Citation NR: 9606460 Decision Date: 03/14/96 Archive Date: 03/16/96 DOCKET NO. 92-19 918 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to an increased evaluation for service- connected post-traumatic stress disorder, currently evaluated as 30 percent disabling. 2. Entitlement to a compensable evaluation for scar of the right thigh as a residual of shell fragment wound. 3. Whether new and material evidence has been submitted to reopen a claim of entitlement to service connection for residuals of a left knee injury. 4. Entitlement to service connection for arthritis. 5. Entitlement to service connection for a skin disorder due to Agent Orange exposure. 6. Entitlement to service connection for a gastro-intestinal disorder claimed as secondary to service-connected post- traumatic stress disorder. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD C. Chaplin, Associate Counsel INTRODUCTION The veteran had active service from March 1966 until February 1968. He received the Purple Heart for wounds received in combat action on November 2, 1967. This matter came before the Board of Veterans’ Appeals (Board) on appeal from a rating decision of August 1990, from the Nashville, Tennessee, regional office (RO) which granted service connection for post-traumatic stress disorder (PTSD), and assigned an evaluation of 10 percent disabling; and denied service connection for a left knee injury; exposure to Agent Orange; and arthritis. This matter further arises from a rating decision of June 1991 which granted service connection for scar of the right thigh as residuals of a shell fragment wound and assigned a noncompensable evaluation. In Nehmer v. United States Veterans Administration, 712 F. Supp. 1404 (N.D. Cal., May 2, 1989), a United States District Court voided all benefit denials under 38 C.F.R. § 3.311a, the “dioxin” (Agent Orange) regulation, which was promulgated under the “Dioxin and Radiation Exposure Compensation Standards Act,” 38 U.S.C.A. § 1154(a) (West 1991), and remanded the case to the Department of Veterans Affairs for revision of the regulation in accordance with the ruling of the Court. Final regulations were promulgated by VA in February 1994, and in May 1994 the Board remanded the issue of service connection for a skin disorder due to exposure to Agent Orange to be reviewed in its entirety with consideration of the new regulations. The RO, in an December 1994 rating decision, denied the appellant’s claim for service connection for service connection for a skin disorder due to exposure to Agent Orange after considering the new regulations. Although the veteran, through his representative, claims that the agency of original jurisdiction has not adjudicated the issue of service connection for a left knee disability as being secondary to the veteran’s service-connected residuals shell fragment wound to the right thigh, we would refer to rating decision dated in March 1995 which included a decision on this claim. The issue of service connection for a gastro-intestinal disorder claimed as secondary to service-connected post- traumatic stress disorder was not certified for appeal; however, we find that the issue was developed for appellate review. After the March 1995 rating decision denying entitlement to service connection for a gastro-intestinal disorder as secondary to service-connected post-traumatic stress disorder, the veteran expressed his disagreement with this decision, and through his representative filed a substantive appeal. This issue will be discussed in the Remand portion of this decision. CONTENTIONS OF APPELLANT ON APPEAL The appellant contends that the RO erred in not granting a higher evaluation for service-connected PTSD and service- connected scar of the right thigh as a residual of shell fragment wound; and in not granting service connection for arthritis, Agent Orange exposure, and a left knee injury. He contends that loud noises cause a great degree of distress to the point of not being able to concentrate on his work for a period of some time. He also points out that he is being prescribed strong medication for PTSD on a continuing basis. He claims that the wound for which he received the Purple Heart was to his left knee and as a result of the trauma, arthritis has developed. He further claims that he still has a rash on his feet and his hands crack open, bleed and itch, due to the condition of systemic dermatophytosis. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991 & Supp. 1995), has reviewed and considered all of the evidence and material of record in the veteran’s claims file. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the preponderance of the evidence is against an increased evaluation for service- connected post-traumatic stress disorder. Further, it is the decision of the Board that the evidence supports a 10 percent disability evaluation for service- connected scar of the right thigh as a residual of shell fragment wound. Further, it is the decision of the Board that the appellant has not submitted evidence of a well-grounded claim for either entitlement to service connection for a skin condition as a result of exposure to Agent Orange, or for entitlement to service connection for arthritis. Further, it is the decision of the Board that new and material evidence has not been submitted to reopen a claim of entitlement to service connection for residuals of a left knee injury. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the appeal for an increased evaluation for post-traumatic stress disorder, and for a compensable evaluation of scar of the right thigh as residual of shell fragment wound has been obtained by the agency of original jurisdiction. 2. The manifestations of the veteran’s post-traumatic stress disorder result in definite social and industrial impairment. 3. Residuals of the shell fragment wound to the right thigh include a slight scar, retained foreign bodies, and limitation of extension to 10 degrees. 4. Neither an exceptional nor unusual disability picture has been presented so as to render impractical the application of the regular schedular standards for the evaluation of post- traumatic stress disorder and for scar of the right thigh as residual of shell fragment wound. 