Citation Nr: 0011459 Decision Date: 05/01/00 Archive Date: 05/09/00 DOCKET NO. 94-41 939A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUES 1. Entitlement to service connection for post-traumatic stress disorder (PTSD). 2. Entitlement to service connection for parotid tumor and subcutaneous nodules below the ear lobes secondary to exposure to herbicide agents. 3. Entitlement to an evaluation in excess of 10 percent for bronchitis. 4. Entitlement to a compensable evaluation for bilateral hearing loss. 5. Entitlement to a compensable evaluation for bilateral otitis externa. 6. Entitlement to a compensable evaluation for tinea pedis. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Jeffrey J. Schueler, Counsel INTRODUCTION The appellant had active service from November 1966 to November 1968. This matter comes to the Board of Veterans' Appeals (Board) from a March 1994 rating decision of the Department of Veterans Affairs (VA) Los Angeles Regional Office (RO) which (1) denied the appellant's application to reopen the claim of service connection for PTSD, previously denied by March 1984 Board decision; (2) denied a claim of service connection for parotid tumor and subcutaneous nodules below the ear lobes secondary to exposure to herbicide agents in Vietnam; (3) denied a claim for an evaluation in excess of 10 percent for bronchitis; and denied claims seeking compensable evaluations for bilateral hearing loss, bilateral otitis externa, and tinea pedis. The appellant disagreed with these determinations and this appeal ensued. For the reasons discussed below, the Board herein determines that the appellant has submitted new and material evidence, thereby reopening the previously denied claim of service connection for PTSD. The issued regarding PTSD is, therefore, as styled on the title page of this decision. The claims of entitlement to service connection for PTSD, an evaluation in excess of 10 percent for bronchitis, and a compensable evaluation for tinea pedis are addressed in the Remand portion of this decision below. FINDINGS OF FACT 1. The additional evidence concerning PTSD, received into the record after March 1984, is new, probative, and material, as it bears directly and substantially on the specific matter at hand. 2. Competent evidence has been submitted linking the current findings of PTSD to service. 3. No competent evidence has been submitted linking the post-service findings of parotid tumor and subcutaneous nodules below the ear lobes to service. 4. The most recent audiometry showed an average pure tone loss of 36 decibels (dB) in the right ear and 38 dB in the left ear with speech recognition ability of 92 percent correct, bilaterally. 5. The otitis externa disability is constant, manifested by a cloudy-yellow left tympanic membrane, erythema with exudate against the tympanic membranes, and a painful right ear with a swollen and purulent canal, fungus, and candidiasis. CONCLUSIONS OF LAW 1. The appellant has submitted new and material evidence to reopen the matter of entitlement to service connection for PTSD. 38 U.S.C.A. § 5108 (West 1991); 38 C.F.R. § 3.156(a) (1999). 2. The claim of service connection for PTSD is well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 3. The claim of entitlement to service connection for parotid tumor and subcutaneous nodules below the ear lobes is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 4. The criteria for a compensable evaluation for bilateral hearing loss are not met. 38 U.S.C.A. §§ 1155, 5107(a) (West 1991); 38 C.F.R. §§ 4.1, 4.2, 4.85, 4.86, 4.87, Diagnostic Code 6100 (1999). 5. The criteria for a 10 percent evaluation for otitis externa are met. 38 U.S.C.A. §§ 1155, 5107(a) (West 1991); 38 C.F.R. §§ 4.1, 4.2, 4.87a, Diagnostic Code 6210 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Service Connection Claims A. Reopening of PTSD Determination The Board in March 1984 denied the appellant's claim of service connection for PTSD, reasoning that the record did not include current medical evidence of the disorder. Decisions of the Board are final. 38 U.S.C.A. § 7104(a). Final decisions may not be reopened in the absence of new and material evidence. If new and material evidence is submitted, the claim will be reopened and adjudicated on the merits. 38 U.S.C.A. § 5108. New and material evidence means evidence not previously submitted to agency decisionmakers which bears directly and substantially on the specific matter under consideration, which is neither cumulative nor redundant, and which by itself or in connection with evidence previously assembled is so significant that it must be considered in order to fairly decide the merits of the claim. 38 C.F.R. § 3.156(a). Whether new and material evidence is submitted is a jurisdictional test, with the Board being required to reopen if such evidence is submitted and prohibited doing so and considering the claim if such evidence is not submitted. Barnett v. Brown, 83 F.3d 1380, 1383-84 (Fed. Cir. 1996); Winters v. West, 12 Vet. App. 203 (1999). VA must (1) determine whether the appellant has presented new and material evidence in order to have a finally denied claim reopened; (2) if so, determine whether the reopened claim is well grounded based upon all the evidence of record, presuming its credibility; and (3) if the claim is well grounded, evaluate the merits of the claim after ensuring that VA's duty to assist has been fulfilled. Elkins v. West, 12 Vet. App. 209, 214 (1999); Winters, 12 Vet. App. at 206- 07. Thus, the Board must determine whether the appellant has submitted new and material evidence. See Hodge v. West, 155 F.3d 1356, 1363 (Fed. Cir. 1998); Elkins, 12 Vet. App. at 214 (must provide a more complete picture of the circumstances surrounding the origin of an injury or