Citation Nr: 0301910 Decision Date: 01/30/03 Archive Date: 02/07/03 DOCKET NO. 02-05 603 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Pittsburgh, Pennsylvania THE ISSUES 1. Whether new and material evidence has been received to warrant reopening the claim of entitlement to service connection for additional gastrointestinal disability. 2. Whether new and material evidence has been received to warrant reopening the claim of entitlement to service connection for a residuals of a concussion, and if so, whether service connection is warranted. 3. Entitlement to service connection for a chest scar. (The issue of entitlement to service connection for additional gastrointestinal disability will be the subject of a later decision). REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The veteran ATTORNEY FOR THE BOARD J. M. Daley, Counsel INTRODUCTION The veteran had active service in the United States Army from December 1942 to February 1946, from January 1948 to January 1949 and from October 1950 to September 1951. This matter is before the Board of Veterans' Appeals (Board) on appeal from a July 2001 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO), located in Pittsburgh, Pennsylvania. In connection with his appeal the veteran testified before Decision Review Officer at the RO in June 2002; a transcript of that hearing is associated with the claims file. The Board notes that in 1951 the veteran pursued a claim of entitlement to service connection for a stomach disability. In an unappealed January 1952 rating decision, the RO granted service-connection for amebiasis, without inclusion of any other gastro-intestinal diagnosis. The RO denied entitlement to service connection for duodenal ulcer disease in an unappealed rating decision dated in March 1957. Then, in an unappealed rating decision dated in February 2000, the RO denied an increased rating for amebiasis, evaluated as noncompensably disabling. In February 2001, the RO received the veteran's claim of entitlement to service connection for gastrointestinal disability. To the extent that the veteran is again seeking an increase in the rating assigned for his service-connected amebiasis, he should advise the RO such that appropriate actions may be taken. The Board otherwise notes that insofar as the veteran has in the past been denied entitlement to service connection for disability of the gastrointestinal system, other than amebiasis, his general claim of entitlement to service connection for a gastrointestinal disability at this time is more appropriately viewed as an application to reopen. See Ephraim v. Brown, 82 F.3d 399, 401 (Fed. Cir. 1996); cf. Ashford v. Brown, 10 Vet. App. 120, 123 (quoting Harris v. Derwinski, 1 Vet. App. 180, 183 (1991); (citing McGraw v. Brown, 7 Vet. App. 138, 142 (1994); cf. Ephraim v. Brown, 82 F.3d 399, 402 (Fed. Cir. 1996). In this regard the Board also notes that in an unappealed rating decision dated in February 1946, the RO denied entitlement to service connection for residuals of a concussion; the veteran is now seeking to reopen that claim, specifically claiming residuals in the form of memory loss. The RO did not discuss the issue of whether new and material evidence had been submitted to warrant reopening these claims. However, the Board is required to consider the issue of finality prior to any consideration on the merits. 38 U.S.C.A. §§ 7104(b), 5108; see Barnett v. Brown, 8 Vet. App. 1 (1995). Accordingly, the Board will address the issues of entitlement to service connection for residuals of a concussion and entitlement to service connection for additional gastrointestinal disability on a finality basis herein. The United States Court of Appeals for Veterans Claims (Court) has indicated that when the Board addresses a question not considered by the RO, the Board must consider whether the claimant had notice of that issue and whether the claimant would be prejudiced by lack of such notice. In the instant case, the Board concludes that the veteran would not be prejudiced by such an action in that its consideration of the new and material evidence is favorably resolved in both instances herein. See Barnett, supra at 4; Bernard v. Brown, 4 Vet. App. 384, 390-92 (1993). Based on these facts, the issues have been rephrased as shown on the first page of this decision. FINDINGS OF FACT 1. All information and evidence necessary for an equitable disposition of the issues decided herein have been obtained. 2. By rating decision dated in January 1952, the RO granted entitlement to service connection for amebiasis, without other gastro-intestinal disability; and by unappealed rating decision dated in March 1957, the RO denied entitlement to service connection for duodenal ulcer disease. 3. The evidence submitted subsequent to the March 1957 rating decision includes evidence that bears directly and substantially upon the specific matter under consideration; is not cumulative or redundant; and is so significant that it must be considered in order to fairly decide the merits of the claim. 4. By unappealed rating decision dated in March 1946, the RO denied entitlement to service connection for residuals of a concussion. 5. The evidence submitted subsequent to the March 1946 rating decision includes evidence that bears directly and substantially upon the specific matter under consideration; is not cumulative or redundant; and is so significant that it must be considered in order to fairly decide the merits of the claim. 