Citation Nr: 9835079 Decision Date: 11/27/98 Archive Date: 12/01/98 DOCKET NO. 97-08 726 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Louisville, Kentucky THE ISSUES 1. Entitlement to an increased rating for chronic dermatitis, currently evaluated as 30 percent disabling. 2. Entitlement to service connection for a respiratory condition, to include chronic obstructive pulmonary disease (COPD), claimed as due to exposure to Agent Orange. 3. Entitlement to service connection for an acquired psychiatric disorder, to include depression, dysthymia and paranoia. 4. Whether new and material evidence has been submitted to reopen a claim of entitlement to service connection for hypertension. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Thomas A. Yeager, Associate Counsel INTRODUCTION The veteran had active military service from January 1969 to November 1971. This appeal arises from a February 1996 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Louisville, Kentucky. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends that the RO erred in denying the benefits sough on appeal. He maintains, in essence, that the 30 percent rating currently assigned for his chronic dermatitis does not adequately reflect the severity of that condition. He also maintains that a respiratory condition, diagnosed as COPD, and a psychiatric disorder, to include depression, dysthymia and paranoia, are etiologically related to his active military service. He further maintains that evidence submitted since the last final denial of his claim for service connection for hypertension is new and material, so as to warrant reopening that claim. Accordingly, more favorable determinations are requested. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991 & Supp. 1998), 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 evidence supports a 50 percent disability rating for chronic dermatitis; that the claims of entitlement to service connection for a respiratory condition, to include COPD, and for a psychiatric disorder, to include depression, dysthymia and/or paranoia, are not well grounded; and that new and material evidence has not been submitted to reopen the veteran’s claim of entitlement to service connection for hypertension. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable determination of the veteran’s claim for an increased rating for dermatitis has been obtained by the RO. 2. The veteran’s dermatitis is manifested by constant itching, extensive exfoliation and crusting, with nervous manifestations. 3. There is no medical evidence demonstrating that any respiratory condition from which the veteran may now suffer, including COPD, is related in its etiology to the veteran’s period of active military service generally, or Agent Orange exposure specifically. 4. There is no competent medical evidence of record that establishes a causal nexus between an acquired psychiatric condition, including depression, dysthymia and/or paranoia, and the veteran’s active military service. 5. In April 1985, the Board denied the veteran’s appeal of a claim for service connection for hypertension on the basis that it was not shown in, incurred in or aggravated by his active military service. That decision is the latest final denial of the veteran’s claim on any basis. 6. Evidence received since the Board’s April 1985 decision is not cumulative or redundant, but by itself or in connection with the evidence previously assembled, is not so significant that it must be considered in order to fairly decide the merits of the veteran’s claim for service connection for hypertension. CONCLUSIONS OF LAW 1. The criteria for an evaluation of 50 percent for chronic dermatitis have been met. 38 U.S.C.A. §§ 1155, 5107(a) (West 1991 & Supp. 1998); 38 C.F.R. §§ 3.321(b), 4.1, 4.2, 4.7, 4.118, Diagnostic Code (DC) 7899-7806 (1997). 2. The claim of entitlement to service connection for a respiratory condition, including COPD, as due to Agent Orange exposure, is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 3. The veteran’s claim of entitlement to service connection for an acquired psychiatric disorder, to include depression, dysthymia and paranoia, is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 4. Evidence received since the last final denial of the veteran’s claim for service connection for hypertension on any basis is not new and material, and the veteran’s claim is not reopened. 38 U.S.C.A. §§ 5108, 7104 (West 1991 & Supp. 1998); 38 C.F.R. §§ 3.156, 20.1100 (1997). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Entitlement to an Increased Rating for Chronic Dermatitis, Currently Evaluated as 30 Percent Disabling. The veteran has requested an increased rating for chronic dermatitis, currently evaluated as 30 percent disabling. Since this condition was previously service connected and rated, and the veteran is asserting that a higher rating is justified due to an increase in the severity of his disability, the claim must be deemed “well grounded” within the meaning of 38 U.S.C.A. § 5107(a). See Caffrey v. Brown, 6 Vet. App. 377, 381 (1994). Under these circumstances, pursuant to its duty to assist, the VA may be required to provide a new medical examination to obtain evidence necessary to adjudicate the increased rating claim. Id., citing Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992). This obligation was satisfied by the December 1995 and November 1996 examinations conducted at the VA Medical Center (VAMC) in Lexington, Kentucky, described below and the Board is satisfied that all relevant facts have been properly and sufficiently developed. Service medical records indicate that the veteran developed a rash during his active duty, and he was noted to have keloids on his chest at the time of his September 1971 pre-separation physical examination. Service connection for chronic dermatitis was granted by the RO in September 1983, with an effective date in June 1983. A noncompensable evaluation was assigned at that time. The veteran filed his current claim for an increased rating in August 1995. In December 1995, the veteran received a skin examination at the Lexington VAMC. The examiner reported that evaluation of the upper torso revealed a formation of multiple keloid scarring of the mid-chest wall at the nipple line. The scars were horizontal, three to four centimeters linearly, forming firm ridges. The scars were not tender. Other lesions of the upper torso included multiple small pustular lesions on the front and back chest wall with multiple scars, which the examiner opined indicated the chronic nature of the outbreak. The veteran’s hands and feet had eczematous lesions of the lateral aspects of the fingers and feet. There were no palmar or interdigital lesions. The lesions were cracked, dry and peeling, but not weeping. The examiner reported that none of the lesions were cosmetically disfiguring, but reported “[t]here are nervous manifestations, in that the veteran appears to be anxious.” She diagnosed a history of dermatitis of the anterior chest wall with keloid scar formation, acneiform rash of the upper torso and chronic eczematous hand and foot dermatitis. Based on this examination, the RO raised the veteran’s rating for chronic dermatitis from 0 to 10 percent. In November 1996, the veteran received another skin examination at the Lexington VAMC. The examining physician reported numerous perifollicular papules scattered over the back with more deeply seated cystic lesions on the lower back as well as in the right axilla. There were old, healing, erythematous, slightly depressed scars in the axilla as well. A similar disease was said to be present in the groin. There was diffuse xerosis primarily over the hands, forearms and upper trunk, with some deeper fissures on the fingers. Papules were present, one on the left hand and one on the right third finger. The examiner diagnosed hidradenitis suppurativa of the axilla and groin, folliculitis, xerosis with mild eczema of the hands and verruca vulgaris. On the basis of this examination, the RO increased the veteran’s evaluation for chronic dermatitis from 10 percent to 30 percent, effective as of the date his claim for an increase was filed in August 1995. Under the laws administered by VA, disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994) (emphasis added). However, the Board must also consider the history of the veteran’s injury, as well as the current clinical manifestations of its residuals and the overall effect that the disability has on the earning capacity of the veteran. See 38 C.F.R. §§ 4.2. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The veteran’s multiple skin conditions, characterized as chronic dermatitis, are evaluated “as for” eczema under 38 C.F.R. § 4.118, DC 7899-7806 (see comment following 38 C.F.R. § 4.118, DC 7819). Under that code, a 30 percent rating is appropriate where there is constant exudation or itching, extensive lesions, or marked disfigurement. The maximum 50 percent schedular evaluation is reserved for cases of ulceration or extensive exfoliation or crusting, with systemic or nervous manifestation, or where the condition is “exceptionally repugnant.” The VA examination reports above indicate that the veteran’s skin condition is active and extensive, involving his feet, groin, torso, axilla, forearms, fingers and neck. The veteran has reported cracking of the skin and bleeding from some of his skin lesions and the RO has accepted his testimony as credible. The examiners have reported numerous papules and cystic lesions, together with multiple small pustular lesions on the front and back chest wall. Further, the veteran testified that on VA examination, he was experiencing an average day with respect to his skin, although he appeared to indicate that the condition worsened with extremes in weather conditions. The Board notes, therefore, that his skin condition may not have been examined during its period of maximum activity. Cf. Ardison v. Brown, 6 Vet. App. 405, 407-408 (1994). In addition, VA’s examiner has reported nervous