disability, though it need not convince the Board to alter the prior rating decision). Since March 1984, the record shows receipt of additional evidence, including copies of private and VA clinical, hospital, and examination records documenting current findings of PTSD. This additional evidence is new and material as it may provide a more complete picture of the circumstances surrounding the origin of the claimed disability. Therefore, the application to reopen the claim is granted. B. Pertinent Law and Regulations Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Because the appellant served continuously for 90 days or more during a period of war, psychosis and sensorineural hearing loss manifest to a degree of 10 percent within one year from the date of termination of such service shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. The threshold question in any such case is whether the appellant has presented evidence of a well-grounded claim. See 38 U.S.C.A. § 5107(a); Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). A well-grounded claim is a plausible claim that is meritorious on its own or capable of substantiation. See Murphy, 1 Vet. App. at 81. An allegation of a disorder that is service connected is not sufficient; the appellant must submit evidence in support of a claim that would justify a belief by a fair and impartial individual that the claim is plausible. 38 U.S.C.A. § 5107(a); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992). The quality and quantity of the evidence required to meet this statutory burden of necessity will depend upon the issue presented by the claim. Grottveit v. Brown, 5 Vet. App. 91, 92-93 (1993). For a claim to be well grounded, there must be competent medical evidence of a current disability, lay or medical evidence of incurrence or aggravation of a disease or injury in service, and competent medical evidence of a nexus, or link, between the in-service injury or disease and the current disability. Epps v. Gober , 126 F.3d 1464, 1468 (Fed. Cir. 1997); Caluza v. Brown, 7 Vet. App. 498 (1995). A claim may also be well grounded if the condition is observed in service or during an applicable presumptive period, if continuity of symptomatology is demonstrated thereafter, and if competent evidence relates the present condition to that symptomatology. 38 C.F.R. § 3.303(b); Savage v. Gober, 10 Vet. App. 488 (1997). A well-grounded claim of service connection for PTSD requires medical evidence of a current disorder, lay evidence, presumed credible, of an in-service stressor, and medical evidence linking the two. Gaines v. West, 11 Vet. App. 353, 357 (1998); Cohen (Douglas) v. Brown, 10 Vet. App. 128 (1997). A claimant who, during active service, served in the Republic of Vietnam during the Vietnam era and has a disease listed at § 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. See 38 U.S.C.A. § 1116; 38 C.F.R. § 3.307(a). A "herbicide agent" is a chemical in a herbicide used in support of the U.S. and allied military operations in the Republic of Vietnam during the Vietnam era. 38 C.F.R. § 3.307(a)(6)(i). "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), 3.313. The "Vietnam era" is the period beginning on February 28, 1961 and ending on May 7, 1975, inclusive, in the case of a veteran who served in the Republic of Vietnam during that period. 38 C.F.R. § 3.2(f). The evidence of record reveals the appellant served in Vietnam as he received the Vietnam Service Medal and Vietnam Campaign Medal, both of which signify service in the Republic of Vietnam. Also, the service personnel records associated with the claims file indicate his service in Vietnam from March to November 1968. Thus, the record strongly supports the conclusion that the appellant served in Vietnam within the appropriate period, and thereby had qualifying Vietnam service. 38 C.F.R. §§ 3.2(f), 3.307(a)(6)(iii), 3.313(a). Because the appellant is presumed to have been exposed to a herbicide agent during active military, naval, or air service, the following diseases shall be service-connected if the requirements of 38 C.F.R. § 3.307(a)(6) are met, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 C.F.R. § 3.307(d) are also satisfied: chloracne or other acneform disease consistent with chloracne; Hodgkin's disease; non-Hodgkin's lymphoma; porphyria cutanea tarda; multiple myeloma; acute and subacute peripheral neuropathy; prostate cancer; respiratory cancers (cancers of the lung, bronchus, larynx, or trachea); and soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). The term "soft-tissue sarcoma" includes the following: adult fibrosarcoma; dermato-fibrosarcoma protuberans; malignant fibrous histiocytoma; liposarcoma; leiomyosarcoma; epithelioid leiomyosarcoma (malignant leiomyoblastoma); rhabdomyosarcoma; ectomesenchymoma; angiosarcoma (hemangiosarcoma and lymphangiosarcoma); proliferating (systemic) angioendotheliomatosis; malignant glomus tumor; malignant hemangiopericytoma; synovial sarcoma (malignant synovioma); malignant giant cell tumor of tendon sheath; malignant schwannoma, including malignant schwannoma with rhabdomyoblastic differentiation (malignant Triton tumor), glandular and epithelioid malignant schwannomas; malignant mesenchymoma; malignant granular cell tumor; alveolar soft part sarcoma; epithelioid sarcoma; clear cell sarcoma of tendons and aponeuroses; extraskeletal Ewing's sarcoma; congenital and infantile fibrosarcoma; and malignant ganglioneuroma. 38 C.F.R. § 3.309(e). The Secretary has determined that there is no positive association between exposure to herbicides and any other condition for which he has not specifically determined a presumption of service connection is warranted. 