6. The veteran sustained a concussion during active military service and is currently shown to have memory loss (amnesia), which has been etiologically attributed to the in-service injury. 7. A keloid chest scar was noted to exist upon initial entry into active military service and did not undergo any increase in severity during or as a result of service. CONCLUSIONS OF LAW 1. New and material evidence has been received to reopen the claim of entitlement to service connection for additional gastrointestinal disability. 38 U.S.C.A. § 5108 (West 1991); 38 C.F.R. § 3.156(a) (2001). 2. New and material evidence has been received to reopen the claim of entitlement to service connection for residuals of a concussion. 38 U.S.C.A. § 5108 (West 1991); 38 C.F.R. § 3.156(a) (2001). 3. Memory impairment is due to a concussion incurred in active military service. 38 U.S.C.A. §§ 1110, 1131 (West Supp. 2002); 38 C.F.R. § 3.303 (2002). 4. A chest scar was not incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131, 1153, 1154 (West 1991 & Supp. 2002); 38 C.F.R. §§ 3.303, 3.306 (2002). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Legal Criteria To establish service connection for a claimed disability, the facts must demonstrate that a disease or injury resulting in current disability was incurred in the active military service or, if pre-existing active service, was aggravated therein. 38 U.S.C.A. §§ 1110, 1131 (West Supp. 2002); 38 C.F.R. § 3.303 (2002). Every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of examination, acceptance, and enrollment. Clear and unmistakable evidence that the disability manifested in service existed before service will rebut the presumption. 38 U.S.C.A. §§ 1111 (West 1991); 38 C.F.R. § 3.304. A pre- existing injury or disease will be considered to have been aggravated by active service where there is an increase in disability during such service, unless the increase in disability is clearly and unmistakably due to natural progress. 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. 38 U.S.C.A. 1153 (West 1991); 38 C.F.R. 3.306 (2002). Where a veteran served for at least 90 days during a period of war or after December 31, 1946, and certain chronic diseases, such as ulcers, become manifest to a degree of 10 percent within one year from the date of termination of such service, such diseases shall be presumed to have been incurred in or aggravated by service, even though there is no evidence of such diseases during the period of service. 38 U.S.C.A. §§ 1101, 1112 (West 1991); 38 C.F.R. §§ 3.307, 3.309 (2002). Service connection may also be granted for a disease initially 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). In the case of any veteran who engaged in combat with the enemy in active service, satisfactory lay or other evidence that an injury or disease was incurred or aggravated in combat will be accepted as sufficient proof of service incurrence if the evidence is consistent with the circumstances, conditions or hardships of such service even though there is no official record of such incurrence or aggravation in such service, and, to that end, every reasonable doubt shall be resolved in favor of the veteran. See 38 U.S.C.A. § 1154(b) (West 1991); 38 C.F.R. § 3.304(d); see also Collette v. Brown, 82 F.3d 389 (Fed. Cir. 1996). Where a veteran has established that he is a combat veteran, Collette and Caluza v. Brown, 7 Vet. App. 498 (1995), set out the correct application of 38 U.S.C.A. § 1154(b), requiring a three-step, sequential analysis: 1) Has the claimant produced "satisfactory lay or other evidence of such injury or disease." "Satisfactory evidence" is defined as "credible evidence that would a allow a reasonable fact finder to conclude that the alleged injury or disease was incurred in or aggravated by the veteran's combat service?" 2) Is the proffered evidence, "consistent with the circumstances, conditions, or hardships of such service?" 3) Once these first two steps are met, the Secretary will accept the combat veteran's evidence as sufficient proof of service incurrence, even if no official record of such incurrence exists, unless the government can meet the burden of showing "clear and convincing evidence to the contrary." In the third step contrary evidence may be brought into play. Collette, 82 F.3d at 393. The statute does not presumptively establish service connection for a combat veteran; rather, it relaxes the evidentiary requirements for determining what happened in service. See Brock v. Brown, 10 Vet. App. 155, 162 (1997); see also Wade v. West, 11 Vet. App. 302 (1998); Velez v. West, 11 Vet. App. 148 (1998); Libertine v. Brown, 9 Vet. App. 521, 524 (1996). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (West Supp. 2002); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Generally, a claim which has been denied in an unappealed RO decision or an unappealed Board decision may not thereafter be reopened and allowed. 38 U.S.C.A. §§ 7104(b), 7105(c) (West 1991). The exception to this rule is 38 U.S.C.A. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. New and material evidence is defined as evidence not previously submitted to agency decisionmakers which bears directly and substantially upon the specific matter under consideration; which is neither cumulative nor redundant; and which, by itself or in connection with evidence previously assembled, is so significant that it must be considered in order to fairly decide the merits of the claim. 38 C.F.R. § 3.156(a) (2001). The Board notes that § 3.156(a) has been amended; the amended definition of new and material evidence is not liberalizing. It applies to any claim to reopen a finally decided claim received on or after August 29, 2001. 