Citation Nr: 9927400 Decision Date: 09/23/99 Archive Date: 10/05/99 DOCKET NO. 93-04 676 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Philadelphia, Pennsylvania THE ISSUES 1. Entitlement to service connection for a psychiatric disability. 2. Entitlement to service connection for a kidney disorder. 3. Entitlement to an increased evaluation for a laparotomy scar due to status post repair of small laceration on right renal parenchyma, currently evaluated as 10 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant, his spouse, and his mother. ATTORNEY FOR THE BOARD M. L. Wright, Counsel INTRODUCTION The veteran had active service from September 1972 to January 1973. This appeal arises from a May 1992 rating decision of the San Juan, Puerto Rico, Regional Office (RO). In this decision, the RO denied service connection for a psychiatric disability and a kidney disorder. The RO also denied an compensable evaluation for his laparotomy scar. All of these determinations were appealed by the veteran. In February 1995, the Board remanded this claim to the RO for development of the medical evidence. By rating decision of September 1995, the RO granted an increased evaluation to 10 percent disabling for the veteran's laparotomy scar. The veteran requested that his claims file be transferred to the RO located in Philadelphia, Pennsylvania, in October 1995 because of his change of residence. The case has now returned for final appellate consideration. The issue of an increased evaluation of the veteran's laparotomy scar is discussed in the remand section of this decision. FINDINGS OF FACT 1. The veteran's current neurosis disorder was first diagnosed after his separation from the military. His current psychosis disorder was first diagnosed many years after his military service. 2. The medical opinions of record linking the veteran's current psychiatric disability to his military service were not based on a review of the veteran's entire medical history, but instead, on his subjective history. 3. Competent medical opinion, based on the veteran's entire medical history, has failed to link his current psychiatric disorders with his military service. 4. The medical opinions of record have determined that the veteran's current kidney disorders are congenital in nature and were not permanently aggravated by his military service. CONCLUSIONS OF LAW 1. The veteran's psychiatric disability was not incurred in active service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1154(b), 5107(a) (West 1991); 38 C.F.R. §§ 3.303, 3.307, 3.309 (1998). 2. The veteran's kidney disorders were not incurred or permanently aggravated by his military service. 38 U.S.C.A. §§ 1110, 1154(b), 5107(a) (West 1991); 38 C.F.R. §§ 3.303, 3.304, 3.306 (1998). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Factual Background. In preparation for the veteran's entry into active service, he was afforded a comprehensive physical examination in August 1972. He denied any medical history of frequent trouble sleeping, depression, excessive worry, loss of memory, amnesia, or nervous trouble. The veteran also reported no medical history of any renal disorders. On initial examination, his abdomen, viscera, genitourinary system, and psychiatric evaluation were all normal. However, a subsequent examination on the same date by a different physician reported that the veteran's genitourinary system was abnormal. The veteran's defect was summarized as a congenital anomaly of a "caked" kidney with crossed renal ectopia and fusion. This disorder was found to have existed prior to the veteran's military service. The service medical records reported in November 1972 that the veteran had been kicked in the right lower quadrant area and subsequently had passed blood in his urine. He was hospitalized from November 1972 until January 1973. The discharge summary noted that the veteran's past medical history was noncontributory. It was reported that the veteran received exploratory laparotomy surgery. The diagnoses were a laceration of the right renal parenchyma without major artery or nerve involvement that was repaired by surgery and hematuria secondary to this laceration. These disorders were determined to have been in the line of duty. The diagnoses also included congenital anomaly of a "caked" kidney with crossed renal ectopia and fusion. It was determined that this latter disorder was not in the line of duty and had pre-existed the veteran's military service. It was opined by the physician that the veteran was not qualified for military service due to his congenital kidney abnormality which made them extremely vulnerable to trauma. A military Medical Board Proceedings (DA Form 8-118) found that the veteran had a physical defect characterized as an "Anomaly, congenital, 'caked' kidney, with crossed renal ectopia and fusion." It was determined that this disorder had existed prior to the veteran's military service and was not incurred or aggravated by such service. A box on the form was marked next to the statement that the veteran was medically fit for further military service. However, on the subsequent page of the form, the Medical Board recommended that the veteran be separated from military service because of his pre-existing kidney anomaly. In February 1973, the veteran filed claims for stomach and psychiatric disabilities. The veteran received a VA compensation examination in March 1973. He noted a history of kidney trauma and surgery during his military service. The veteran complained of back pain and urinary frequency. On examination, the veteran's kidneys were not felt. It was noted that the veteran had no nervous complaints and the examiner found no history or evidence of a psychiatric disorder. The diagnoses were anomalies of both kidneys and residuals of laparotomy. By rating decision of August 1973, the RO denied service connection for residuals of a laparotomy, psychiatric disorder, and gastrointestinal disability as there was no evidence in the medical records