61 Fed. Reg. 41,446 (1996); 59 Fed. Reg. 341-46 (1994). The appellant is not, though, precluded from establishing service connection with proof of actual direct causation. Combee v. Brown, 34 F.3d 1039, 1041-42 (Fed. Cir. 1994). C. PTSD With respect to whether the claim of service connection for PTSD is well grounded, the record includes numerous private and VA clinical, hospital, and examination reports documenting diagnoses of PTSD. These documents satisfy the initial element of a well-grounded claim requiring competent medical evidence of a current disorder. See Gaines, 11 Vet. App. at 357. The record also indicates that the appellant served in Vietnam and that he claimed to have been exposed to combat. The truthfulness of this evidence must be presumed when determining whether a claim is well grounded, thereby satisfying the second element of a well-grounded claim. King v. Brown, 5 Vet. App. 19, 21 (1993). Finally, for the third element of a well-grounded claim, the record must include competent medical evidence linking the current disorder to the presumed in-service stressor. Gaines, 11 Vet. App. at 357. This requirement is satisfied by VA psychiatric examination in February 1997, which included a diagnosis of PTSD based at least in part on the appellant's asserted involvement in active combat in Vietnam during the Tet Offensive. Thus, the appellant has submitted competent evidence of a current disorder, a stressor in service, and a link between the two; thus, his claim is well grounded. Further development of the record is addressed in the Remand below. D. Parotid Tumor and Subcutaneous Nodules Below the Ear Lobes The initial concern raised by the appellant's allegation that he was exposed to herbicide agents in Vietnam is whether he currently has a disorder listed at 38 C.F.R. § 3.309(e), as is required to prevail in a presumptive service connection claim based on such exposure. The Board acknowledges the appellant's service in Vietnam. In addition, the record includes competent evidence of the appellant's complaints of parotid tumor and subcutaneous nodules below the ear lobes. May 1993 VA clinical records indicated that the appellant had excised a malignant-looking growth from behind his left ear and a pathology report concluded that the growth was a capillary hemangioma. VA clinical records from April to August 1996 noted the appellant's complaints of a subcutaneous nodule below the right ear lobe, the right parotid region, and multiple skin tags. These complaints and findings, though, do not represent a disorder listed at 38 C.F.R. § 3.309(e). In light of these findings, the Board cannot conclude that the appellant has a disorder listed at 38 C.F.R. § 3.309(e) presumptively related to herbicide exposure in Vietnam. Service connection may still be established with proof of actual direct causation. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(d); Combee, 34 F.3d at 1041-42. The initial inquiry is whether the claim is well grounded. See Epps, 126 F.3d at 1468. The May 1993 and April to August 1996 VA clinical records, discussed above, constitute competent medical evidence of a current disorder, thereby satisfying the initial element of a well-grounded claim. The appellant alleges that this current disorder arose in service, an assertion that must be presumed true for purposes of determining whether the claim is well grounded. See King, 5 Vet. App. at 21. As to the third element, requiring competent medical evidence linking the current parotid tumor and subcutaneous nodules below the ear lobes to herbicide exposure in Vietnam, Epps, 126 F.3d at 1468, pertinent evidence includes the following: ? The service medical records, which are silent as to any skin disease affecting the areas near the ears. ? VA examination in January 1969 indicating that the appellant complained of a rash in his crotch. Examination of the groin area failed to reveal any skin disease. ? VA examination in September 1974 revealed the appellant's complaints of a skin eruption on his hands and groin, which he stated started in Vietnam in 1967 and for which he claimed he was treated in service. The diagnoses included hyperhidrosis of the palms, mild dyshidrotic eruption of the hands, and probable atopic diathesis. ? A private social worker's statement in June 1987 showing that the appellant identified a rash on his legs, with pain and poor circulation. ? A VA clinical record in January 1988 noting the appellant's complaints of an itch on his penis with scales and erythematous lesions. The impression was monilial balanitis, an inflammation of the penis. ? A VA clinical record in April 1988, which found "jungle rot" as past medical history. ? A private clinical record in June 1994 showing the appellant's complaints of a growth on his body with itching on his legs. Significantly, the evidence summarized above does not discuss in any way the current findings of parotid tumor and subcutaneous nodules below the ear lobes. These documents discuss the appellant's complaints of rash on his legs, groin, or penis, but are silent as to any findings regarding a parotid tumor and subcutaneous nodules below the ear lobes. The first and only findings of this disorder are contained in the May 1993 and April to August 1996 VA clinical records. In short, there is no evidence linking such current findings to service or to the appellant's presumed exposure to herbicide agents in Vietnam. Thus, the record fails to establish any etiologic link between service and the current findings, or between these findings and any exposure to herbicide agents in service. The only opinion of record linking the appellant's current symptomatology with service or with exposure to herbicide agents in service is that of the appellant himself, in his various statements and December 1994 hearing testimony. Generally, statements