manifestations secondary to the skin condition and there is no contrary medical evidence in the claims file. On the basis of this evidence, the Board concludes that the veteran’s condition more nearly approximates the schedular criteria for a 50 percent rating, i.e., extensive exfoliation and crusting with nervous manifestations, and that an increased rating is warranted. Finally, when evaluating an increased rating claim, it is well established that the Board may affirm an RO’s conclusion that a claim does not meet the criteria for submission for an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1), or may reach such a conclusion on its own. See Floyd v. Brown, 8 Vet. App. 88, 96 (1996); Bagwell v. Brown, 9 Vet. App. 337, 338-339 (1996). In the present case, the Board notes that there has been no assertion by the veteran and no showing through medical or other evidence that the veteran’s service- connected skin condition has caused marked interference with employment or necessitated frequent periods of hospitalization. In the absence of such factors, the Board finds that the record does not present such “an exceptional or unusual disability picture as to render impractical the application of the regular rating schedule standards” and is not required to remand this matter to the RO for the procedural actions outlined in 38 C.F.R. § 3.321(b)(1). See Bagwell, 9 Vet. App. at 338-339; Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). II. Service Connection for a Respiratory Condition, to include COPD, Claimed as Due to Agent Orange Exposure. The veteran has claimed entitlement to service connection for a respiratory condition, to include COPD, claimed as due to Agent Orange exposure during his service in the Republic of Vietnam. As explained below, the Board finds that the veteran has not presented well-grounded claims of service connection for a respiratory disorder on either a direct basis or as due to Agent Orange exposure. The veteran’s lungs and chest were found to be in normal condition when evaluated at the time of his pre-induction physical examination in February 1968. Service medical records show no complaints or treatment of respiratory problems during active duty and, except for notation of keloids on the chest, the veteran’s lungs and chest were again evaluated as normal during his September 1971 pre- separation physical examination. In July 1983, the veteran was examined at the VAMC in Lexington. During evaluation of his hypertension the veteran denied any “breathing problems,” although he reported dyspnea on exertion. In June and July 1989 the veteran was seen as an outpatient at VAMC Lexington complaining of high blood pressure. In October and November 1993, the veteran was admitted by his private physician, Danny Whitley, M.D., to Baptist Regional Medical Center (BRMC) in Corbin, Kentucky. He had complained of marked increased shortness of breath, wheezing, difficulty breathing at night, having to sit up to breathe, and “a lot” of yellow, productive sputum which was not responsive to antibiotics and bronchodilators. He also reported apparent sleep apnea. The veteran’s conditions were diagnosed as respiratory failure, chronic obstructive pulmonary disease and bronchitis. Secondary diagnoses were diabetes, hypokalemia, obesity, congestive heart failure, cardiomegaly, hypertension, hypoxia, hypercarbia, sleep apnea and venous insufficiency. The veteran was described as morbidly obese, with diet having reportedly been discussed with him in the past. In October 1994, the veteran again was admitted to BRMC with complaints of severe shortness of breath and leg swelling. Other diagnoses included chronic obstructive pulmonary disease with acute and chronic respiratory failure, and obesity with obstructive sleep apnea syndrome with cor pulmonale. He reportedly had recently gained 60 pounds. X-rays showed severe congestive heart failure which was treated and improved. Upon discharge, he was placed on a strict diet for weight loss, sodium and sugar. In December 1995, the veteran was examined at the Lexington VAMC in connection with his current claim. The veteran reported a “long history of dyspnea and shortness of breath,” with sleep apnea and congestive heart failure. Objectively, the veteran was audibly dyspneic. His lungs were clear without rales, wheezes or rhonchi, but with slight diminished breath sounds. There was no sign of asthma, no cyanosis or clubbing and no productive cough. There was dyspnea on exertion and mild dyspnea at rest. Based on the veteran’s history and the physical examination (but prior to reviewing X-rays, EKG and pulmonary function studies) the examiner diagnosed sleep apnea, congestive heart failure and chronic obstructive pulmonary disease. Chest X-rays revealed a slightly enlarged heart with no evidence of pulmonary vascular congestion, and they were described by the radiologist as demonstrating mild cardiomegaly. The veteran’s enlarged heart was assessed as secondary to his obesity. Pulmonary function tests demonstrated a moderate reduction in lung volume (restrictive defect) but no obstruction of flow. No cause of the veteran’s reduced lung volume was suggested. A similar admission for marked shortness of breath, wheezing and dyspnea on exertion occurred in May and June 1995, during which the veteran was treated and his acute symptoms resolved. Upon discharge, he was placed on an 1,800 calorie diet and referred for sleep apnea studies. VA may pay compensation for “disability resulting from personal injury or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service.” 