5. The veteran had active service in Vietnam during the Vietnam era. 6. A skin disorder was not shown in service. No competent medical evidence has been submitted establishing a link between a history of a skin disorder and exposure to Agent Orange. 7. There is no competent medical evidence of a current skin disorder. 8. Service medical records show no complaint of, treatment for, or diagnosis of arthritis. No evidence was submitted showing manifestations of arthritis during the applicable presumptive period. 9. No competent medical evidence has been submitted establishing a link between any incident of service including the shell fragment wound to the right knee with retained foreign bodies and the current rheumatoid arthritis. 10. Entitlement to service connection for a left knee injury was denied by the RO in August 1984 and the veteran did not complete his appeal. 11. The evidence received since the RO’s 1984 decision either is cumulative or evidence previously considered, does not bear directly or substantially upon the specific matter under consideration or is not probative of the instant issue, in that it does not present a reasonable possibility that, when considered in the context of all the evidence, it would change the outcome of the case. CONCLUSIONS OF LAW 1. The criteria for a disability evaluation greater than 30 percent for post-traumatic stress disorder have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. § 3.321(b)(1), Part 4, Diagnostic Code 9411 (1995). 2. The criteria for a 10 disability evaluation for scar of the right thigh as residual of shell fragment wound have been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. Part 4, Diagnostic Codes 5261, 7805 (1995). 3. The appellant has not submitted evidence of a well- grounded claim for entitlement to service connection for a skin disorder claimed as due to exposure to herbicide agents used in Vietnam. 38 U.S.C.A. §§ 1110, 5107 (West 1991); 38 C.F.R. §§ 3.303, 3.307, 3.309 (1995). 4. The appellant has not submitted evidence of a well grounded claim for service connection for arthritis. 38 U.S.C.A. §§ 1110, 5107 (West 1991); 38 C.F.R. § 3.303, 3.307, 3.309 (1995). 5. Evidence received since the RO’s decision in August 1984 denying entitlement to service connection for a left knee injury is not new and material and the veteran’s claim for that benefit has not been reopened. 38 U.S.C.A. §§ 5108, 7104 (West 1991); 38 C.F.R. § 3.156, 20.1105 (1995). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Increased evaluations By a rating action in August 1990, the veteran was granted service connection for PTSD which was evaluated as 10 percent disabling, and by a rating action in December 1994 the evaluation was increased to 30 percent disabling. By a rating action in June 1991, service connection was granted for scar of the right thigh as a residual of shell fragment wound, and evaluated as noncompensable. The veteran disagreed with the evaluations and is appealing the original assignment of a disability rating. The initial assignment of a rating following the award of service connection is part of the original claim. See West v. Brown, 7 Vet.App. 329, 332 (1995) (en banc) (“successful claimant has not had his case fully adjudicated until there is a decision as to all essential elements, i.e., status, disability, service connection, rating, and when in question, effective date”). In light of the above, the United States Court of Veterans Appeals (Court) held that when a claimant was awarded service connection for a disability and subsequently appealed the RO’s initial assignment of a rating for that disability the claim continued to be well grounded as long as the rating schedule provided for a higher rating and the claim remained open. Shipwash v. Brown, 8 Vet.App. 218 (1995). Accordingly, the Board finds the claim for an increased rating for service-connected post traumatic stress disorder and for a compensable rating for scar of the right thigh as a residual of shell fragment wound to be well-grounded. Furthermore, he has not indicated that any probative evidence not already associated with the claims folder is available; therefore the duty to assist him has been satisfied. 38 U.S.C.A. 5107(a) (West 1991). A. Post traumatic stress disorder Background Evidence reviewed included the outpatient records for February and March 1990 from the psychiatric clinic at a Department of Veterans Affairs (VA) medical center. The veteran was being treated and followed for problems of insomnia, nightmares, depression, crying without reason, reduced interest, not wanting to be around people, and recurrent dreams of Vietnam. The veteran was afforded a psychiatric examination in July 1990. His complaints were sleep disturbance with difficulty getting to sleep, and nightmares two to three times a week. He described no discrete episodes of flashbacks, but reported that whenever he hears a gun fire or a helicopter, he becomes very anxious. He avoids reminders of Vietnam. He related that he had worked as a butcher until his rheumatoid arthritis prevented him from continuing in that occupation. He was diagnosed with rheumatoid arthritis in 1988. He then worked as a part time real estate agent and also measured houses for a construction company. The examiner noted the veteran was oriented as to time, place, and person with no evidence of delusions or hallucinations. The examiner observed the mood and affect to be one of a chronic, moderate depression with mixtures of anxiety. The diagnosis was chronic PTSD. The examiner opined “social and industrial impairment secondary to Axis I diagnosis is considered to be slight to definite.” Outpatient treatment records for the period from September 1990 to January 1992 show that the veteran was having difficulty sleeping. In April 1991, he reported that during Desert Storm, he dreamed he was bombed by the enemy. He had increased depression and was very frightened. He would awaken and not be able to fall back to sleep. In August 1991, the veteran reported doing fairly well. The entry noted he still had nightmares; some daytime anxiety; and no significant depression. In December 1991, he reported early morning awakening three to four times a week. He had frightening dreams, and during the daytime, thoughts about the war. An entry in January 1992 noted that the treatment plan was to continue as