prepared by lay persons, who are ostensibly untrained in medicine, cannot constitute competent medical evidence to render a claim well grounded. A lay person can certainly provide an eyewitness account of his/her visible symptoms. Layno v. Brown, 5 Vet. App. 465, 469 (1994); Moray v. Brown, 5 Vet. App. 211, 214 (1994). However, the capability of a witness to offer such evidence is different from the competence of a witness to offer evidence that requires medical knowledge. For the most part, a witness qualified as an expert by knowledge, skill, experience, training, or education must provide medical testimony. Espiritu v. Derwinski, 2 Vet. App. 492, 494-95 (1992). The record does not show that the appellant is trained to provide expert medical testimony, which therefore cannot serve as competent evidence providing the basis for a well-grounded claim. On review of the record, absent competent evidence of a nexus between the current symptomatology and service, or exposure to a herbicide agent in service, the claim is not well grounded. As the claim is not well grounded, VA cannot further assist the appellant in the development of the claim. 38 U.S.C.A. § 5107(a); Morton v. West, 12 Vet. App. 477, 485 (1999). Although where claims are not well grounded VA does not have a statutory duty to assist the claimant in developing facts pertinent to the claim, VA may be obligated under 38 U.S.C.A. § 5103(a) to advise a claimant of evidence needed to complete the application. This duty depends on the particular facts of the case and the extent to which VA has advised the claimant of the evidence necessary to be submitted with a VA benefits claims. Robinette v. Brown, 8 Vet. App. 69 (1995). In this case, the RO fulfilled its obligation under § 5103(a) in the August 1994 statement of the case and in the February 1995 and April 1999 supplemental statements of the case in which the appellant was informed that the reason for the denial of the claim was the lack of evidence linking a current skin disorder to service. Furthermore, by this decision, the Board is informing the appellant of the evidence which is lacking and that is necessary to make the claim well grounded. When the Board addresses in its decision a question that has not been addressed by the RO, in this case well groundedness, it must consider whether the appellant has been given adequate notice to respond and, if not, whether he has been prejudiced thereby. Bernard v. Brown, 4 Vet. App. 384 (1993). The Board finds that the appellant has been accorded ample opportunity by the RO to present argument and evidence in support of his claim. Any error by the RO in deciding this case on the merits, rather than being not well grounded, was not prejudicial to the appellant. II. Increased Rating Claims A. Pertinent Law and Regulations The claims of entitlement to compensable evaluations for bilateral hearing loss and bilateral otitis externa are well grounded; that is, they are capable of substantiation and not inherently implausible. See Drosky v. Brown, 10 Vet. App. 251, 254 (1997); Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992) (contention of an increase in disability severity renders claim well grounded). The Board finds that VA has satisfied its duty to assist the appellant in the development of facts pertinent to the claims. 38 U.S.C.A. § 5107(a). On review, the Board sees no areas in which further development may be fruitful. Disability evaluations are determined by the application of a schedule of ratings based on average impairment in earning capacity. 38 U.S.C.A. § 1155. Requests for increased disability ratings require consideration of the medical evidence of record compared to the criteria in the VA Schedule for Rating Disabilities. 38 C.F.R. Part 4. If the preponderance of the evidence is in favor of the veteran's claim, or the evidence is in equipoise, the claim will be granted. A claim will be denied only if the preponderance of the evidence is against the claim. See 38 U.S.C.A. § 5107 (West 1991); 38 C.F.R. § 3.102 (1996); Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). However, where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability to make a more accurate evaluation, regulations do not give past medical reports precedence over current findings. 38 C.F.R. § 4.2; Francisco v. Brown, 7 Vet. App. 55, 58 (1994). B. Bilateral Hearing Loss The evaluation of the bilateral hearing loss is governed by 38 C.F.R. § 4.85 and 4.86 of VA's Schedule for Rating Disabilities. Impairment of auditory acuity is evaluated using the criteria in 38 C.F.R. § 4.85.? The assignment of disability ratings for hearing impairment requires a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are rendered. Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). Evaluations of bilateral hearing loss range from noncompensable to 100 percent based on organic impairment of hearing acuity as measured by the results of controlled speech discrimination tests together with the average hearing threshold level as measured by pure tone audiometry tests in frequencies 1000, 2000, 3000, and 4000 cycles per second divided by four. To evaluate the degree of disability from bilateral service- connected defective hearing, the rating schedule establishes eleven auditory acuity levels designated from level "I" for essentially normal acuity through level "XI" for profound deafness. 38 C.F.R. § 4.85 and Part 4, Diagnostic Codes 6100 to 6110. The evaluations derived from this schedule are intended to make proper allowance for improvement by hearing aids. 38 C.F.R. § 4.86. When the pure tone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz (Hz)) is 55 dB or more, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral. 38 C.F.R. § 4.86(a). When the pure tone threshold is 30 dB or less at 1000 Hz, and 70 dB or more at 2000 Hz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral. That numeral will then be elevated to the next higher Roman numeral. 