66 Fed. Reg. 45,620, 45,629. It does not apply to the veteran's claims to reopen, which were received before that date. In Hodge v. West, 155 F.3d 1356, 1363 (Fed. Cir. 1998), the Federal Circuit noted that new evidence could be sufficient to reopen a claim if it could contribute to a more complete picture of the circumstances surrounding the origin of a veteran's injury or disability, even where it would not be enough to convince the Board to grant a claim. For the purpose of establishing whether new and material evidence has been submitted, the credibility of the evidence, although not its weight, is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). II. Veterans Claims Assistance Act of 2000 (VCAA) During the pendency of the veteran's appeal, the VCAA, Pub. L. No. 106-475, 114 Stat. 2096 (2000), was signed into law. It is codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West Supp. 2002). In addition, regulations implementing the VCAA were published at 66 Fed. Reg. 45,620, 45,630-32 (August 29, 2001) (codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326 (2002)). The Act and the implementing regulations essentially eliminate the requirement that a claimant submit evidence of a well-grounded claim, and provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. The Board will assume for the purpose of this decision that the liberalizing provisions of the VCAA are applicable to the veteran's claims to reopen, and to the veteran's claims of entitlement to service connection for a chest scar and memory loss residual to a concussion. As explained below, the Board has determined that reopening of the veteran's claims of entitlement to service connection for a stomach/intestinal disability and for residuals of a concussion is warranted. Therefore, no additional information or evidence is necessary to substantiate the claims to reopen. Herein the Board has further granted entitlement to service connection for memory impairment, the manifestation now claimed by the veteran as residual to an in-service concussion. In this regard this decision is fully favorable to the veteran and no further development is required. Finally, the Board has determined that additional development is warranted with respect to the gastrointestinal disability claim; such will be accomplished prior to consideration of the merits of that claim. Accordingly, no further discussion of the VCAA is required relevant to these claims. Relevant to the chest scar, the Board notes that the VCAA and the implementing regulations were in effect when the veteran's claim of entitlement to service connection for a chest scar was most recently considered by the RO. The record reflects that through the statement of the case and a supplement thereto, the veteran has been informed of the requirements to establish entitlement to that benefit, the evidence considered by the RO, and the reasons for its determination. In a letter dated in June 2001, the veteran was informed that he should submit medical evidence showing diagnosis of the claimed disability and medical evidence of a causal relationship between such and his period of active service. In this letter the RO also informed the veteran of the assistance that it would provide in obtaining evidence and information in support of the claim and of the information needed from him to enable the RO to obtain evidence and information in support of his claim. Moreover, in the statement of the case issued in February 2002, the veteran was advised of the provisions of the implementing regulations. Therefore, the Board is satisfied that the RO has complied with the notification requirements of the VCAA and the implementing regulations. See Quartuccio v. Principi, 16 Vet. App. 183 (2002). Relevant to the duty to assist, the Board notes that service medical records have been associated with the claims file and documentation from the appropriate service department do not reveal the availability of any additional records. Further, identified records of private treatment have been associated with the claims file and the veteran has been afforded appropriate VA examinations. There is no indication that other Federal department or agency records exist that should be requested. The claims file also contains medical reports pertaining to the onset and etiology of a chest scar. Neither the veteran nor his representative has identified any additional evidence or information which could be obtained to substantiate the claim. The Board is also unaware of any such outstanding evidence or information. Therefore, the Board is also satisfied that the RO has complied with the duty to assist requirements of the VCAA and the implementing regulations pertinent to the chest scar claim. III. Factual Background The veteran had active service in the United States Army from December 1942 to February 1946, from January 1948 to January 1949, and from October 1950 to September 1951. The report of a December 1942 physical examination at induction notes that a keloid scar was present on the veteran's chest. No defects or abnormalities of the gastrointestinal system, head or neurologic system were noted at entrance. Medical entries and hospital notes from the veteran's December 1942 to February 1946 service period include note of left foot cellulitis, hemorrhoids, and ringworm. The report of physical examination dated in February 1946 notes the veteran's psychiatric and neurologic status as normal, without note of any defects or abnormalities