38 U.S.C.A. § 1110 (West 1991). If a disability is not shown to be chronic during service, service connection may nevertheless be granted when there is continuity of symptomatology post- service. 38 C.F.R. § 3.303(b) (1998). Regulations also provide that service connection may be granted for a disease diagnosed after service discharge when all the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (1998). A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or disease incurred in service. Watson v. Brown, 4 Vet. App. 309, 314 (1993). Further, a veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the Vietnam era, and has a disease listed at 38 C.F.R. § 3.309(e), shall be presumed to have been exposed during such service to a herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. The last date on which such a veteran shall be presumed to have been exposed to an herbicide agent shall be the last date on which he or she served in the Republic of Vietnam during the Vietnam era. “Service in the Republic of Vietnam” includes service in the waters offshore and service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam. 38 C.F.R. § 3.307(a)(6)(iii) (1998). If a veteran was exposed to a herbicide agent during active military, naval, or air service, the following diseases shall be service-connected if the requirements of 38 U.S.C.A. § 1116, 38 C.F.R. § 3.307(a)(6)(iii) are met, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 U.S.C.A. § 1113; 38 C.F.R. § 3.307(d) are also satisfied: chloracne or other acneform diseases consistent with chloracne, Hodgkin's disease, multiple myeloma, non-Hodgkin's lymphoma, acute and subacute peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx, or trachea) and soft-tissue sarcomas (other than osteosarcoma, chondrosarcoma, Kaposi’s sarcoma, or mesothelioma). 38 C.F.R. § 3.309(e) (1998). The diseases listed at 38 C.F.R. § 3.309(e) shall have become manifest to a degree of 10 percent or more at any time after service, except that chloracne or other acneform disease consistent with chloracne, porphyria cutanea tarda, and acute and subacute peripheral neuropathy shall have become manifest to a degree of 10 percent or more within a year, and respiratory cancers within 30 years, after the last date on which the veteran was exposed to an herbicide agent during active military, naval, or air service. 38 C.F.R. § 3.307(a)(6)(ii) (1998). The Secretary of the Department of Veterans Affairs has determined that there is no positive association between exposure to herbicides and any other condition for which the Secretary has not specifically determined that a presumption of service connection is warranted. See Notice, 59 Fed. Reg. 341-346 (1994); see also 61 Fed. Reg. 57586-57589 (1996). Notwithstanding the foregoing, the United States Court of Appeals for the Federal Circuit has determined that the Veteran’s Dioxin and Radiation Exposure Compensation Standards 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, 1043 (Fed. Cir. 1994). Before reaching the merits of the claim, however, the veteran has the initial 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). A well- grounded claim is “a plausible claim, one which is meritorious on its own or capable of substantiation.” See Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). For a service connection claim to be well grounded, there must be (1) a medical diagnosis of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between an in-service disease or injury and the current disability. Where the determinative issue involves medical causation, competent medical evidence to the effect that the claim is plausible is required. Epps v. Gober, 126 F.3d 1464, 1468 (Fed. Cir. 1997). Evidentiary assertions by the veteran must be accepted as true for the purposes of determining whether a claim is well- grounded, except where the evidentiary assertion is inherently incredible or when the fact asserted is beyond the competence of the person making the assertion. King v. Brown, 5 Vet. App. 19, 21 (1993). Upon careful review of the evidentiary record, the Board finds that it is clear that the veteran served in Vietnam and is entitled to a presumption of herbicide exposure. The Board further notes that the medical record indicates the veteran has been diagnosed as having a current respiratory disorder to include COPD. However, this diagnosis is not a disease listed at 38 C.F.R. § 3.309(e). Furthermore, pursuant to applicable law, the Secretary of