38 C.F.R. § 4.86(b). VA audiology evaluation in February 1993 showed pure tone thresholds, in dB, as follows: HERTZ 1000 2000 3000 4000 RIGHT 25 20 40 45 LEFT 25 20 55 50 Average pure tone loss in the right ear was 33 dB and in the left ear was 38 dB. Speech audiometry revealed speech recognition ability of 88 percent correct in the right ear and 80 percent correct in the left ear. Private audiology in January 1994 revealed mild to moderate sensorineural hearing loss in both ears. VA audiology in May 1996 showed pure tone thresholds, in dB, as follows: HERTZ 1000 2000 3000 4000 RIGHT 30 25 55 45 LEFT 30 25 55 60 The average pure tone threshold loss was 38 dB in the right ear and 45 dB in the left ear. Speech recognition ability was not measured. VA audiology in February 1997 showed pure tone thresholds, in dB, as follows: HERTZ 1000 2000 3000 4000 RIGHT 25 25 45 50 LEFT 20 20 55 60 Average pure tone loss on the right was 36 dB and on the left was 39 dB. Speech audiometry revealed speech recognition ability of 92 percent correct, bilaterally. Sensorineural hearing loss and the need for earplugs or hearing aids was also noted in May and August 1996 and September and November 1997 VA clinical records. To determine the appropriate evaluation, the audiometry measurements set forth above are applied to Table VI of 38 C.F.R. § 4.85. This application yields the following Roman numeric designation results: Examination: Right Ear: Left Ear: February 1993 II III January 1994 I II May 1996 I II February 1997 I I Each set of Roman numerals is then applied to Table VII to determine the percentage disability evaluation applicable to each test date. In this case, the analysis produces a noncompensable rating for each examination date. For this reasons, it is the determination of the Board that the preponderance of the evidence is against the claim of entitlement to a compensable rating for bilateral hearing loss. C. Bilateral Otitis Externa Service connection was established for bilateral otitis externa in an April 1969 rating decision, based on findings from the service medical records and a VA examination of chronic bilateral otitis media. The disability was assigned a noncompensable evaluation under the criteria of Diagnostic Code 6210. The appellant has, over the years, claimed that the disability has increased in severity. However, the RO has consistently denied these claims and continued the noncompensable evaluation. The evidence relevant to the current severity of the disability is as follows: ? VA ear, nose, and throat examination in February 1993 indicated intact tympanic membranes and canals. An audiology evaluation that same month showed that the appellant wore hearing aids, but had constant otitis externa with the aids inserted in his ears. ? A March 1993 VA clinical record noted the appellant's complaints of bilateral ear pain. Examination revealed the left tympanic membrane to be cloudy yellow. ? A June 1993 VA clinical record showed the appellant had a history of ear infections in both ears. Examination found erythema with exudate against the tympanic membranes, which were green in color. ? An October 1993 VA clinical record indicated a painful right ear, with a swollen and purulent canal. The diagnosis was otitis externa. ? VA clinical records in January 1994 revealed that the prior month the appellant had an ear infection, and that he has had frequent ear infections, fungus, and candidiasis in both ears, controlled with diet. ? At a hearing in December 1994, the appellant testified that he had constant otitis externa causing swelling and discomfort. ? A May 1996 VA clinical record noted intact tympanic membranes. ? An August 1996 VA clinical record noted the need for earplugs. ? VA audiology evaluation in February 1997 noted fungus in the ears. An audio-ear disease examination that same month revealed intact tympanic membranes and canals. A 10 percent evaluation under the criteria of Code 6210 requires competent medical evidence of swelling, dry and scaly or serous discharge, and itching requiring frequent and prolonged treatment. 38 C.F.R. § 4.87a. Documentation in 1993 identified symptomatology including constant otitis externa with hearing aids inserted into his ears, a cloudy- yellow left tympanic membrane, erythema with exudate against the tympanic membranes, and a painful right ear with a swollen and purulent canal. These findings correspond roughly with the rating criteria, thereby supporting a compensable evaluation. The January 1994 VA clinical records revealed that the prior month the appellant had an ear infection, and that as history he had frequent ear infections, fungus, and candidiasis in both ears, controlled with diet. The subsequent May and August 1996 VA clinical records and the February 1997 VA examination noted intact tympanic membranes, but the February 1997 VA examiner found fungus in the ears. These findings essentially show continuing otitis externa. Thus, it is the determination of the Board that the evidence supports a 10 percent evaluation for otitis externa under the criteria of Diagnostic Code 6210. Because the criteria of Code 6210 does not provide for an evaluation in excess of 10 percent, the Board must look to other potentially applicable diagnostic codes. The only other diagnostic codes that might provide for a higher evaluation are Code 6204 for chronic labyrinthitis, Code 6205 for Meniere's syndrome, and Code 6207 for loss of an auricle. However, the record is entirely silent as to any evidence suggesting chronic labyrinthitis, Meniere's syndrome, or loss of an auricle. Thus, an evaluation