that such disabilities existed. The veteran was notified of these decisions in a letter of mid-August 1973. This letter informed him of his appellate rights. A private physician submitted a letter dated in late August 1973 that reported that the veteran had been treated on three different occasions for a nervous depressive condition since March 1973. The veteran was afforded a VA psychiatric examination in October 1973. He claimed that since his separation from the military he had done nothing productive and had no plans for the future. The veteran's medical history concerning his kidney disorder was noted. After an examination, the diagnosis was psychophysiological "G.V." disorder. It was opined by the examiner that his diagnosis should hold only after a genitourinary examination had been completed and its findings did not confirm the veteran's complaints. In December 1993, the RO again determined that the veteran's current psychiatric disability was not service- connected. He was notified of this decision in a letter of late December 1973 and informed of his appellate rights. Another letter was received from the veteran's private physician in July 1974. It was noted that the veteran had been treated for a nervous condition and severe bladder disorder. The physician reported that, according to the veteran's history, he had been treated for the same problems while in the military. The RO again reviewed the veteran's claim for service connection for psychiatric and kidney disabilities in September 1974 and both were denied. A letter was sent to the veteran in the same month that notified him of this decision and his appellate rights. The veteran again filed a claim for service connection for a kidney disorder in April 1975. In a response of late April 1975, the RO drew the veteran's attention to its previous letter of September 1974 that had denied such a claim. VA outpatient records dated from February to June 1975 were associated with the claims file in June 1975. These records noted the veteran's history of laparotomy in the military and treated him for left side ureterolithiasis. The RO again denied service connection for psychiatric and kidney disorders and notified the veteran of this decision and his appellate rights in a letter of late June 1975. A private physician's letter of July 1975 reported that the veteran had been recently hospitalized for surgery to remove an obstruction from the right kidney. The veteran's current genitourinary and restlessness complaints were noted. In July 1975, the RO again denied service connection for psychiatric and kidney disabilities. The veteran was notified of this decision and his appellate rights by letter. In a written statement of November 1975, the veteran filed a claim for service connection for a kidney disorder. He asserted that this kidney disorder was the result of an injury he had sustained during his military service and had led to surgery at that time and again in February 1975. A VA hospital summary for a period of hospitalization from February to April 1975 was incorporated into the claims file in November 1975. The veteran was treated for left flank pain, sigmoid kidney, right hydronephrosis, obstruction in both pelvocaliceal systems, and diminished right parenchyma. While the veteran was hospitalized, a right pyeloplasty was performed. The diagnoses included sigmoid kidney with crossed and fused renal ectopia, left ureterolithiasis, and right ureteropelvic junction obstruction. By rating decision of February 1976, the RO granted service connection for a laparotomy scar. However, the RO denied the veteran's claim for service connection for a kidney disorder. It was determined that the veteran's kidney disability was congenital in nature and had not been permanently aggravated by his military service. The veteran was notified of this decision and his appellate rights by letter of March 1976. In March 1976, the veteran filed a notice of disagreement with the RO's decision of February 1976 that denied his claim for service connection for a kidney disability. A statement of the case (SOC) was issued in April 1976. However, this SOC only dealt with the issues of service connection for psychiatric and stomach disabilities. The veteran submitted a written statement in October 1976 in which he reported that he had no additional records to submit regarding his claims. He asserted that his service incurred ailments rendered him unable to engage in gainful activity. By letter of November 1976, the RO informed the veteran that his claim for service connection for a kidney disability remained denied and that a compensable evaluation for his laparotomy scar was not warranted. He was again informed of his appellate rights. In December 1991, the veteran requested that his claim for service connection for residuals of an operation he received in the military be reopened. The RO sent a letter to the veteran in January 1992 informing him that his laparotomy scar was service-connected. He was informed that to receive an increased evaluation for this disorder he needed to submit medical evidence of its increased severity. The RO also noted that the veteran's claim for service connection for a psychiatric disability had previously been denied. He was instructed to submit new and material evidence regarding this issue in order to reopen it. The veteran was further informed that his failure to submit this type of evidence could have an adverse effect on his claims. The report of a private psychiatric examination dated in December 1991 was submitted in January 1992. The diagnosis was major depression without psychotic features. A private physician's letter was also received in January 1992. This physician noted that the veteran had been treated since 1986 for renal and urinary problems, chronic anxiety, and "manic depressive." The veteran's VA medical records dated from November 1991 to January 1992 were associated with the claims file in March 1992. A discharge summary of December 1991 