Veterans Affairs has specifically determined that the credible evidence against an association between respiratory disorders (other than certain respiratory cancers) and exposure to herbicides used in the Republic of Vietnam outweighs the credible evidence for such an association, and a positive association does not exist. See Notice, “Disease Not Associated With Exposure to Certain Herbicide Agents,” 61 Fed. Reg. 41442, 41448 (1996). Accordingly, under the law, the veteran is not entitled to a presumption that his respiratory disorder is etiologically related to exposure to herbicide agents used in Vietnam. Further, having carefully reviewed the entire record, the Board finds that there is no medical evidence of record suggesting a connection between the veteran's presumed Agent Orange exposure and any currently diagnosed respiratory disorder. In this regard, as noted above, in Combee, the United States Court of Appeals for the Federal Circuit held that when a veteran is found not to be entitled to a regulatory presumption of service connection for a given disability, the claim must nevertheless be reviewed to determine whether service connection can be established on a direct basis. That is, the material in the claims file must be evaluated to determine whether there is at least evidentiary equipoise as to the question of whether any currently diagnosed disability is related to an illness or injury sustained or manifested by the veteran while on active duty. Combee, 34 F.3d at 1044; 38 U.S.C.A. §§ 1116, 1113(b). In the veteran’s case, there is evidence of a current respiratory disorder, COPD, but there is no evidence of the incurrence or existence of this condition during service. Furthermore, there is no medical evidence of a link between the veteran’s current COPD and any aspect of his active duty. The veteran has asserted that exposure to Agent Orange during the time he was stationed in Vietnam is the cause of his current respiratory problems. However, the United States Court of Appeals for Veterans Claims (Court) has held that lay testimony is not competent to prove a matter requiring medical expertise. See Layno, 6 Vet. App. at 469; Fluker v. Brown, 5 Vet. App. 296, 299 (1993); Moray v. Brown, 5 Vet. App. 211, 214 (1993); Cox v. Brown, 5 Vet. App. 93, 95 (1993); Grottveit, 5 Vet. App. at 92-93; Clarkson v. Brown, 4 Vet. App. 565, 567 (1993). It is the province of trained health care professionals to enter conclusions which require medical opinions as to causation, Jones v. Brown, 7 Vet. App. 134, 137 (1994), and, since he has no medical expertise, the lay opinion of the veteran does not provide a basis upon which to make any finding as to the origin or development of his condition. See Espiritu v. Derwinski, 2 Vet. App. 492, 494-5 (1992). As noted above, however, there is no evidence of any respiratory problems during the veteran’s active duty, or for many years thereafter. Accordingly, he cannot obtain service connection by showing that his was a chronic condition at the time he separated from service, or demonstrate that he is entitled to service connection for COPD by virtue of continuous symptomatology. Since a well grounded claim must be supported by evidence and not merely allegations, the Board is compelled by the record to find the veteran’s claim not well-grounded. Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992). The Board recognizes that this appeal is being disposed of in a manner that differs from that used by the RO. The RO denied the veteran’s claim on the merits, while the Board has concluded that the claim is not well grounded. However, the Court has held that “when an RO does not specifically address the question whether a claim is well grounded but rather, as here, proceeds to adjudication on the merits, there is no prejudice to the veteran solely from the omission of the well-grounded-claim analysis.” Meyer v. Brown, 9 Vet. App. 425, 432 (1996). III. Service Connection for an Acquired Psychiatric Disorder, to Include Depression, Dysthymia and Paranoia. The veteran has also claimed entitlement to service connection for an acquired psychiatric disorder, to include depression, dysthymia and paranoia. As explained above, the veteran has the initial burden under 38 U.S.C.A. § 5107(a) of submitting evidence sufficient to justify a belief by a fair and impartial individual that the claim is well grounded. This evidence must include a medical diagnosis of a current disability; medical, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and medical evidence of a nexus between an in- service disease or injury and the current disability. Competent medical evidence establishing that the claim is plausible is required where the determinative issue involves medical causation. Epps, 126 F.3d at 1468. In the cases amenable to presumptive service connection, the nexus requirement may be satisfied by evidence of the existence of the disease, manifested to the required extent, within any prescribed time period. See Traut v. Brown, 6 Vet. App. 495, 497 (1994); Goodsell v. Brown, 5 Vet. App. 36, 43 (1993). The law and regulations cited above pertaining to chronic conditions and continuous symptomatology also apply. See 38 C.F.R. § 3.303(b); Savage, 10 Vet. App. at 495-497. During his October 1996 RO hearing, the veteran appeared to attribute his nervous condition to his active duty experience in Vietnam and, in particular, an incident he reportedly witnessed where a civilian bus struck a mine. However, there is no indication that the veteran sought treatment for any nervous condition while in service, and his psychiatric status was evaluated as normal at the time of his pre- separation examination in September 1971. He reported receiving medication from a family doctor on one occasion to relieve sleeplessness, but otherwise stated that he had not sought or received treatment for any nervous condition, either from VA or from any private doctor. The Board notes that the records of the veteran’s private physician contain no indication of prescription of sleeping medication, and relate his sleeplessness to his sleep apnea. In December 1995, the veteran received an examination from a psychiatrist at the Lexington VAMC. At that time, the veteran reported he occasionally dreamed of his experiences in Vietnam, which, according to the veteran, included combat and witnessing the deaths of several individuals, both fellow U. S. servicemen and South Vietnamese nationals. After returning from Vietnam, he reportedly was heckled by U. S. civilians and felt that he was not respected. The veteran’s wife was present at the interview and stated that he was occasionally harsh, irritable and verbally abusive (but not physically abusive), as well as suspicious of others. She stated that he denied these characteristics whenever confronted by her. The veteran described occasional “down moods,” during which he had suicidal thoughts without current plans. He also reported some crying spells, mostly in the morning. He was concerned about balding. He admitted having dreams and nightmares about Vietnam, but stated that he could quickly recover his composure. He denied any flashbacks. He reported problems sleeping, but attributed these to his diagnosed sleep apnea, and indicated that he could sleep up to six hours when using his breathing machine. He advised that he got along well with his brothers and in- laws. Objectively, the veteran was oriented in all three spheres and cooperative, with good eye contact. He showed good insight and judgment, and appeared to be competent in terms of using his money. The examiner diagnosed dysthymic disorder on Axis I, and assigned a global assessment of functioning (GAF) scale score of 75, indicating that no more than transient and expectable reactions to psychosocial stressors were present, with no more than slight impairment in social, occupational or school functioning. See American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (4th Ed., 1994) (DSM-IV). No etiology for the veteran’s condition was offered. Again, the Board finds no competent medical evidence suggesting that the veteran’s currently diagnosed dysthymic disorder is related to or otherwise had its origin during the veteran’s active military service. The veteran apparently attributes his condition to his Vietnam service. However, as noted before, lay testimony is not competent to prove a matter requiring medical expertise. See Layno v. Brown, 6 Vet. App. 465, 469 (1994); Fluker v. Brown, 5 Vet. App. 296, 299 (1993); Moray v. Brown, 5 Vet. App. 211, 214 (1993); Cox v. Brown, 5 Vet. App. 93, 95 (1993); Grottveit v. Brown, 5 Vet. App. 91, 92-93 (1993); Clarkson v. Brown, 4 Vet. App. 565, 567 (1993). It is the province of trained health care professionals to enter conclusions which require medical opinions as to causation, Jones v. Brown, 7 Vet. App. 134, 137 (1994), and the lay opinion of the veteran cannot support a finding as to the origin or development of his condition. Espiritu, 2 Vet. App. at 494-5. Therefore, the veteran’s claim of entitlement to service connection for an acquired psychiatric disorder, to include depression, dysthymia and paranoia is not well grounded and must be denied. IV. Whether New and Material Evidence Has Been Submitted to Reopen a Claim for Service Connection for Hypertension. In April 1985, the Board denied the veteran’s appeal of a claim for service connection for hypertension on the basis that it was not shown in, incurred in or aggravated by his active military service. That decision became final and is the latest final denial of the veteran’s claim on any basis. See 38 U.S.C.A. § 7104; 38 C.F.R. § 20.1100. As such, the veteran’s claim may only be reopened and considered on the merits if new and material evidence has been submitted. See 38 U.S.C.A. §§ 5108, 7104(b); 38 C.F.R. § 3.156(a). Barnett v. Brown, 83 F.3d 1380, 1384 (Fed. Cir. 1996). The Board notes that since its April 1985 decision, the non- duplicate evidence added to the file consists of: (1) VA treatment records from June and July 1989 showing