the symptoms were not resolved. The veteran was afforded a VA psychiatric examination in June 1992. The report noted that the veteran had been followed in the Neuro-psychiatric outpatient clinic. The veteran stated that he no longer received psychiatric medication. The veteran maintained that his gastro-intestinal symptoms and bleeding ulcer were consequences of his chronic stress and anxiety and therefore were complications of his post- traumatic stress disorder. He stated that frequently at night he is awakened by dreams of Vietnam, but he did not provide additional details. Since the previous examination, he has had no psychiatric admissions for his symptoms of post-traumatic stress disorder. The examiner found the veteran oriented as to time, place, and person, showing no evidence of delusion, hallucination, or thought disorder. Memory for recent and remote events remained intact. Mood and affect remained one of a chronic mild pervasive mixture of anxiety and depression with the impairability (sic) [impaired ability?] to be spontaneous in terms of comments and statements about his symptoms in his current life. The examiner considered the veteran’s claims of worsening symptoms of post-traumatic stress disorder were subjective and no objective correlations were possible. The examiner diagnosed chronic post-traumatic stress disorder. He determined social and industrial impairment from his symptoms of post-traumatic stress disorder remained slight or “perhaps greater.” The veteran was being seen at the Mental Health Clinic every four months. He had complaints of depression and nervousness. An entry in November 1992 assessed depression, anxiety, not otherwise specified, and post-traumatic stress disorder. An entry in September 1993 described the veteran as somewhat anxious and suspicious. He stated he was doing as well as usual without specific complaints. He continued to have nightmares and daytime anxiety but minimized complaints. When he was offered extending visits to 6 months, he declined rapidly. His return visit was scheduled for four months. No psychoses were noted. He was anxious and had poor eye contact. The veteran was afforded a psychiatric examination in November 1994. The report noted that the veteran had been followed as an outpatient at the mental hygiene clinic. He was being treated with medication for his psychiatric symptoms which he thought did not improve his sleep patterns. He dreamed “foolish stuff” but did not elaborate. He reported that he received Social Security benefits because of his arthritic pains and presumably was unemployable due to the arthritis. The examiner observed that the veteran was oriented as time, place, and person. He showed no evidence of delusion, hallucination, or thought disorder. There was no change in his intellect or memory since the last evaluation. He appeared moderately anxious, wrung his hands frequently throughout the evaluation, became tearful briefly, and was able to express some hostility about his symptoms. The diagnosis was chronic post-traumatic stress disorder and the global assessment of functioning (GAF) was 60. The examiner further commented that the progress notes in the claims file suggested that the symptoms of PTSD had increased somewhat since the last evaluation. Psychological testing was recommended. Based on the above findings, in a rating action dated in December 1994, the RO determined that the veteran’s condition had increased in severity and definite social and industrial impairment was demonstrated. It increased the evaluation to 30 percent disabling, effective from March 1990. At the request of the veteran, a letter dated in February 1995 was submitted by his private physician, Russell D. McKnight, M.D. At the evaluation, the veteran described himself as “all tore up with his nerves” and easily upset. He ruminated and worried all the time about things that did not really concern him and he felt chronically depressed. He stated that he had persistent dreams about Vietnam that awakened him although he was amnesiac for the dreams. He was able to sleep only 4 to 5 hours a night. He reported that in the past he had suppressed memories of Vietnam by working two jobs and staying very busy. Since he has been unable to work, his Vietnam experiences have come back. He gave a personal history of being married for approximately 26 years, and of having two children. After service, he was a farmer and a butcher. He worked at the latter occupation for 14 years, until 1989. He obtained Social Security disability in 1989 and his last day of work was in October 1989. He was alert, cooperative, correctly oriented, and spoke in a coherent and logical manner. He appeared tense, irritable, depressed, and restless. He stated that doctors made him nervous and he was noticeably wringing his hands. He appeared to be functioning in the normal range of intelligence and there were no psychotic features. He described having dreams of Vietnam 2 to 3 times a week. The clinical impression was that the veteran was suffering from Vietnam post traumatic stress disorder. He also suffered from anxiety/depressive syndrome with insomnia associated with chronic pain. By history, he suffered from rheumatoid arthritis and duodenal ulcer. In Dr. McKnight’s opinion, the veteran’s deteriorating health and pain and discomfort from rheumatoid arthritis had re-activated symptoms of PTSD which were unabated by the current medications regime. Analysis The evaluation for the veteran’s service-connected PTSD is based on the degree of impairment of his social and industrial adaptability. A 30 percent evaluation is warranted for post-traumatic stress disorder when there is definite impairment in the ability to establish or maintain effective and wholesome relationships with people and when psychoneurotic symptoms result in such reductions in initiative, flexibility, efficiency, and reliability levels as to produce definite industrial impairment. A 50 percent evaluation requires that the ability to establish or maintain effective or favorable relationships with people be considerably impaired and that reliability, flexibility, and efficiency levels be so reduced by reason of psychoneurotic symptoms as to result in considerable industrial impairment. A 70 percent evaluation requires that the ability to establish and maintain effective or favorable relationships with people be severely impaired and that the psychoneurotic symptoms be of such severity and persistence that there is severe impairment in the ability to obtain or retain employment. A 100 percent evaluation requires that attitudes of all contacts except the most intimate be so adversely affected as to result in virtual isolation in the community; there be totally incapacitating psychoneurotic symptoms bordering on gross repudiation of reality with disturbed thought or behavioral processes (such as fantasy, confusion, panic, and explosions of aggressive energy) associated with almost all daily activities resulting in a profound retreat from mature behavior. The individual must be demonstrably unable to obtain or retain employment. 