of the abdominal wall or viscera, and without note of gastrointestinal disability. The veteran was noted to have multiple chest and left lower leg scars, opined to have existed prior to service, without sequelae and non- disabling. The report includes note of disabilities opined to have been incurred in service, as follows: chronic headaches caused by a concussion of a 220 shell in December 1945; bilateral trench foot; athlete's foot on the left foot; prostatic infection; and gonorrhea. In March 1946, the veteran applied for VA compensation benefits for residuals of a concussion, and for trench foot and venereal disease. He identified no other injury or disability as having been incurred in service. In March 1946, the RO denied entitlement to service connection for a head concussion and notified the veteran of that determination by letter also dated in March 1946. He did not appeal. In a July 1946 statement, the veteran reported that he was having pains in the right side of his head. A report of examination completed when reporting for a second period of service reflects note of a keloid scar on the anterior chest, without any change in size for several years. There was no evidence of hernia, abdominal defects, or defects or abnormalities of the nervous system. In October 1948, during his second period of service, the veteran presented with complaints of right lower quadrant pain radiating to his flank. He denied any similar episodes. The impression was uretal colic and physical examination was essentially negative. On the report of medical examination dated in August 1951, at the end of the veteran's third period of service, the veteran's neurologic, psychiatric, and abdomen and viscera (to include hernia) were evaluated as normal. The veteran was noted to have a scar on his chest. In October 1951, the veteran claimed entitlement to service connection for a stomach and kidney disability. A physician's certificate notes treatment of the veteran in October 1951 for pain radiating to the side and the back. The veteran was hospitalized in October and November 1951 and treated for intestinal amebiasis and Ascaris lumbricoides. At that time he was noted to experience headaches, with a history of an in-service concussion. A rating decision dated in January 1952 reflects a grant of service connection for intestinal amebiasis. In January 1957, the veteran appeared for a VA examination. He complained of lower abdominal pains since 1949, relieved by defecation. The examiner noted the veteran had been thrown by an explosion in World War II, with a loss of consciousness of 15 minutes and a concussion. The veteran complained of right-sided head pain. Also noted were complaints of stomach pain with a question of diverticulosis. The diagnosis was chronic duodenal ulcer, as suggested by clinical test results. In March 1957, the RO denied entitlement to service connection for a duodenal ulcer. The veteran did not appeal the decision. The claims file contains records of treatment by K. Maceyko, which note the presence of a chest scar since 1944. The claims file also contains records of treatment at Shadyside Hospital, dated from January to May 1993, and pertaining to hiatal hernia, splenectomy and ventral hernia repair, without opinion as to date of approximate onset or cause. In November 1999, the veteran appeared for examination of the digestive system in connection with his claim for an increase in the rating assigned to amebiasis. The veteran reported taking Pepcid occasionally for reflux and gave a history for hiatal hernia, as well as ventral hernia. The veteran gave a history of having had a severe concussion with displacement of the stomach and intestines displaced into chest. The examiner noted that there was no obvious sign of residual affects of any amebic dysentery that the veteran may have had in service. In March 2001, the veteran reported for VA examinations. In connection with the intestines examination, the veteran reported incurrence of an injury during service in Korea. He stated he received a concussion and that such caused a displacement of the stomach and small intestine into his chest cavity. He reported resulting problems with reflux and water brash as well as epigastric burning. The veteran indicated he had had surgery in or around 1994 to bring his stomach and intestines back into the abdomen and at the same time had had a ventral herniorrhaphy. The examiner diagnosed gastroesophageal reflux disease, status post ventral herniorrhaphy, status post surgery to remove his stomach and intestines from the chest cavity and return to the abdominal cavity. In connection with the scars examination, the veteran reported that on December 16, 1944, during the Battle of the Bulge, he was wounded in the chest by an unknown object, which caused a superficial puncture wound to the chest. H indicated that he was treated in the field and in a field hospital, and that his keloid chest scar was the result of such injury. The mental disorders examination conducted in March 2001 reflects review of the claims file by the examiner. The examiner noted that the first mention of memory loss appeared in statements dated in the year 2000. The examiner also noted that the veteran's service records, to include note of headaches, post concussion, shown on a discharge report. The examiner continued to note the veteran's complaints of having no memory of the time he was in Korea, except for three or four isolated incidents. He indicated that his memory problems bothered him upon return to civilian life, but that his family