reported that the veteran had been hospitalized with psychiatric complaints. The diagnosis was substance abuse disorder (cocaine) with secondary depression. He was also treated for low back pain in January 1992. The veteran's private counseling records dated from August to December 1991 were received in April 1992. These records noted the veteran's psychiatric complaints and diagnoses for anxiety, nervousness, and questionable schizophrenia. Other noted problems included possible lumbar hernia, renal problems, frequent urinary infections, and neurodermatitis. His therapist advised him to file for Social Security Administration (SSA) disability benefits. An additional set of private medical records was received in April 1992. However, these records were written in Spanish and the translator noted that the writing was too illegible to prepare a useful translation into English. A letter from the veteran's private psychiatrist dated in November 1991 was received in April 1992. This letter noted the veteran had been treated for major depression with psychotic symptoms. It was recommended that he receive a psychiatric hospitalization. In a rating decision of May 1992, the RO denied an increased evaluation for the veteran's laparotomy scar. It was also determined that the evidence of record did not indicate that the veteran's current psychiatric disability had been incurred during his military service or any applicable presumptive period. The veteran's renal disability was also determined not to have been incurred in the military or any applicable presumptive period. By letter of the same month, the RO informed the veteran of these decisions and his appellate rights. The veteran appealed this decision. A private psychiatric examination of April 1992 was received in June 1992. It appears that this examination was conducted in connection with the veteran's claim for SSA disability benefits. The examiner noted that the veteran had a medical history that included psychiatric and renal problems. It was then noted that "[e]verything seems to indicate that he became sick in the U.S. Army, but he cannot be specific about the year. As time went by the condition got worse." It was the examiner's opinion that the veteran could not perform any kind of work because of his problems with concentration and memory. The diagnosis was major depression, single episode, without psychotic features. At his hearing on appeal in August 1992, the veteran's representative contented that the veteran had entered the military in normal condition. It was noted that he had been kicked in the abdomen by a fellow soldier and started to bleed. This injury was asserted to have resulted in the veteran's military surgery. By the time the veteran returned home, he weighted 93 pounds. When he entered the military he had weighted between 160 to 170 pounds. It was noted that the veteran had required another renal operation in 1975. The representative related that the veteran had been told by his VA surgeon that his renal blockage at that time had been caused by the surgery performed while he was in the military. It was contended that the veteran's laparotomy scar was "long and awful" and required the veteran to wear a shirt all the time, even when swimming. The representative noted that the veteran had been awarded SSA benefits for his claimed disabilities. The veteran testified that his laparotomy scar caused his legs to swell resulting in his inability to walk. He also claimed that this scar caused pain in his back and legs and prevented him from bending over. The veteran alleged that his psychiatric disability had been caused by the pressures and surgery during his military service. It was the veteran's testimony that he did not have a "high" education and could only do manual labor, which his claimed disabilities prevented. He believed that had he not been injured in the military he would now have been a normal individual. The veteran alleged that he was able to function properly in sports prior to his service in the military. He acknowledged that his military physicians had told him that he had a congenital kidney disorder, but he emphasized that he had been found to be normal at the time of his entrance into the military. The veteran could not remember when he had first been treated for his psychiatric complaints. His mother testified that the veteran had been healthy when he entered the military, but had returned home looking like a skeleton. It had been a struggle for the veteran to get better. It was reported that the veteran had been treated by a local physician soon after leaving the military, but this physician was now dead and the family's attempts to obtain these records had been futile. The veteran's spouse testified that she had married the veteran in 1979. At the time she met the veteran, he complained of kidney problems. He now had back, kidney, and feet problems that the physicians had linked to his "abdomen" condition. She noted that the veteran had first received psychiatric treatment in 1991. The Board remanded this case in February 1995 for development of the medical evidence. Specifically, the RO was instructed to request the veteran's pertinent medical records and SSA records. He was to be informed about the private outpatient records that had been found illegible for translation and provided the opportunity to submit translated copies. Finally, he was to be given VA psychiatric, renal, and surgical examinations to evaluate his claimed disabilities. By letter of March 1995, the RO requested that the veteran complete an authorization form so that his private medical records could be obtained. He was also informed that parts of his private medical records were illegible and that he should submit legible copies. The veteran was warned that his failure to provide this evidence could have an adverse effect on his claims. Also in March 1995, the RO requested the veteran's pertinent SSA records. Copies of the veteran's SSA records were obtained in April 