in excess of 10 percent is not appropriate. It is the determination of the Board that the evidence supports a 10 percent evaluation for otitis externa, and that the preponderance of the evidence is against an evaluation in excess of 10 percent. ORDER New and material evidence having been submitted in support of the claim of service connection for PTSD, the application to reopen the claim is granted. Service connection for a parotid tumor and subcutaneous nodules below the ear lobes is denied. Entitlement to a compensable evaluation for bilateral hearing loss is denied. Entitlement to a 10 percent evaluation for otitis externa is granted. REMAND As noted above, the claim of service connection for PTSD is well grounded. In addition, the claims of entitlement to an evaluation in excess of 10 percent for bronchitis and a compensable evaluation for tinea pedis are well grounded; that is, they are cabable of substantiation and not inherently implausible. See Drosky v. Brown, 10 Vet. App. 251, 254 (1997); Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992) (contention of an increase in disability severity renders claim well grounded). Thus, VA has a duty to assist the appellant in the development of facts pertinent to these claims. 38 U.S.C.A. § 5107(a). PTSD Prior to March 7, 1997, service connection for PTSD required medical evidence establishing a clear diagnosis of the condition, credible supporting evidence that the claimed in- service stressor actually occurred, and a link, established by medical evidence, between current symptoms and the claimed in-service stressor. If the claimed stressor was related to combat, service department evidence that the appellant engaged in combat or that he was awarded a combat citation would be accepted, absent of evidence to the contrary, as conclusive evidence of the claimed in-service stressor. 38 C.F.R. § 3.304(f) (1997). See Cohen, 10 Vet. App. at 136. Effective on and after March 7, 1997, service connection for PTSD required medical evidence diagnosing the condition in accord with 38 C.F.R. § 4.125(a); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. If the evidence established that the appellant engaged in combat with the enemy and the claimed stressor was related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor was consistent with the circumstances, conditions, or hardships of the veteran's service, the appellant's lay testimony alone could establish the occurrence of the claimed in-service stressor. See 64 Fed. Reg. 32,807-08 (June 18, 1999) (codified at 38 C.F.R. § 3.304(f) (1999)) and 38 C.F.R. § 4.125 (requiring PTSD diagnoses to conform to the criteria in AMERICAN PSYCHIATRIC ASSOCIATION, DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (4th ed. 1994) (DSM-IV)). When a regulation changes after a claim has been filed but before the administrative appeal process has been concluded, the version more favorable to appellant should apply. Karnas v. Derwinski, 1 Vet. App. 308, 313 (1991). The appellant's claims must be fully adjudicated under both the new and the old criteria to determine which version is more favorable. DeSousa v. Gober, 10 Vet. App. 461 (1997). The amendment is only effective on and after March 7, 1997, and may not retroactively applied prior to that date. 38 U.S.C.A. § 5110(g); VA O.G.C. Prec. Op. 3-2000 (Apr. 10, 2000). In approaching a claim of service connection for PTSD, the question of the existence of an event claimed as a recognizable stressor must be resolved by adjudicatory personnel. If the adjudicators conclude that the record established the existence of such a stressor(s), then and only then, should the case be referred for medical examination to determine the sufficiency of the stressor and as to whether the remaining elements required to support the diagnosis of PTSD have been met. In such a referral, the adjudicators should specify to the examiner(s) precisely what stressor or stressors has been accepted as established by the record, and the medical examiners must be instructed that only those events may be considered in determining whether the appellant was exposed to a stressor and what the nature of the stressor or stressors was to which the appellant was exposed. In other words, if the adjudicators determine that the record does not establish the existence of an alleged stressor or stressors in service, a medical examination to determine whether PTSD due to service is present would be pointless. Likewise, if the examiners render a diagnosis of PTSD that is not clearly based on stressors in service whose existence the adjudicators have accepted, the examination would be inadequate for rating purposes. West v. Brown, 7 Vet. App. 70 (1994); Zarycki v. Brown, 6 Vet. App. 91 (1993). See also Moreau v. Brown, 9 Vet. App. 389 (1996) (neither noncombat claimant's testimony alone nor medical statements finding a relationship between claimant's recitation of claimed stressors and a diagnosis of PTSD can qualify as corroborating evidence of a stressor). As discussed below, the RO should make a specific adjudicatory determination as to whether the appellant was in combat; if not, ask him to provide any further specific information as to his alleged stressors; utilize the assistance of the U.S. Armed Services Center for Research of Unit Records (USASCRUR); make a specific determination as to which stressor(s) are verified; and, only if a stressor has been verified, have the appellant examined by a VA psychiatrist to assess whether there is any link between any diagnosis of PTSD and any verified stressor. Bronchitis Prior to October 7, 1996, bronchitis was rated 10 percent disabling if there was competent medical evidence of a moderate degree of disability, with considerable night or morning cough, slight dyspnea on