38 C.F.R. Part 4, Diagnostic Code 9411 (1995). In Hood v. Brown, 4 Vet.App. 301 (1993), the United States Court of Veterans Appeals (Court) stated that the term “definite” in 38 C.F.R. § 4.132 was “qualitative” in character, whereas the other terms were “quantitative” in character, and invited the Board to “construe” the term “definite” in a manner that would quantify the degree of impairment for purposes of meeting the statutory requirement that the Board articulate “reasons or bases” for its decision. 38 U.S.C.A. § 7104(d)(1)(West 1991). In a precedent opinion, dated November 9, 1993, the General Counsel of the VA concluded that “definite” is to be construed as “distinct, unambiguous, and moderately large in degree.” It represents a degree of social and industrial inadaptability that is “more than moderate but less than rather large.” VA O.G.C. Prec. 9-93 (Nov. 9, 1993). The Board is bound by this interpretation of the term “definite.” 38 U.S.C.A. § 7104(c)(West 1991). With these considerations in mind, the Board will address the merits of the claim at issue. In assessing the severity of a psychoneurosis, such as the veteran’s post-traumatic stress disorder, effects of that disorder on the veteran’s ability to interact on both a social and industrial level as confirmed by the current clinical findings, are considered. In this regard, however, social inadaptability is evaluated only as it affects or impairs industrial adaptability. The evidence in this case indicates that the veteran’s post-traumatic stress disorder symptoms result in definite social and industrial impairment. It is apparent that he experiences symptomatology of this disorder, as noted, the examiner found symptoms of depression and post-traumatic stress disorder. However, he appeared oriented in time, place and person, has an appropriate affect and displayed an ability to cooperate. Despite sleep disturbance, cognition seems intact. In addition, he has managed to sustain a 26 year marriage and to help rear two children. He maintained employment for 14 years as a butcher until his rheumatoid arthritis interfered with his employment. He then obtained a position as a part time real estate agent and also measured houses for a construction company until his physical condition forced him to stop. The overall effect of the veteran’s symptoms has not been shown to reduce the veteran’s reliability, flexibility, and efficiency levels so as to result in more than definite industrial impairment. The disorder represents a degree of social and industrial inadaptability that is distinct, unambiguous and moderately large, but less than rather large, in degree. Consequently, post-traumatic stress disorder is considered appropriately compensated by the rating now in effect. Consideration has also been given to the potential application of the extraschedular evaluation provisions of 38 C.F.R. § 3.321(b)(1) (1995). The evidence does not present such an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards. Specifically, there has not been a demonstration of marked interference with employment or frequent periods of hospitalization so as to render impractical the application of the regular schedular criteria. B. Scar of the right thigh as a residual of shell fragment wound By a rating action in June 1991, service connection was granted for scar of the right thigh as a residual of shell fragment wound, and evaluated as noncompensable effective from March 1990. The RO based its decision on information that the veteran received a Purple Heart in 1968 and an almost undetectable scar on his right thigh and resolved all reasonable doubt in favor of the veteran. The RO assigned this rating under the provisions of Diagnostic Code 7805 of the Schedule for Rating Disabilities, 38 C.F.R. § 4.118 (1995). The provisions contained in the rating schedule represent as far as can practicably be determined, the average impairment in earning capacity in civil occupations resulting from disability. An entry dated November 2, 1967, in the service medical records show that the veteran was wounded in action. He received a wound of the right upper leg from an exploding mortar in the vicinity of Quang Tri Province, Republic of Vietnam, on this date. He was treated in the field and returned to duty. On November 9, 1967, a stitch was removed from the right leg. The veteran was afforded a VA medical examination in May 1991. He related being hit with a mortar blast in service. The measurement of the right thigh was 16 1/2 inches and the left thigh was 15. 6 inches. The calves measured the same or close to the same at about 13 inches. There was a slight hard area in the right thigh which the examiner suspected was the scar from the injury. X-rays revealed projections of the right hip and proximal femur were within normal limits. X- rays of the right knee demonstrated 2 small metal densities, in the soft tissues of the distal femur, medially, with the smaller 2 mm density at the level of the distal femur, and the larger 6 mm density posteriorly situated. The opinion was of metal foreign bodies as described. The diagnosis was old shrapnel injury to the right medial thigh. J. Frederick Wolfe, M.D., the veteran’s private treating physician for rheumatoid arthritis, submitted a copy of an X- ray report dated in March 1992. Dr. Wolfe’s impression was “changes of both osteo and rheumatoid disease.” He noted a small metal fleck in the right leg. At a VA examination in June 1992, the range of motion for the