1995. In a June 1992 decision, the SSA determined that the veteran had been disabled since October 1991 due to depression and renal lithiasis. This evidence consisted mostly of VA medical records dated from November 1991 to March 1992 that noted treatment for the veteran's psychiatric, renal, and substance abuse complaints. The veteran was afforded a series of VA examinations in July 1995. A nephrology examination noted that the veteran's history included operations for repair of a laceration of the right renal parenchyma in 1972 and complications from renal stones in 1975 and 1994. The examiner noted that the veteran's medical records were not available for review. On the basis of the veteran's oral history and physical examination, the diagnoses were congenital crossed renal ectopia with fusion (horseshoe kidney), status post repair of small laceration on the right renal parenchyma in 1975, nephrolithiasis in 1978 with status post right pyeloplasty, and nephrolithiasis in 1974 with status post surgery. The psychiatric examination noted that the veteran had two VA hospitalizations for his psychiatric complaints, the first was in November 1991 and the latter was in July 1993. It was claimed by the veteran that he had not worked in the last seven years and complained of difficulty sleeping. He acknowledged a past history of substance abuse, but asserted he had abstained from such use since 1993. The veteran asserted that his substance abuse started "since" his days in active military service. After examination, the diagnoses were substance use disorder in apparent remission by history and psychophysiological genitourinary disorder by history. In a letter of April 1996, the veteran informed the RO that he had been unable to obtain copies of his private medical records. He noted some of these records were now unavailable and the rest would require the payment of a fee that he could not afford. The veteran's representative contended in May 1996 that the VA examination of July 1995 was inadequate, as it did not provide a nexus opinion between the veteran's current psychiatric disability and his experiences in the military. A new examination was requested. The RO sent a letter to the veteran in May 1996. He was informed that the RO had directly requested copies of the medical evidence for which he claimed a fee was required. The veteran was warned that any failure in the VA receiving this evidence could adversely effect his claims. In late June 1996, the RO informed the veteran that its letter to his private physician had been returned because the provided address was insufficient. He was requested to provide a complete address for this physician. He responded to this inquiry and another letter requesting the veteran's private medical records were sent to his physician in early July 1996. The veteran's private psychiatrist submitted a report of the veteran's treatment in March 1997. It was noted that the veteran had been treated from November 1991 to July 1994. The physician reported that the veteran's mother felt that he was already "sick" when he was discharged from the military, but had refused treatment for many years after this time. The diagnosis was major depression, single episode, with severe psychosis. The psychiatrist wrote: [The veteran's] psychiatric condition began during his time in the military service...the evolution of his sickness was gradual and deceiving/deceptive up to some point that it became a very noticeable psychiatric condition. In early April 1997, the veteran was given another VA nephrology examination. It was noted that a review of the veteran's medical records indicated that the veteran had undergone a right pyeloplasty in 1972 and, in 1975, had an ureteropelvic obstruction secondary to high ureteral insertion and right pyeloplasty. The veteran noted his history of an abdomen injury and exploratory surgery in the military. He claimed that he had developed a kidney stone one year later due to hematuria resulting from his in-service injury. The veteran complained of intermittent right upper quadrant and right flank pain with suprapubic discomfort lasting up to two hours. He claimed to take prescription medication to control this pain. The veteran also complained of intermittency, hesitancy, and nocturia twice every night for the last year. He felt a burning sensation on urination. After examination, the assessments were intermittent right upper quadrant and right flank pain the etiology of which needed to be determined, palpable mass probably the congenital cross renal ectopia of both kidneys, status post right pyeloplasty in 1972, history of recurrent kidney stones in 1975 and 1994, and ureteral pelvic obstruction secondary to high ureteral insertion and right pyeloplasty as noted in 1975. A urology examination was also given to the veteran in early April 1997. He complained of right side pain and intermittent dyspnea. On examination, the veteran's abdomen was noted to be tender over the site of his scar. The assessment was crossed and fused renal ectopia, right hydronephrosis, left renal calculus, and nephralgia. It was opined by the examiner that the veteran's abdominal pain may be due to either right hydronephrosis or to a renal calculus (kidney on right side of abdomen). A VA psychiatric examination was provided to the veteran in late April 1997. It was noted by the examiner that he had reviewed the veteran's medical history. The veteran complained of depressed mood, anxiety, prominent difficulty sleeping, and auditory hallucinations. He believed that he had started to experience psychiatric symptoms in 1975, but did not seek treatment until 1991. The veteran acknowledged a history of substance abuse, but asserted that he currently abstained from such use. After an examination of the veteran, the diagnosis was major depressive illness. The examiner noted the following: I cannot elicit either from the records or from the patient's own description just when this illness would have had its