assisted him in functioning. The examiner then stated that the veteran remembered the details of his life prior to duty in Korea quite well, and that the veteran's current memory was exceptionally good for a man his age. The examiner noted that examination revealed the veteran to experience an impairment of thought processes and communications when dealing with the period of time spent in service in Korea, and for an undetermined amount of time prior and subsequent thereto. The examiner opined the veteran met the criteria for a diagnosis of amnestic disorder secondary to concussion. After noting the absence of any drug or alcohol use, and questioning the lack of documented proof of a concussion during service, the examiner stated that the veteran described a credible story that would lead to such a concussion and had symptoms of post-concussive syndrome. The examiner opined that a retrograde or anterograde amnesia was not unusual post concussion. The claims file contains VA outpatient records dated from April 2001 to July 2002. In April 2001, the veteran reported requesting treatment options for a keloid across his upper chest, stated to have developed after an injury at the Battle of the Bulge. A May 2001 entry includes note that prior to treatment with injections the veteran had had sharp pains in the scar and that several small pieces of metal, likely shrapnel, had been removed. A November 2001 note indicates the veteran had a keloid scar "from a shrapnel wound" sustained in World War II, with subsequent removal of shrapnel. Subsequent entries continue to reference a keloid chest scar residual to a shrapnel wound incurred during World War II service. In a statement received in November 2001, the veteran identified the in-service incident resulting in his concussion and stomach injury as having occurred April 7, 1951. He submitted a newspaper article citing his receipt of the Bronze Star for heroism in action on that date. In June 2002, the veteran testified before a Decision Review Officer at the RO. He stated that he had been hit in the chest with a "big thing like a club" during the Battle of the Bulge, resulting in a cut approximately eight-to-ten inches long on his chest. He indicated he had been treated at a field hospital and that there was no way of getting records. He also stated that it must have been shrapnel that hit him due to the length of the cut. The veteran's representative stated that the veteran did not have the chest scar prior to service and that any service notation must have been made subsequent to receipt and healing of the injury. The veteran reported that after service pieces of shrapnel were taken out of his chest. (Transcript at 1-7). The veteran stated that when taking ammunition to the front lines he heard a big bang and remembers nothing thereafter. He stated that after that incident he had stomach problems characterized by difficulty eating and having problems with choking. He indicated also that he had no memory of his time in Korea and had had problems since his concussion. (Transcript at 9-11). IV. New and Material Evidence Gastrointestinal Disability Subsequent to the final decision denying service connection for gastrointestinal disability, additional medical evidence showing diagnoses of hiatal hernia, a ventral hernia, and gastroesophageal reflux disease has been received. The evidence added to the record, including the January 2002 VA examination reports, suggest a potential link between the veteran's service and his current gastrointestinal complaints. For the purposes of determining materiality, the credibility of the veteran's account of in-service injury with progression of gastrointestinal symptoms is presumed. Therefore, the Board is satisfied that the evidence added to the record includes evidence that is not cumulative or redundant and is so significant that it must be considered to fairly decide the merits of the veteran's gastrointestinal claim. The Board will not herein decide the merits of the reopened claim, however, but rather is undertaking additional development on matter pursuant to 38 C.F.R. § 19.9(a)(2) (2002). When it is completed, the Board will provide any notice of the development required by 38 C.F.R. § 20.903 (2002). After giving the notice and reviewing any response to the notice, the Board will prepare a separate decision addressing the reopened claim of entitlement service connection for additional gastrointestinal disability. Residuals of a Concussion Subsequent to the unappealed rating decision in March 1946, the RO has obtained a VA examination of the veteran, which resulted in diagnosis of amnesia secondary to the veteran's in-service concussion. The report of this examination is clearly new and material since it suggests that the veteran has memory impairment due to a service-incurred concussion. As such, the claim may be reopened. The merits of that claim are discussed herein below. V. Service Connection Residuals of a Concussion Available service medical records include note that the veteran was injured and incurred a concussion during service in 1945. At discharge it was noted that the veteran thereafter experienced headaches. In connection with the instant appeal the veteran argues that due to his in-service concussion he has experienced memory loss. A review of the post-service medical evidence reveals that the veteran did, in fact, complain of right-sided head pain and headaches in the years proximate to his discharge. Further, more recent medical records are consistent in noting memory loss, particularly memory