prescription of medication to control the veteran’s hypertension and an impression of “well controlled” blood pressure; (2) the report of a December 1995 physical examination at the VAMC in Lexington which provides a diagnosis of essential hypertension and indicates that the veteran takes Procardia, Capoten and Lasix to control his blood pressure; (3) treatment records from the Baptist Regional Medical Center (BRMC), Corbin, Kentucky, indicating in pertinent part that the veteran was treated for respiratory difficulties on several occasions from May through November 1995, with diagnoses including “long- standing,” “poorly-controlled” hypertension with left ventricular hypertrophy; (4) a March 1996 letter from Abdi Vaezy, M.D., F.C.C.P., reporting that he saw the veteran in June 1995 at BRMC, and offering an opinion that the veteran has chronic and severe heart and lung disease and obstructive sleep apnea; (5) treatment records dated from June 1988 through July 1996, apparently prepared by Dr. Whitley, which document continuing treatment of hypertension by medication; (6) a March 1996 letter from Daniel W. Whitley, M.D., reporting that the veteran had been treated for hypertension since 1970; (7) a November 1996 note from Dr. Whitley, indicating that the veteran had been treated for hypertension “by Dr. Prewitt and myself” since November 1971; (8) the testimony of the veteran at his RO hearing in October 1996 that he was told he had high blood pressure in service, that he was treated for hypertension by his family doctor, Dr. Prewitt, in the 1970s, that the treatment included medication to control his blood pressure, and that Dr. Whitley took over Dr. Prewitt’s practice and treatment of the veteran’s hypertension following Dr. Prewitt’s retirement; and (9) a February 1997 note from Dr. Whitley, in response to the RO’s request for his “specific records relating to treatment for the veteran’s hypertension in 1971,” advising that “I do not have any specific records from 1971[. I] started seeing [the veteran] in 1988.” The issue of whether evidence is “new and material” is analyzed under 38 C.F.R. § 3.156(a), and requires a three- step test. The first step requires determining whether the newly presented evidence “bears directly and substantially upon the specific matter under consideration,” i.e., whether it is probative of the issue at hand. Evans v. Brown, 9 Vet. App. 273, 283 (1996). Evidence is probative when it “tend[s] to prove, or actually prov[es] an issue.” Routen v. Brown, 10 Vet. App. 183, 186 (1997), citing Black’s Law Dictionary 1203 (6th ed. 1990). Secondly, the evidence must be shown to be actually “new,” that is, not of record when the last final decision denying the claim was made. See Evans, 9 Vet. App. at 283; Struck v. Brown, 9 Vet. App. 145, 151 (1996). The final question is whether the evidence “is so significant that it must be considered in order to fairly decide the merits of the claim.” Hodge v. West, No. 98- 7107, slip op. at 6 (Fed. Cir. Sep. 16, 1998), citing 38 C.F.R. § 3.156(a). This need not mean that the evidence warrants a revision of the prior determination, but is intended to ensure the Board has all potentially relevant evidence before it. See Hodge, No. 98-7107, slip op. at 14- 15, citing “Adjudication; Pensions, Compensation, Dependency: New and Material Evidence; Standard Definition,” 55 Fed. Reg. 19088, 19089 (1990). New evidence will be presumed credible at this point solely for the purpose of determining whether a claim should be reopened. Justus v. Principi, 3 Vet. App. 510, 513 (1992). If all three tests are satisfied, the claim must be reopened. Applying this analysis to the evidence submitted by the veteran since the last final rating decision, the Board finds that all the above-cited evidence is new, since it was not contained in the file at the time of the Board’s April 1985 decision and does not duplicate evidence of record as of that date. However, items numbered (1) through (5), above, are not probative of the veteran’s claim, since they pertain only to treatment long after service for hypertension and do bear on whether the veteran’s hypertension was incurred or aggravated during his active duty. Items (6) through (9) are probative of the issue of service connection, since they provide evidence relative to the date treatment began for the veteran’s hypertension. Unless it is inherently incredible, the evidence must be presumed credible for the purpose of determining whether the claim should be reopened. Justus, 3 Vet. App. at 513. Since the new evidence is assumed to be credible, the Board must consider it with all other evidence of record to determine whether it 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); See Hodge, No. 98-7107, slip op. at 6, 14-15. In reviewing Dr. Whitley’s three communications with the RO (the March 1996 letter reporting that he had treated the veteran for hypertension since 1970, the November 1996 note indicating that the veteran had been treated for hypertension “by Dr. Prewitt