exercise, and scattered bilateral rales. A 30 percent evaluation could be assigned where there was competent medical evidence of a moderately severe degree of disability, such as a persistent cough at intervals throughout the day, considerable expectorant, considerable dyspnea on exercise, rales throughout the chest, and beginning chronic airway obstruction. The next higher rating of 60 percent was appropriate for a severe degree of disability characterized by such symptoms as severe productive cough and dyspnea on slight exertion and pulmonary function tests indicative of severe ventilatory impairment. A pronounced degree of disability, with copious productive cough and dyspnea at rest, pulmonary function testing showing severe chronic airway obstruction, symptoms of severe emphysema or cyanosis, and findings of right-sided heart involvement warrant a 100 percent rating. 38 C.F.R. § 4.97, Code 6600 (1996). Effective October 7, 1996, the regulation governing evaluations of respiratory disorders, including bronchitis, was amended to ensure it used current medical terminology and unambiguous criteria, and reflected recent medical advances. 61 Fed. Reg. No. 173, 46,720 (September 5, 1996) (codified at 38 C.F.R. §§ 4.96, 4.97 (1999). The new criteria for Diagnostic Code 6600 provides for a 10 percent evaluation where there is competent medical evidence of forced expiratory volume in one second (FEV-1) of 71- to 80-percent predicted, or forced expiratory volume in one second as percent of forced vital capacity (FEV-1/FVC) of 71- to 80- percent predicted, or diffusion capacity of carbon monoxide, single breath (DLCO (SB)) of 66- to 80-percent predicted. A 30 percent evaluation may be assigned where there is competent medical evidence of FEV-1 of 56- to 70-percent predicted; or FEV-1/FVC of 56- to 70-percent; or DLCO (SB) 66- to 80-percent predicted. The next higher rating of 60 percent requires FEV-1 of 40- to 55-percent predicted; or FEV-1/FVC of 40- to 55-percent; or DLCO (SB) of 40- to 55- percent predicted; or maximum oxygen consumption of 15 to 20 ml/kg/min (with cardiorespiratory limit). A 100 percent rating is appropriate with FEV-1 less than 40 percent of predicted value; or the ratio of FEV-1/FVC less than 40 percent; or DLCO (SB) less than 40-percent predicted; or maximum exercise capacity less than 15 ml/kg/min oxygen consumption (with cardiac or respiratory limitation); or cor pulmonale (right heart failure); or pulmonary hypertension (shown by Echo or cardiac catheterization); or episode(s) of acute respiratory failure; or requires outpatient oxygen therapy. 38 C.F.R. § 4.97, Diagnostic Code 6600 (1999). When a regulation changes after a claim has been filed but before the administrative appeal process has been concluded, the version more favorable to appellant should apply. Karnas v. Derwinski, 1 Vet. App. 308 (1991). As the RO did in April 1999, this claim must be fully adjudicated under both new and old criteria to determine which version is more favorable. DeSousa v. Gober, 10 Vet. App. 461 (1997). The amendment is only effective on and after October 7, 1996, and may not be applied prior thereto. 38 U.S.C.A. § 5110(g); VA O.G.C. Prec. Op. 3-2000 (Apr. 10, 2000). In this case, VA examination in December 1993 and February 1997 included pulmonary function testing, the results of which are associated with the claims file. While these examination results included values for FEV-1 and FEV-1/FVC, neither discussed any values for DLCO (SB). Therefore, a complete appellate adjudication of the claim is not possible. The claim is remanded for a VA examination, to include complete pulmonary function testing. Tinea Pedis The tinea pedis is currently assigned a noncompensable evaluation under the criteria of Code 7813 for dermatophytosis, which is evaluated based on the criteria for scars. See 38 C.F.R. § 4.118, Codes 7800-7806. The most recent VA examination, in February 1997, includes comments by an examiner that the appellant had fungal toenails, but no discussion of any actual examination of the severity of the service-connected tinea pedis. VA is required to provide a contemporaneous examination to determine the severity of the disability. Caffrey v. Brown, 6 Vet. App. 377, 381 (1995); Green v. Derwinski, 1 Vet. App. 121, 124 (1991). As the appellant has not been afforded such examination, the claim is remanded for same. The case is REMANDED for the following development: 1. The RO should request the appellant to supply the names and addresses of any individuals or facilities that treated him for PTSD, bronchitis, and tinea pedis since October 1998, and the dates of such treatment. After securing any needed releases, the RO should obtain complete clinical records of such treatment and add them to the claims file. 2. The RO must determine whether the appellant, based on the evidence of record, engaged in combat. If so, absent evidence to the contrary, that conclusion must be accepted as conclusive evidence of the claimed in-service stressor. The RO's attention is directed to the law cited above and to a recent VA General Counsel opinion. VA O.G.C. Prec. Op. 12- 99 (Oct. 18, 1999). 3. If the RO determines that the appellant was not engaged in combat, then he should be requested to provide, within a reasonable time, any additional information relevant to his claimed stressor(s), including specific information as to the date and location of the incident(s), full names of any casualties, the unit designation and that of any other unit involved. All information obtained should be added to the claims file. 4. On receipt of the appellant's response, or after a reasonable period of time has passed without response, the RO should review the claims file and prepare a summary of the claimed stressor(s) based on a review of all pertinent documents. This summary, and any supporting documentation regarding the claimed stressor(s), should be sent to USASCRUR, at 7798 Cissna Road, Suite 101, Springfield, Virginia 22150-3197. They should be asked to certify the occurrence of the incident(s) and any indication of the appellant 's involvement therein. If unable to provide such information, USASCRUR should be asked to identify the agency or department that could provide such information and the RO should follow up accordingly. 