obvious beginning. The matter is complicated further by the fact that he has a many year history of substance abuse. Since he has been free of any illicit substances for a number of years and the psychiatric disturbance is prominent, I can say with some degree of confidence that the illness was not caused by his substance abuse. The only way of relating his psychiatric illness to his military service would be in the form of dating the onset of symptoms of psychiatric illness. By his own description and by the records I cannot tell when it began, but have no reason to say that it began during military service. I would not attribute a causative relationship between his military experience or any physical problems that he might have experienced during that time to his psychiatric illness. A VA discharge summary of July 1997 reported that the veteran had been hospitalized for placement of an indwelling stent. The diagnoses were crossed and fused renal ectopia, right hydronephrosis, and left renal calculus. The veteran was afforded a VA general medical examination in early August 1997. The diagnosis was cross fused renal ectopia with recurrent kidney stones and urinary tract obstructions. It was noted by the examiner that the veteran's recent surgery presumably had removed his urinary tract obstruction. Another VA psychiatric examination was provided to the veteran in mid-August 1997. The examiner reported that he had previously interviewed the veteran in April 1997 and had provided an opinion on the etiology of his current psychiatric disability in that examination report. The diagnosis was major depressive illness. It was commented by the examiner that: There is no change in the individual's mental illness...I cannot date the origin of this individual's illness any better than I could in April. I cannot describe any more clearly what relationship is possible between his military service and his psychiatric illness any better than what I did in April 1997. In May 1998, the veteran's VA medical records dated from March 1992 to May 1998 were associated with the claims file. These records noted continued treatment of the veteran's psychiatric and genitourinary complaints. VA medical records dated from August 1993 to August 1997 were incorporated into the claims file in May 1998. These records also reported the treatment of the veteran's genitourinary problems. A VA discharge summary reported that the veteran was hospitalized for progressive right flank pain. Radiological test results were noted to be consistent with hydronephrosis and he was hospitalized to undergo endoluminal ultrasound. While hospitalized, the veteran underwent right percutaneous endopyelotomy, right nephrostomy, and right double "J" insertion. The discharge diagnoses were right ureteropelvic obstruction and crossed fused renal ectopia. The veteran was given a VA genitourinary examination in July 1998. It was noted that the veteran was unable to speak English and the examiner was not able to obtain a medical history from him. It was noted by the examiner that he had reviewed the veteran's entire medical file. After examination, the diagnoses were crossed and fused renal ectopia with "UPJ" in the right and none on the left. It was opined that the veteran's radiating low back pain could be the result of his urological problems of chronic hydronephrosis and nephrolithiasis of the left kidney. Another VA genitourinary examination was provided to the veteran in December 1998 at which a translator was present. His history of an in-service abdominal injury and surgery was noted. It was also noted that the veteran had experienced multiple renal stones that required surgery in 1974, 1994, and 1997. After a physical examination, the examiner provided diagnoses for crossed and fused renal ectopia, urolithiasis, and chronic lower back and abdomen pain. The examiner described the veteran's in-service abdomen injury and laparotomy and opined: I see no evidence that this trauma had any aggravating effect on [the veteran's] congenital kidney disease or altered its course...[His] congenital fussed renal ectopia - horseshoe kidney - detected in 1972 and [his] recurrent kidney stones [are] not infrequently seen with above condition...His chronic pain in the abdomen and lower back could be related to the scars and adhesions from previous surgeries and right hydronephrosis. A supplemental statement of the case (SSOC) was issued to the veteran in January 1999. This SSOC informed the veteran that his claims for service connection for psychiatric and kidney disabilities had been denied as neither disorder was incurred or linked to his military service or any appropriate presumptive period. II. Service Connection. a. Applicable Criteria. Service connection may be granted for disability resulting from personal injury suffered or disease contracted in the line of duty or for aggravation of a pre-existing injury suffered, or disease contracted, in the line of duty. 38 U.S.C.A. §§ 1110, 1131 (West 1991); 38 C.F.R. §§ 3.303, 3.304 (1998). Where a veteran served ninety days or more during a period of war or during peacetime service after December 31, 1946, and a psychosis, calculi of the kidney, and/or nephritis becomes manifest to a degree of ten percent within one year 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. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 1991 and Supp. 1999); 38 C.F.R. §§ 3.307, 3.309 (1998). This presumption is rebuttable by affirmative evidence to the contrary. Id. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (1998). The veteran will be considered to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable (obvious or manifest) evidence demonstrates that an injury or disease existed prior thereto. Only such conditions as are recorded in examination reports are to be considered as noted. 