right knee was flexion of 120 degrees, and extension of 10 degrees. The X-ray report noted that the two metallic foreign bodies at the medial to distal right thigh were unchanged in position. There were degenerative changes in the right knee which were also unchanged. The impression was mild degenerative changes. The veteran was afforded X-rays in November 1994. The impression was two small densities anterior to the tibia likely representing vascular calcifications; and cortical irregularity of the posterior fibula distally most likely representing old trauma. No metallic fragments were seen. Analysis Residuals of gunshot and shell fragment wounds are evaluated on the basis of the following factors: the velocity, trajectory and size of the missile which inflicted the wounds; extent of the initial injury and duration of hospitalization; the therapeutic measures required to treat the disability; and current objective findings, such as evidence of damage to muscles, nerves and bones which results in pain, weakness, limited or excessive motion, shortening of extremities, scarring, or loss of sensation. 38 C.F.R. § 4.56 (1995). Muscle injuries are classified into four general categories; slight, moderate, moderately severe, and severe. Separate evaluations are assigned for the various degrees of disability. 38 C.F.R. § 4.56 (1995). Scars may be evaluated on the basis of any related limitation of function of the body part which they affect. 38 C.F.R. § 4.118, Diagnostic Code 7805 (1995). A compensable evaluation for scars (other than burn scars or disfiguring scars of the head, face, or neck) requires that they be poorly nourished, with repeated ulceration; that they be tender and painful on objective demonstration; or that they produce limitation of function of the body part which they affect. 38 C.F.R. Part 4, Diagnostic Codes 7803, 7804, and 7805 (1995). Limitation of extension (normal being to approximately 0 degrees) of either leg to 5 degrees warrants a noncompensable evaluation. A 10 percent evaluation requires that extension be limited to 10 degrees. A 20 percent evaluation requires that extension be limited to 15 degrees. A 30 percent evaluation requires that extension be limited to 20 degrees. A 40 percent evaluation requires that extension be limited to 30 degrees. A 50 percent evaluation requires that extension be limited to 45 degrees or more. 38 C.F.R. § 4.71a, Diagnostic Code 5261 (1995). Based on the foregoing medical evidence, we conclude that a 10 percent rating more appropriately provides adequate compensation for symptomatology related to the veteran’s service-connected scar of the right thigh as residual of shell fragment wound. The evidence indicates that the veteran was treated in the field and returned to duty which suggests a slight injury. In addition, current objective findings describe the scar as barely detectable. Moreover, the most recent reading of X-rays did not find any metallic fragments. However, several earlier X-ray reports noted the presence of two metallic fragments. We find the earlier reports more persuasive. Additionally, the range of motion findings for the right leg showed extension limited to 10 degrees which under diagnostic code 5261 warrants a 10 percent evaluation. Therefore, dipping deep into the generous pool of reasonable doubt provided by 38 C.F.R. § 3.102, we are of the opinion that a ten percent evaluation is appropriate for the right thigh disorder. Consideration has also been given to the potential application of the extraschedular evaluation provisions of 38 C.F.R. § 3.321(b)(1) (1995). The evidence does not present such an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards. Specifically, there has not been a demonstration of marked interference with employment or frequent periods of hospitalization so as to render impractical the application of the regular schedular criteria. II. Service connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service and not the result of the veteran's own willful misconduct. 38 U.S.C.A. §§ 101(16), 1110, 1131 (West 1991); 38 C.F.R. §§ 3.301, 3.303, 3.304 (1995). Service connection may 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. Presumptive periods are not intended to limit service connection to disease so diagnosed when the evidence warrants direct service connection. The presumptive provisions of the statute and Department of Veterans Affairs regulations implementing them are intended as liberalizations applicable when the evidence would not warrant service connection without their aid. 38 C.F.R. § 3.303(d) (1995). Well-grounded claim requirements The law provides that “a person who submits a claim for benefits under a law administered by the Secretary shall have the burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that the claim is well grounded.” 38 U.S.C.A. § 5107(a) (West 1991). Establishing a well grounded claim for service connection for a particular disability requires more than an allegation that the disability had its onset in service or is service-connected; it requires evidence relevant to the requirements for service connection and of sufficient weight to make the claim plausible and capable of substantiation. See Franko v. Brown, 4 Vet.App. 502, 505 (1993); Tirpak v. Derwinski, 2 Vet.App. 609, 610 (1992); Murphy v. Derwinski, 1 Vet.App. 78, 81 (1990). The three elements of a “well grounded” claim are: (1) evidence of a current disability as provided by a medical diagnosis; (2) evidence of incurrence or aggravation of a disease or injury in service as provided by either lay or medical evidence, as the situation dictates; and, (3) a nexus, or link, between the inservice disease or injury and the current disability as provided by competent medical evidence. See Caluza v. Brown, 7 Vet.App. 498, 506 (1995); see also 38 U.S.C.A. § 1110 (West 1991); 38 C.F.R. § 3.303 (1994). A service-connection claim must be accompanied by evidence which establishes that the claimant currently has the claimed disability. See Rabideau v. Derwinski, 2 Vet.App. 141, 144 (1992); see also Brammer v. Derwinski, 3 Vet.App. 223, 225 (1992) (absent “proof of a present disability there can be no valid claim”). A. Residuals of exposure to Agent Orange During the veteran’s active service he served a tour of duty in the Republic of Vietnam. Diseases associated with exposure to Agent Orange A disease associated with exposure to certain herbicide agents, listed in 38 C.F.R. § 3.309(e) (1995) will be considered to have been incurred in service under the circumstances outlined in this section even though there is no evidence of such disease during the period of service. No condition other than one listed in 38 C.F.R. § 3.309(a) (1995) will be considered chronic. 