and myself” since November 1971, and the February 1997 note advising that he started seeing the veteran in 1988), the Board must attempt to interpret them in a way which is consistent with other evidence of record. Dr. Whitley’s statement that he first saw the veteran in 1988 is supported by his treatment records, which begin in June 1988. Any report by Dr. Whitley that the veteran was treated for hypertension prior to that time must therefore be based either on a history provided by the veteran or knowledge obtained from another source. The veteran’s testimony at his October 1996 RO hearing provides a probable source for that knowledge. The veteran stated that he was told that he had high blood pressure in service, was treated with medication for hypertension by his family doctor, Dr. Prewitt, in the early to mid 1970s, and that Dr. Whitley took over Dr. Prewitt’s practice and treatment of the veteran’s hypertension following Dr. Prewitt’s retirement. Dr. Whitley’s November 1996 note reporting the veteran’ treatment “by Dr. Prewitt and myself” since November 1971 is essentially consistent with this testimony, as is his March 1996 letter reporting treatment for hypertension since 1970. The evidence previously of record supports a history of treatment prior to service. At the time of the veteran’s pre-induction physical examination in February 1968, he reported a history of high blood pressure, and indicated he had been treated by a “Dr. Prewitt.” Given that Dr. Whitley apparently treated many of Dr. Prewitt’s patients following his retirement, the Board cannot say that Dr. Whitley’s statements pertaining to the veteran’s treatment before June 1988 are based solely on a history provided by the veteran. Since Dr. Whitley’s statements indicate that the veteran was treated for hypertension by Dr. Prewitt from 1970 or 1971 to 1988, and thereafter, by himself, they pertain directly to the issue of whether the veteran’s hypertension was first noted during service or during the presumptive period thereafter, i.e., whether there may be a nexus or link to active service for the incurrence of the veteran’s current hypertension. However, other materials already of record appear to provide the best, most reliable evidence of the date of onset of the veteran’s condition. In his February 1984 statement in support of his original service connection claim, the veteran reported that he first went to see a doctor for hypertension following service in February 1977, and was placed on medication at that time. The veteran also stated that he was told he had high blood pressure during service and at the time of his discharge physical examination, but contemporary service medical records do not support that statement since they show no indication of high blood pressure at any time during service. The most probative evidence, however, is a January 1984 medical certificate from Dr. Elmer G. Prewitt, the veteran’s family physician from prior to active service until 1988, which indicates the veteran had experienced elevated blood pressure and provided a diagnosis of essential hypertension (controlled by medication) with a date of onset of February 7, 1977. Since Dr. Prewitt’s was the veteran’s treating physician during all times at which the initial incurrence of hypertension is at issue, the Board must afford his statements near-preclusive weight when compared to the second-hand reports even of the veteran’s other physicians. Dr. Whitley’s somewhat inconsistent statements regarding the date the veteran was initially treated for high blood pressure, apparently made without access to the relevant treatment records, are clearly outweighed by Dr. Prewitt’s clear and unambiguous report of the date of onset of the veteran’s condition. Therefore, although the evidence submitted by the veteran is new and probative, it is not of substantial weight when compared to the clear and contemporaneous evidence already of record, is not essential to establish a complete evidentiary record and, accordingly, is not so significant that it must be considered in order to fairly decide the merits of the claim. Therefore, the Board concludes that it provides no basis to reopen the veteran’s claim for entitlement to service connection for hypertension. 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156(a). ORDER A rating of 50 percent for chronic dermatitis is granted. Service connection for a respiratory condition, to include chronic obstructive pulmonary disease (COPD), claimed as due to exposure to Agent Orange, is denied. Service connection for an acquired psychiatric disorder, to include depression and paranoia, is denied. New and material evidence not having been submitted, the veteran’s claim of entitlement to service connection for hypertension is denied. S. L. KENNEDY Member, Board of Veterans’ Appeals NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991 & Supp. 1998), 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 which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans’ Appeals. - 2 -