38 C.F.R. § 3.304(b) (1998). A preexisting injury or disease will be considered to have been aggravated by active military service, where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. Clear and unmistakable evidence (obvious or manifest) is required to rebut the presumption of aggravation where the preservice disability underwent an increase in severity during service. This includes medical facts and principles which may be considered to determine whether the increase is due to the natural progress of the condition. Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. The usual effects of medical and surgical treatment in service, having the effect of ameliorating disease or other conditions incurred before enlistment, including postoperative scars, absent or poorly functioning parts or organs, will not be considered service- connected unless the disease or injury is otherwise aggravated by service. 38 C.F.R. § 3.306(a), (b) (1998). In order for a claim to be well grounded, there must be competent evidence of a current disability in the form of a medical diagnosis, of incurrence or aggravation of a disease or injury in service in the form of lay or medical evidence, and of a nexus between the in-service injury or disease and the current disability in the form of medical evidence. Caluza v. Brown, 7 Vet. App. 498 (1995). Where there is a chronic disease shown as such in service or within the presumptive period under 38 C.F.R. § 3.307 (1998) so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b) (1998). This rule does not mean that any manifestation in service will permit service connection. To show chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." When the disease identity is established, there is no requirement of evidentiary showing of continuity. Continuity of symptomatology is required where the condition noted during service or in the presumptive period is not shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the condition noted during service is not shown to be chronic or the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). The regulation requires continuity of symptomatology, not continuity of treatment. Wilson v. Derwinski, 2 Vet. App. 16, 19 (1991). The United States Court of Appeals for Veterans Claims (known as the United States Court of Veterans Appeals prior to March 1, 1999) (hereinafter, "the Court") has established the following rules with regard to claims addressing the issue of chronicity. The chronicity provision of 38 C.F.R. § 3.303(b) is applicable where evidence, regardless of its date, shows that a veteran had a chronic condition in service and still has such condition. Such evidence must be medical unless it relates to a condition as to which, under the Court's case law, lay observation is competent. If the chronicity provision is not applicable, a claim may still be well grounded if (1) the condition is observed during service, (2) continuity of symptomatology is demonstrated thereafter and (3) competent evidence relates the present condition to that symptomatology. Savage v. Gober, 10 Vet. App. 489 (1997). A lay person is competent to testify only as to observable symptoms. See Savage; Falzone v. Brown, 8 Vet. App. 398, 403 (1995). A lay person is not, however, competent to provide evidence that the observable symptoms are manifestations of chronic pathology or diagnosed disability. Id. Where the determinant issue involves a question of medical diagnosis or medical causation, competent medical evidence to the effect that the claim is plausible or possible is required to establish a well-grounded claim. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). Although the veteran is competent to testify as to his in-service experiences and symptoms, where the determinative issue involves a question of medical diagnosis or causation, only individuals possessing specialized medical training and knowledge are competent to render such an opinion. Espiritu v. Derwinski, 2 Vet. App. 492 (1992). Lay assertions of medical causation will not suffice initially to establish a plausible, well- grounded claim, under 38 U.S.C.A. § 5107(a). Grottveit v. Brown, 5 Vet. App. 91 (1993). b. Service Connection for a Psychiatric Disability. Initially, the undersigned notes that this issue had been previously denied in a rating decision of October 1976. This decision is final. However, in its rating decision of May 1992, it appears that the RO reopened this claim on the basis of the veteran's submission of new and material evidence. The undersigned concurs with this determination and will proceed with an analysis of the merits of the claim. The undersigned also finds that this claim is well-grounded. The medical evidence indicates that the veteran has a current psychiatric disorder and a private physician opined in March 1997 that this disorder was related to the veteran's military service. Thus, the veteran has filed a plausible claim for service connection. See Caluza v. Brown, 7 Vet. App. 498 (1995). The Board is also satisfied that all appropriate development has been completed. Specifically, the VA has retrieved or attempted to obtain all pertinent evidence identified by the record. It has obtained private, VA, and SSA medical evidence; provided the veteran with an opportunity to submit legible copies of his private medical records; and conducted the requested examinations with appropriate opinions. The undersigned is also satisfied that the RO has fully complied with its remand instructions of February 1995. See Stegall v. West, 11 Vet. App. 268 (1998). In addition, the VA has repeatedly informed the veteran of the evidence required to establish his claims for service connection to include the RO's letter of January 1992, a SOC and multiple SSOCs, and the Board's remand of February 1995. See Robinette v. Brown, 8 Vet. App. 69 (1995). Therefore, the VA has met its obligations under 38 U.S.C.A. § 5107(a) (West 1991). The service medical records do not contain any treatment or diagnosis for a psychiatric disability. The first medical evidence of a psychiatric disorder was the private physician's letter of August 1973 that indicated the veteran had