to palmar flexion limited in line with the forearm. As such, a compensable evaluation is not warranted under Diagnostic Code 5215. The Board notes that the February 1993 VA examination report findings show less motion than described in the standardized description of wrist joint motion found at Plate I of 38 C.F.R. § 4.71. However, much of the veteran’s symptomatology appears to be due to an old fracture and arthritis of the right wrist that are not service-connected. The notation of mild weakness in the left wrist in December 1991 is noted, and the examination, per the veteran’s history, attributed the weakness to the ganglion removal. However, the February 1993 VA examination makes it clear that the veteran fractured or at least injured his right wrist at another time that required surgery and insertion of “plastic” into the joint. He currently has arthritis of the wrist, but the scarring is asymptomatic. Diagnostic Codes 7803 to 7804 provide for compensable evaluations for superficial, poorly nourished scars with repeated ulceration, and for superficial scars tender and painful on objective demonstration. There is no evidence, however, that the veteran’s scar on the right wrist manifests such symptoms; in fact, the veteran testified at the August 1992 hearing that the scar tissue was healed and the February 1993 VA examination report indicated that the transverse scar was soft and pliable. In short, the scar is not painful, tender, or otherwise symptomatic. The Board recognizes the veteran’s August 1992 hearing testimony and his complaints of pain, numbness, and weakness in his grip, as well as the clinical evidence of numbness and weakness and mild degenerative changes in the right wrist. The evidence of record, however, does not demonstrate that the symptomatology associated with the service-connected disability here on appeal is compensably disabling. The preponderance of the evidence is against the claim of entitlement to a compensable evaluation for a ganglion of the right wrist. IV. Temporary Total Ratings Following 1989 and 1990 Hospitalizations VA clinical records show that the veteran was hospitalized on September 20, 1989, through October 23, 1989, for more than 21 days for treatment of his service-connected lumbosacral strain disability. In an April 1990 rating decision, the RO granted the veteran a temporary total evaluation under 38 C.F.R. § 4.29, effective September 20, 1989, through October 31, 1989. Thereafter, the 20 percent schedular evaluation was assigned effective November 1, 1989. Evidence of record also shows that the veteran was hospitalized from January 3, 1990, through January 26, 1990, for more than 21 days for treatment of his service-connected lumbosacral strain disability. In a July 1990 rating action, the RO granted a temporary total disability rating under 38 C.F.R. § 4.29, effective January 3, 1990. The 20 percent schedular evaluation was again assigned effective February 1, 1990. The veteran claims that his temporary total evaluations should be extended under the provisions of 38 C.F.R. §§ 4.29, 4.30. In his August 1992 hearing testimony, the veteran and his wife stated that he was hospitalized in September 1989 and January 1990, each in excess of 21 days, primarily for treatment of his low back disability. The veteran and his wife indicated that the veteran required convalescence for his back treatment into May 1991. Initially, it is noted that a total disability rating will be assigned under 38 C.F.R. § 4.30 if treatment of a service- connected disability resulted in: (1) surgery necessitating at least one month of convalescence; (2) surgery with severe postoperative residuals such as incompletely healed surgical wounds, stumps of recent amputations, therapeutic immobilization of one major joint or more, application of a body cast, or the necessity for house confinement, or the necessity for continued use of a wheelchair or crutches (regular weight-bearing prohibited); (3) immobilization by cast, without surgery, of one major joint or more. 38 C.F.R. § 4.30(a). Extensions may be granted under § 4.30(a)(1), (2), or (3). 38 C.F.R. § 4.30(b). There is no documentation in the record that the veteran underwent surgery in the September to October 1989 hospitalization or that he was immobilized by cast without surgery during that hospitalization. Nor do the records associated with the January 1990 hospitalization indicate that the veteran underwent surgery or was immobilized by cast without surgery during that hospitalization. Surgery or immobilization by cast without surgery of a service-connected disability are predicate elements of entitlement to benefits under § 4.30. Therefore, extension of temporary total disability benefits under § 4.30 is not warranted. Under 38 C.F.R. § 4.29, a total disability rating will be assigned without regard to other provisions of the rating schedule when it is established that a service-connected disability has required hospital treatment in a VA or an approved hospital for a period in excess of 21 days or hospital observation at VA expense for a service-connected disability for a period in excess of 21 days. 38 C.F.R. § 4.29. This increased rating will be effective the first day of continuous hospitalization and will be terminated effective the last day of the month of hospital discharge or effective the last day of the month of termination of treatment or observation for the service-connected disability. Id. § 4.29(a). The temporary total evaluation assigned following the September to October 1989 and the January 1990 hospitalizations was assigned under § 4.29, and made effective through October 31, 1989. The total hospital rating if convalescence is required may be continued for periods of one, two, or three months in addition to the period provided for in § 4.29(a). 38 C.F.R. § 4.29(e). Extensions of periods of one, two, and three months beyond the initial three months may be made upon approval by the Adjudication Officer. 