loss centered around the events of the veteran's service. Finally, a VA physician, with benefit of review of the entire claims file to include service medical records, opined that the veteran's history was consistent with retrograde amnesia attributable to a concussion during active service. There is no competent evidence of record refuting that conclusion. As such, the competent evidence supports entitlement to service connection for memory impairment as residual to a concussion. Chest Scar The veteran and his representative have argued that the veteran incurred injury to the chest during his first period of service, thus resulting in his keloid chest scar. The Board first points out, however, that the December 1942 report of physical examination completed at service induction clearly notes the presence of a keloid scar on the veteran's chest at entry into service. Thus, despite his statements to the contrary, the veteran is not entitled to the presumption of soundness at entry with respect to his chest scar. The Board next emphasizes that later service examination reports note the continued presence of the veteran's chest scar and describe such as having existed prior to service, without sequelae, and/or without any change in size for several years. Furthermore, despite service documentation of multiple injuries and complaints, ranging from hemorrhoids to ringworm, and including note of the veteran's concussion, there is no objective documentation of incurrence of any in- service chest injury and also no service evidence of any flare-ups, worsening or other change in the status of the pre-existing chest scar. In fact, the record reflects that decades passed subsequent to service before the veteran complained of chest scar problems. Relevant complaints are only noted in the 1990s, many years later and in connection with his claim of entitlement to VA compensation benefits. Thus, there is no persuasive evidence of an increase in severity of the pre-existing chest scar during or as a result of service. In fact, neither the veteran nor his representative has presented any argument on the question of aggravation. The Board acknowledges the veteran's combat status, but emphasizes that this is a case where there is clear and convincing evidence contradicting the veteran's account of an in-service chest injury resulting in a scar. As stated, service medical records show that the scar existed when the veteran entered active duty. See Collette, 82 F.3d at 393. The Board does recognize that the claims file contains contemporary medical evidence that describes the veteran's chest scar as residual to an in-service shrapnel wound. The weight of a medical opinion is, however, diminished where that opinion is ambivalent, based on an inaccurate factual premise, is based on an examination of limited scope, or where the basis for the opinion is not stated. See Reonal v. Brown, 5 Vet. App. 548 (1993); Sklar v. Brown, 5 Vet. App. 140 (1993); Guerrieri v. Brown, 4 Vet. App. 467 (1993). The Board is not bound to accept medical opinions which are based on history supplied by the veteran where that history is unsupported by the medical evidence. Black v. Brown, 5 Vet. App. 177 (1993); Swann v. Brown, 5 Vet. App. 229 (1993); Reonal, op. cit.; and Guimond v. Brown, 6 Vet. App. 69 (1993) and most recently, Pond v. West, 12 Vet. App. 341 (1999) where the appellant was himself a physician. In this case, the medical descriptions of a shrapnel scar, with a history of shrapnel removal from the chest, are wholly inconsistent with available service medical records that definitively note the pre-existence of the scar and the lack of change in such scar during service. As such the Board affords no weight to the notations made by the VA physicians treating the veteran for scar symptoms decades after service discharge. The Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the veteran's claim, that doctrine is not applicable to this claim. 38 U.S.C.A. § 5107(b). (CONTINUED ON NEXT PAGE) ORDER The Board having determined that new and material evidence has been received, reopening of the claim of entitlement to service connection for additional gastrointestinal disability is granted. The Board having determined that new and material evidence has been received, reopening of the claim of entitlement to service connection for residuals of a concussion is granted. Service connection for memory impairment residual to a concussion is granted. Entitlement to service connection for a chest scar is denied. Shane A. Durkin Member, Board of Veterans' Appeals IMPORTANT NOTICE: We have attached a VA Form 4597 that tells you what steps you can take if you disagree with our decision. We are in the process of updating the form to reflect changes in the law effective on December 27, 2001. See the Veterans Education and Benefits Expansion Act of 2001, Pub. L. No. 107-103, 115 Stat. 976 (2001). In the meanwhile, please note these important corrections to the advice in the form: ? These changes apply to the section entitled "Appeal to the United States Court of Appeals for Veterans Claims." (1) A "Notice of Disagreement filed on or after November 18, 1988" is no longer required to appeal to the Court. (2) You are no longer required to file a copy of your Notice of Appeal with VA's General Counsel. ? In the section entitled "Representation before VA," filing a "Notice of Disagreement with respect to the claim on or after November 18, 1988" is no longer a condition for an attorney-at-law or a VA accredited agent to charge you a fee for representing you.