been treated for depression since March 1973. This physician failed to note any diagnosis for a psychosis. The lay evidence has placed the onset of the veteran's current psychiatric disability at a later date. His psychosis was first diagnosed in late 1991. Two nexus opinions of record were given by private physicians, the first in April 1992 and the other in March 1997. These opinions linked the veteran's psychiatric disorder with his experiences in the military. However, it appears that these opinions were based only on the subjective history as related by the veteran and not on a review of the veteran's entire medical history. The Court has held that medical opinions based on the veteran's own subjective opinion without reference to his past medical records do not establish an adequate medical nexus to military service. Godfrey v. Brown, 8 Vet. App. 113 (1995). A VA psychiatrist's opinion was sought in April 1997. This physician conducted a thorough review of the veteran's medical history and interviewed him directly. The examiner found no reason to link the veteran's current psychiatric disability to his experiences in the military. It is the undersigned's determination that the VA examination of April 1997 is of more probative value then the private physician's opinions as it was based on a thorough review of the veteran's entire medical history. The VA examiner's opinion is also buttressed by the lay evidence which places his psychiatric disorder's onset years after his separation from the military. As the veteran and his family are lay persons, they cannot provide competent evidence on the etiology of his current psychiatric disorder. Zang v. Brown, 8 Vet. App. 246 (1995). The lay evidence regarding the veteran's psychiatric symptoms has tended to place its onset many years after service. There is objective evidence that the veteran suffered with some type of depressive illness beginning two months after his separation from the military. However, as this is not a psychosis disorder, the presumptive period found at 38 C.F.R. § 3.307 and 3.309 is not applicable. The medical opinion with the most probative value, the VA examiner's opinion of April 1997, has found no substantive link between the veteran's psychiatric disorder and his military service. In an examination of October 1973, the veteran's current psychiatric disorder was linked to his kidney disorder. As noted in the following section of this decision, the veteran's kidney disorder is congenital in nature and not service-connected. Therefore, this etiological opinion cannot be used to establish service connection. The veteran has also been diagnosed with a substance abuse disorder. However, the lay evidence indicates that the veteran did not start using illicit drugs until after his separation from the military. The veteran has not contended that his substance abuse began during his military service. Thus, this diagnosis also cannot be a basis for service connection. Based on the above analysis, the undersigned finds that the preponderance of the evidence is against the veteran's claim for service connection for a psychiatric disability. Thus, this claim must be denied. c. Service Connection for a Kidney Disorder. A review of the claims file indicates that this issue had been denied in a rating decision of February 1976. The veteran filed a timely NOD to this decision, but no SOC was issued to the veteran until the current appeal in July 1992. Thus, the undersigned finds that the February 1976 rating decision was not final regarding this issue and the case has remained open to the present time. The veteran suffered an abdominal injury to his genitourinary system during his military service in addition to being found to have a congenital disorder. He currently has kidney disorders and has claimed to have had continual genitourinary symptomatology since his military service. Under these circumstances, the undersigned finds this claim to be well- grounded. Savage v. Gober, 10 Vet. App. 488 (1997). It is also determined that all development required by the duty to assist has been conducted. (See discussion of 38 U.S.C.A. § 5107(a) and Stegall in previous section). There is no debate in the medical evidence that the veteran's crossed and fused renal ectopia ("caked" or horseshoe- shaped kidney) is a congenital defect. This finding was repeatedly noted by both military and post-service examiners. However, the veteran did suffer a laceration of the right renal parenchyma during his military service that was surgically repaired. At the time of his release from active service, this injury was determined not to have aggravated his congenital kidney disorder. The medical evidence indicates that the veteran has had ongoing genitourinary problems since his military service. A SSA examination of April 1992 indicated that the veteran's current genitourinary disorders were incurred in his military service, however, this opinion was noted to be based on the veteran's own subjective history. An April 1997 nephrology examination associated the veteran's ureteral pelvic obstruction to a right pyeloplasty, but the assessment indicated that the causative pyeloplasty was performed in 1975 and not during the veteran's military service. Finally, a VA genitourinary examiner in December 1998 ruled out any causative factor between the veteran's military trauma and his current kidney disorders. This examiner, after a review of the veteran's entire medical history and an examination, found no etiological link between the abdominal trauma in service and the veteran's subsequent kidney problems. The lay evidence indicates that the veteran has had continual genitourinary symptoms since his military service. As noted above, lay opinion is not competent evidence of a diagnosis or etiology. He claimed at his hearing on appeal in August 1992 that the VA physician who performed his renal surgery in 1975 had told him that his kidney problems at that time were the result of his in-service trauma