38 U.S.C.A. §§ 1101, 1112, 1113, 1116 (West 1991); 38 C.F.R. § 3.307(a) (1995). Exposure to herbicide agents is presumed for a veteran who served on active duty in the Republic of Vietnam during the Vietnam era and who has a disease listed at 38 C.F.R. § 3.309(e) unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. 38 C.F.R. § 3.307(a)(6)(iii) (1995). If a veteran was exposed to an herbicide agent during active military, naval, or air service, the following diseases shall be service-connected if the requirements of 38 C.F.R. § 3.307(a)(6)(iii) (1995) are met, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 C.F.R. § 3.307(d) (1995) are also satisfied: Chloracne or other acneform disease consistent with chloracne; Hodgkin’s disease; Non- Hodgkin’s lymphoma; Porphyria cutanea tarda; multiple myeloma, respiratory cancers (cancers of the lung, bronchus, larynx, or trachea), and soft-tissue sarcoma. 38 C.F.R. § 3.309(e) (1995). Further, the Secretary of the Department of Veterans Affairs has determined that a presumption of service connection based on exposure to herbicides used in the Republic of Vietnam during the Vietnam era is not warranted for any condition other than those for which the Secretary has specifically determined that a presumption of service connection is warranted. Notwithstanding the foregoing, the United States Court of Appeals for the Federal Circuit determined that the Veterans’ Dioxin and Radiation Exposure Compensation Standards (Radiation Compensation) Act, Pub. L. No. 98-542, § 5, 98 Stat. 2725, 2727-29 (1984) does not preclude a veteran from establishing service connection with proof of actual direct causation. Combee v. Brown, 34 F.3d 1039 (Fed.Cir. 1994). However, the Court has held that where the issue involves medical causation, competent medical evidence which indicates that the claim is plausible or possible is required to set forth a well-grounded claim. Grottveit v. Brown, 5 Vet.App. 91, 93 (1993). Background Service medical records are negative for any complaints of, treatments for, or diagnosis of any disability, particularly a rash, due to exposure to Agent Orange as claimed by the veteran. The veteran filed a claim in May 1984 stating that he had a rash on his toes at one time which might have been due to exposure to Agent Orange. At the VA medical examination in July 1984, he related that he had a rash on toes at one time, not severe[;] scattered. He treated this with Desenex and it healed with no recurrence. The examiner made no diagnosis of a skin condition. In 1991, the veteran claimed that he still suffered from ermatophytosis. He claimed that his hands were a constant source of irritation and crack openee, bled, and itched. Since he had to work in the public arena, he was self- conscious because of the appearance of his hands and acted in a reserved manner. The veteran was afforded a skin examination in November 1994. The report indicated that although the veteran previously complained of a rash on his feet, this was no longer a complaint. His recent complaints of a rash included a rather nonspecific rash across the forearms and around the elbow area on both sides which was quite pruritic. The examiner commented that the veteran had not described anything which suggested chloracne. At the time of the examination, there was no rash at all or nothing which the examiner could see. The examination revealed no skin problems at that time. The impression was a history of what sounded like neurodermatitis of both upper extremities. Analysis Service connection for exposure to Agent Orange may not be granted in that exposure in and of itself is not considered a disability for which compensation is payable. As the objective evidence in this case does not establish that the veteran has a skin condition, we conclude that the claim is not well-grounded. To support the claim, we have only the veteran’s statement that he has a skin condition, and his opinion of a causal connection. The record does not contain any medical evidence corroborating the appellant’s claim. Personal statements made by the appellant are of little probative value without corroborating medical evidence. While we do not doubt that he is sincere in his belief, he is not qualified to offer such an opinion. See Espiritu v. Derwinski, 2 Vet.App. 492 (1992) (A lay person is not qualified to make medical diagnoses). Moreover, mere contentions of the appellant without supporting evidence do not constitute a well-grounded claim. King v. Brown, 5 Vet.App. 19 (1993). The appellant’s claim is not plausible because of the absence of any objective evidence which establishes the claimed disability, and the claim, therefore, is not well-grounded. As the veteran has not provided proof of a present disability with regard to the conditions claimed, we find that the claim is not well-grounded. B. Arthritis In his claim received in March 1990, the veteran sought service connection for arthritis. By a rating action in August 1990, service connection for arthritis was denied. In the veteran’s notice of disagreement, he claimed that service medical records would reveal that he suffered multiple shell fragment wounds in the right and left knee. Service medical records do not disclose any complaint of, treatment for, or diagnosis of arthritis. Service medical records do show that he suffered a shell fragment wound of the right thigh. In his substantive appeal received in April 1991, the veteran stated that he received a left knee injury and a shell fragment wound of the left knee. He claimed that he was awarded the Purple Heart for the wound to his left knee and as a result of the trauma to that knee he has developed arthritis. The veteran was afforded a VA medical examination in May 1991. The veteran claimed that his left knee was injured in service and he has had trouble on and off with swelling. He stated