5. After the above is accomplished, the RO must make a specific determination, based on the complete record, with respect to whether the appellant was exposed to a stressor or stressors in service, and if so, the nature of the specific stressor or stressors. If the RO determines that the record establishes the existence of stressor(s), the RO must specify what stressor or stressors in service it has determined the record establishes. In reaching this determination, the RO should address any credibility questions raised by the record. 6. Only if, the RO determines that the record establishes the existence of stressor(s), then the appellant should be afforded a VA psychiatric examination to determine the nature and etiology of all psychiatric disorders found present. The RO must specify for the examiner the stressor(s) that it has determined are established by the record and the examiner must be instructed that only those events may be considered for the purpose of determining whether the appellant was exposed to a stressor in service. The entire claims file and a copy of this REMAND must be made available to the examiner in conjunction with the examination, and the examination report should reflect review of pertinent material in the claims folder. If a diagnosis of PTSD is made, the examiner should specify (1) whether each alleged stressor found by the RO to be established in the record was sufficient to produce PTSD; (2) whether the remaining diagnostic criteria to support the diagnosis of PTSD have been satisfied; and (3) whether there is a link between the current symptomatology and one or more of the in-service stressors found to be established by the record by the RO and found to be sufficient to produce PTSD by the examiner. The examination report should include the rationale for all opinions expressed. All necessary special testing and evaluation should be accomplished. 7. The RO should schedule the appellant for VA medical examination to determine the nature and severity of the bronchitis disability. The claims folder and a copy of this REMAND must be made available to the physician for review in conjunction with the examination. The pertinent history concerning the disability should be obtained from review of the claims file, and all necessary tests and studies must be accomplished, including pulmonary function testing with predicted FEV-1, FEV-1/FVC, and DLCO (SB) values. The report of examination should contain a detailed account of all manifestations found. 8. The RO should schedule the appellant for an examination to determine the nature and severity of the tinea pedis disability. The claims folder and a copy of this REMAND must be made available to the physician for review in conjunction with the examination. The pertinent history concerning the disabilities should be obtained, and all necessary tests and studies should be accomplished. The report of examination should contain a detailed account of all manifestations of the disabilities found to be present. The examiner should be asked to specifically comment on any tenderness, pain, and ulcerations associated with the tinea pedis and the extent of any exfoliation, exudation, crusting, nervous manifestations, and itching associated with the disability. 9. When the above development has been completed, the RO should review the record to ensure it is in compliance with this REMAND. If not, the RO should undertake remedial action before returning the claim to the Board. See Stegall, 11 Vet. App. at 270-71. On completion of the development requested, to the extent possible, the RO should again review the record. If the benefit sought on appeal remains denied, the appellant and his representative should be furnished a supplemental statement of the case and given an opportunity to respond. The case should then be returned to the Board. The appellant has the right to submit additional evidence/argument on the matters remanded to the RO. Kutscherousky v. West, 12 Vet. App. 369 (1999). J. F. Gough Member, Board of Veterans' Appeals ? The rating criteria for evaluation of diseases of the ear and other sense organs were recently altered effective June 10, 1999. See 38 C.F.R. §§ 4.85, 4.86, 4.86a, 4.87, 4.87a, 4.87b (1998); 64 Fed. Reg. 25,202- 10 (May 11, 1999) (codified at 38 C.F.R. §§ 4.85, 4.86, 4.87, 4.87a (1999)). When a relevant regulation changes during the pendency of an appeal, as is the case here, the version most favorable to appellant applies. Karnas v. Derwinski, 1 Vet. App. 308, 313 (1991). See also DeSousa v. Gober, 10 Vet. App. 461, 467 (1997); Bernard v. Brown , 4 Vet. App. 384, 394 (1993); VA O.G.C. Prec. Op. 3-2000 (Apr. 10, 2000). In this case, though, the regulatory changes were made because medical science has advanced, and commonly used medical terms have changed. The effect of these amendments was to update this portion of the rating schedule to ensure that it used current medical terminology and unambiguous criteria and reflected medical advances that had occurred since the last review. As such, because the amendments did not substantively change the regulation for purposes of appellate review, the Board may proceed to adjudicate the claim in light of the new version of the regulation without prejudice to the appellant.