38 C.F.R. § 4.29(f). With respect to the September to October 1989 period of hospitalization, a period of more than 21 days, on October 23, 1989, the veteran was discharged in order to have surgery for a growth on a bone in his thigh, which is a nonservice- connected disorder. In an October 1989 VA progress note prepared while the veteran was still hospitalized, an examiner reported that the veteran was being treated primarily for his lumbosacral strain and that the disability should end sufficiently for the veteran to resume regular and customary work in approximately six months. Thereafter, the veteran was admitted to a VA medical facility in November 1989 for treatment of a nonservice-connected disability. The October 1989 entry reflecting the need for convalescence is unrefuted. Since the veteran was again admitted to a VA medical facility for treatment of the lumbosacral strain disability on January 3, 1990, an extension of § 4.29 benefits of three months is granted to cover the period from November 1, 1989, through January 2, 1990. As to the January 1990 period of hospitalization, the discharge summary did not specify a return-to-work date, but a VA progress note dated January 26, 1990, showed that the approximate date the disability should end sufficient for the veteran to resume regular or customary work was June 1990. The record shows various VA physical therapy notes in January through April 1990 discussing therapy for his low back pain and right femur pain, which in April 1990 indicated that the veteran was expected to continue therapy for the next two months. However, in a June 1990 VA progress note, an examiner reported that medical care was not completed pending further evaluation on the veteran’s back after his leg healed, and that the veteran was not to return to work due to non-weight bearing status post osteoma resection and low back pain. The VA physical therapy notes during this period, from June to December 1990, indicate that the veteran’s attendance at physical therapy was “sporadic.” The evidence summarized above clearly indicates that the veteran required convalescence following the January 1990 hospital discharge. The veteran continued to attend physical therapy sporadically. Though treatment was for low back and nonservice-connected disability, it is not entirely clear that convalescence was not necessary due solely to the service-connected disability. It is the Board’s decision that an extension of § 4.29 benefits should be granted for three additional months, to cover the period from February 1, 1990, through April 30, 1990. Any further extensions under § 4.29(f) may be made upon approval of the RO. ORDER Entitlement to service connection for hemorrhoids is denied. Entitlement to a compensable evaluation for a ganglion of the right wrist is denied. Entitlement to an three month extensions of temporary total evaluations under the provisions of 38 C.F.R. § 4.29 following periods of hospitalizations from September to October 1989 and in January 1990, are granted. REMAND As to the claim of entitlement to an evaluation in excess of 20 percent for lumbosacral strain, the May 1995 VA examination report is inadequate for rating purposes. The examination report does not refer to any objective demonstration of pain, nor were active or passive range of motion studies conducted. The report itself refers to the veteran as a female and does not recite sufficient findings to evaluate the disability. With respect to the claim of entitlement to a total disability rating based on individual unemployability, in a March 1995 statement the veteran stated that he was “totally disabled” and was injured at the VA Hospital at Long Beach, California, in 1989. This statement gives rise to a claim under 38 U.S.C.A. § 1151 (West 1991). A successful claim of additional disability pursuant to 38 U.S.C.A. § 1151 would necessarily impact his claim of total disability based on individual unemployability. As such, the claims are inextricably intertwined, see Harris v. Derwinski, 1 Vet.App. 180 (1991), and the claim of entitlement to a total disability rating for compensation on the basis of individual unemployability is remanded to the RO for development as specified below. To ensure that the VA has met its duty to assist the claimant in developing the facts pertinent to the claim and to ensure full compliance with due process requirements, the case is REMANDED to the RO for the following development: 1. The RO should request that the veteran supply the names and addresses of any individuals of treatment facilities that have treated him for lumbosacral strain and any other service-connected disability since May 1995, the date of his most recent VA examination, and the dates of such treatment. After securing any necessary releases, the RO should obtain complete clinical records of such treatment and associate them with the claims folder. 2. The veteran should be afforded VA orthopedic and neurologic examinations to determine the nature and severity of his service-connected lumbosacral strain. The claims folder should be made available to the examiner for review before the examination. All indicated tests and studies should be conducted, including active and passive range of motion studies, and straight leg raising in the supine and sitting positions. Any objective evidence of pain should be reported. The examiner should be specifically requested to comment on the presence or absence of muscle spasm, limited motion, loss of lateral motion with osteo-arthritic changes, narrowing or irregularity of joint spaces, abnormal mobility on forced motion, ankylosis, sciatic neuropathy, pain, absent ankle jerk, and other neurological or orthopedic findings. All examination findings should be prepared into typewritten reports and associated with the claims file. 3. The RO should review the record to ensure that all VA clinical and hospital records concerning treatment at the Long Beach, California, VA Medical Center in 1989 are of record. If such documentation is not of record, the RO should take appropriate action to obtain all clinical and hospital reports concerning the veteran from the Long Beach, California, VA Medical Center, prepared during 1989. 4. After the development above has been completed to the extent possible, the RO should again review the record and render decisions on the issues of entitlement to an evaluation in excess of 20 percent for lumbosacral strain, entitlement to a total disability rating for compensation on the basis of individual unemployability, and entitlement to benefits under 38 U.S.C.A. § 1151. If any benefit sought, for which a timely appeal 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. THOMAS J. DANNAHER Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, 741 (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991 & Supp. 1995), a decision of the Board of Veterans’ Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans’ Judicial Review Act, Pub. L. No. 100-687, § 402, 102 Stat. 4105, 4122 (1988). The date that appears on the face of this decision constitutes the date of mailing and the copy of this decision that you have received is your notice of the action taken on your appeal by the Board of Veterans’ Appeals. Appellate rights do not attach to those issues addressed in the remand portion of the Board’s decision, because a remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (1995). - 2 -