that he was having trouble with both knees but he was diagnosed with rheumatoid arthritis in 1988. A X-ray of the left knee was within normal limits. The impression was history of injury to left knee and rheumatoid arthritis. Additional evidence reviewed were treatment records for rheumatoid arthritis and medical examinations showing a diagnosis of rheumatoid arthritis. Also an X-ray report of the knees with a impression of changes of both osteo and rheumatoid disease. Analysis In addition to the above stated regulations regarding service connection, where a veteran served 90 days or more during a period of war and arthritis becomes manifest to a degree of 10 percent within one year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 1991); 38 C.F.R. §§ 3.307, 3.309 (1995). Arthritis was not shown in service. In addition, a review of the evidence fails to demonstrate that arthritis was manifested within the one year presumptive period following the veteran's discharge from military service such that presumptive service connection benefits would be warranted. The evidence indicates that rheumatoid arthritis was diagnosed in 1988, many years after discharge from military service. Although the veteran has provided evidence of a current disability by a medical diagnosis of rheumatoid arthritis, and provided evidence of inservice injury to the right leg, although not to the left knee, no competent medical evidence has been provided showing a nexus between the inservice injury and the current disability of rheumatoid arthritis. Accordingly, we find the claim for entitlement to service connection for arthritis is not well-grounded. Duty to assist: Because we have determined that the appellant has not submitted a well-grounded claim regarding these issues, the VA is under no duty to assist him in further development of his claim. Rabideau v. Derwinski, 2 Vet.App. 141 (1992); Murphy v. Derwinski, 1 Vet.App. 78 (1990). If a claim is not well grounded, the Board does not have jurisdiction to adjudicate it. See Boeck v. Brown, 6 Vet.App. 14, 17 (1993). Where the veteran has not met this burden, the VA has no duty to assist him in developing facts pertinent to his claim, including no duty to provide him with a medical examination. 38 U.S.C.A. § 5107(a) (West 1991); Rabideau, 2 Vet.App. at 144 (where the claim was not well-grounded, VA was under no duty to provide the veteran with an examination). However, where a claim is not well-grounded it is incomplete, and depending on the particular facts of the case, VA is obliged under 38 U.S.C.A. § 5103(a) to advise the claimant of the evidence needed to complete his application. See Robinette v. Brown, 8 Vet. App. 69 (1995). In this case, the RO substantially complied with this obligation in an December 1994 letter with a supplemental statement of the case and a copy of the rating action to the veteran informing him of the denials and the reasons for the decision. Moreover, this Board decision informs the veteran of the evidence that is lacking to make his claim well grounded. Unlike the situation in Robinette, he has not put VA on notice of the existence of any specific, particular piece of evidence that, if submitted, could make his claim well grounded. III. Residuals of left knee injury By a rating action in August 1984, service connection was denied for a left knee injury and the veteran was notified by a letter in the same month. Although the veteran filed a notice of disagreement and a statement of the case was issued, a substantive appeal was not received. The law grants a period of one year from the date of notice of the result of the initial determination for the filing of an application for review on appeal; otherwise, that determination becomes final and is not subject to revision on the same factual basis. 38 U.S.C.A. § 7105 (West 1991). As the RO has previously denied service connection for a left knee injury and no timely substantive appeal was filed, the decision became final. The claim shall be reopened, and the former disposition of the claim reviewed if new and material evidence is secured or presented. 38 U.S.C.A. § 5108 (West 1991). New evidence, however, means more than evidence that was not previously physically of record, and is evidence that is more than merely cumulative. Colvin v. Derwinski, 1 Vet.App. 171 (1991). Stated alternatively, "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 evidence previously assembled is so significant that it must be considered in order to fairly decide the merits of the claim. 38 C.F.R. § 3.156(a) (1995). Evidence which is solely cumulative or repetitious in character will not serve as a basis for reconsideration of a previous decision. 38 C.F.R. § 3.156 (1995). Evidence reviewed at the time of the rating decision in August 1984 were service medical records, and a July 1984 VA medical examination report. Evidence submitted with the claim received in March 1990 included a February 1984 X-ray report, report of an Agent Orange examination in February 1984, treatment records for psychiatric disorder, gastro-intestinal disorder, and rheumatoid arthritis, additional service personnel records, and a March 1990 examination for post-traumatic stress disorder. In his substantive appeal, the veteran stated that he received a left knee injury and a shell fragment wound of the left knee. He claimed that he was awarded the Purple Heart for the wound to his left knee and submitted a copy of the award of the Purple Heart Medal. Other evidence reviewed was a May 1991 X-ray report, a May 1991 VA medical examination report, a letter from J. Frederick Wolfe, M.D. dated in April 1992, report of VA medical examination in June 1992, X-ray report in June 1992, X-ray report dated in March 1992 by Dr. Wolfe, X-ray report and VA medical examination report dated in November 1994. Analysis The evidence submitted by appellant to reopen his claim for service connection for residuals of a left knee injury was not “new and material” evidence as defined in Colvin, and therefore the claim should not be reopened. The notice of the award of the Purple Heart specified it was for wounds received on November 2, 1967, and the service medical records indicate that the veteran received a shell fragment wound of the right leg on that date. The medical evidence