and/or surgery. However, a review of the medical records discussing the 1975 surgery do not evidence such an opinion. In Espiritu v. Derwinski, 2 Vet. App. 492,495 (1992), the Court held that any statement of an appellant as to what a physician told him or her is insufficient to establish a medical diagnosis or etiology. The medical evidence is overwhelming that the veteran's kidney abnormality is congenital in nature. The only medical opinions of record discussing whether the veteran's kidney disorder was aggravated by his military service have both found this not to be the case. Based on this analysis, the undersigned finds that there is clear and convincing evidence that the veteran's kidney disorder was congenital and was not permanently aggravated by his military service. Therefore, his claim for service connection must be denied. ORDER Service connection for a psychiatric disability is denied. Service connection for a kidney disorder is denied. REMAND The veteran is service connected for the residuals of a laparotomy scar. This disorder is currently evaluated as 10 percent disabling under 38 C.F.R. Part 4, Diagnostic Code 7805. The veteran has contended that he experiences abdominal pain that limits his functional ability, specifically this pain prevents him from bending. A VA surgical examination of August 1997 noted a medical opinion that the veteran's claimed pain was not related to his surgical incision. In March 1998, a VA neurologist found no neurological basis for the veteran's complaints of back pain. However, this examiner failed to discuss any pain associated with the veteran's abdominal scars. Contravening these findings was a July 1995 VA examiner that determined the veteran's abdominal scar limited his functioning, but failed to describe this limitation in detail. A VA genitourinary examiner in December 1998 opined that the veteran's abdominal pain was, in part, the result of adhesions from his surgical scar. Since his separation from the military, the veteran has undergone multiple surgeries for his kidney problems. After a review of the record, the undersigned is unable to determine which of these scars is responsible for the veteran's current abdominal pain. It is also evident that the RO has not evaluated the veteran's limitation of motion due to this pain as required by Code 7805. Thus, this issue must be remanded for a medical examination and adjudication to address these matters. Under the circumstances, the undersigned finds that further development is required, and the case is REMANDED to the RO for the following action: 1. The RO should appropriately contact the veteran and request the names and addresses of all healthcare providers who treated his laparotomy scar from December 1998 to the present time. After securing the necessary release(s), the RO should obtain any records not already contained in the claims file; to include those from any identified VA medical center or outpatient clinic. Once obtained, all records must be associated with the claims folder. 2. Following completion of the above development, the veteran should be afforded a VA surgical examination. The purpose of this examination is to determine the residuals and severity of the veteran's service-connected laparotomy scar. Specifically, it should be determined if this scar in anyway interferes with the veteran's functional ability. Such tests as the examining physician deems necessary should be performed. The clinical findings and reasons upon which the opinions are based should be clearly set forth. The claims folders must be made available to the examining physician in connection with the examination so that he or she may review pertinent aspects of the veteran's medical history. If the examiner finds it impossible to answer any of the questions below, it should be so noted on the examination report with the reasons given for this conclusion. The examiner should provide the following opinions: a. Describe in detail the veteran's laparotomy scar that resulted from his in-service surgery in 1972. This description should include exact location and measurement of this scar. b. Does the veteran's laparotomy scar from his surgery in 1972 interfere with his functional ability? Identify all affected joints and their range of motion. 3. Thereafter, the RO must review the claims folders and ensure that all of the foregoing development actions have been conducted and completed in full. If any development is incomplete, including if the requested examination does not include all opinions requested, appropriate corrective action is to be implemented. 4. Following completion of this action, the RO should review the evidence and determine whether the veteran's claim for an increased evaluation for a laparotomy scar may now be granted. The RO should specifically determine if an increased evaluation is warranted under 38 C.F.R. Part 4, Diagnostic Code 7805 for limitation of motion of an affected joint. If this decision remains adverse to the veteran, he and his representative should be furnished an appropriate SSOC, and be given an opportunity to respond. Thereafter, the case should then be returned to the Board for further appellate consideration of all issues which are properly on appeal. This claim must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Veterans Appeals for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 1999) (Historical and Statutory Notes). In addition, VBA's Adjudication Procedure Manual, M21-1, Part IV, directs the RO's to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44-8.45 and 38.02-38.03. The veteran need take no further action until he is notified. The purpose of this REMAND is to obtain additional medical information. No inference should be drawn regarding the final disposition of the claim as a result of this action. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded to the regional office. Kutscherousky v. West, 12 Vet. App. 369 (1999). BARBARA B. COPELAND Member, Board of Veterans' Appeals