regarding other conditions is not pertinent to the veteran’s claim for service-connection for residuals of a left knee injury. The medical reports and X-ray reports pertaining to the left knee dealt with appellant’s current left knee conditions. Medical records describing a current condition are not material to the issue of service connection. See Morton v. Principi, 3 Vet.App. 508 (1992). There is not a “reasonable possibility” that any piece of the evidence submitted “when viewed in the context of all the evidence, both new and old, would change the outcome.” Colvin v. Derwinski, 1 Vet.App. 171, 174 (1991). Accordingly, the claim for entitlement to service connection for a left knee injury is not reopened. ORDER An increased evaluation for post-traumatic stress disorder is denied. A 10 percent evaluation for scar of right thigh as residual of shell fragment wound is granted. New and material evidence not having been submitted, the veteran’s request to reopen his claim for entitlement to service connection for residuals of a left knee injury is denied. A well-grounded claim for service connection for arthritis and for a skin disorder due to exposure to Agent Orange not having been submitted, the claim is denied. REMAND Aggravation of gastro-intestinal disorder The veteran claims that his gastro-intestinal disorder is related to his service-connected post-traumatic stress disorder. Submitted into evidence was a letter dated in January 1995 from Luis C. Pannocchia, M.D. who wrote that the veteran has a past medical history of peptic ulcer disease. Further, the veteran had recurrent abdominal pain, epigastric pain, and burning sensation which had become worse. He noted that the veteran was also extremely anxious. Dr. Pannocchia wrote: “I believe the anxiety from his post-traumatic stress disorder does aggravate and contribute to his recurrent duodenal ulcers and gastric ulcers and GI [gastro-intestinal] complaints.” By a rating action in March 1995, the RO denied service connection for gastrointestinal symptoms and a bleeding ulcer secondary to post-traumatic stress disorder. The RO noted that Dr. Pannocchia did not state that the post-traumatic stress disorder was the cause of the gastrointestinal and ulcer condition. As the evidence did not show that gastrointestinal complaints and duodenal ulcers and gastric ulcers were directly related to the service connected condition of post-traumatic stress disorder, service connection was not warranted. We note that only a few days prior to the RO’s decision, the United States Court of Veterans Appeals (Court) decided Allen v. Brown, 7 Vet.App. 439 (1995) (en banc). The Court determined that in a case in which a claimant's service- connected disability aggravates, but is not the proximate cause of, a non-service-connected disability, the claimant is entitled to service connection for that increment in severity of the non-service-connected disability attributable to the service-connected disability. By way of background, the Court first discussed its interpretation of the law in both Tobin v. Derwinski, 2 Vet.App. 34 (1991), and Leopoldo v. Brown, 4 Vet.App. 216 (1993), addressed the question of which interpretation of the law should prevail and concluded that the interpretation announced in Tobin was the correct standard to be applied. The Court held that the term "disability" as used in § 1110 referred to "impairment of earning capacity, and that such definition mandates that any additional impairment of earning capacity resulting from an already service-connected condition, regardless of whether or not the additional impairment is itself a separate disease or injury caused by the service-connected condition, shall be compensated." Allen at 448. "Thus, pursuant to § 1110 and § 3.310(a), when aggravation of a veteran's non-service-connected condition is proximately due to or the result of a service-connected condition, such veteran shall be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation." Id. Observing that the RO’s decision in the instant case relied exclusively upon a rule which required an etiological relationship between the appellant's service-connected post- traumatic stress disorder and the subsequent onset of duodenal ulcers and gastric ulcers and gastro-intestinal complaints, we remand the case for the RO to determine whether the appellant's post-traumatic stress disorder aggravated his gastro-intestinal disorder and ulcers and, if so, what level of disability is attributable to such aggravation. We notice that an assessment of depression, and anxiety, not otherwise specified, was entered in November 1992 in addition to post-traumatic stress disorder. In November 1994, the examiner stated that in addition to suffering from post- traumatic stress disorder, the veteran also suffered from anxiety/depressive syndrome. At other examinations, anxiety and depression were found but not diagnosed separately from a diagnosis of post-traumatic stress disorder. Clarification is needed to determine if anxiety is a symptom of the veteran’s service-connected post-traumatic stress disorder or is a separate psychiatric disorder. Accordingly, this case is remanded for the following action: 1. The veteran should be afforded a psychiatric examination to clarify the diagnosis. If anxiety is determined to be a separate psychiatric disorder from post-traumatic, an opinion should be rendered by the examiner as to whether the anxiety disorder or the post- traumatic stress disorder aggravated the veteran’s gastro-intestinal disorder and ulcers. 2. If it is determined that the appellant's post-traumatic stress disorder aggravated his gastro-intestinal disorder and ulcers , then the RO must determine what level of disability is attributable to such aggravation. After the development requested above has been completed to the extent possible, the RO 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 representative, if any, 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 in accordance with the usual appellate procedures. JACK W. BLASINGAME Member, Board of Veterans’ Appeals The Board of Veterans’ Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, 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. (CONTINUED ON NEXT PAGE) 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 -