Citation NR: 9733456 Decision Date: 09/30/97 Archive Date: 10/02/97 DOCKET NO. 96-16 538 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Reno, Nevada THE ISSUES 1. Entitlement to service connection for a chronic prostate disorder, claimed as a residual of Agent Orange herbicide exposure. 2. Entitlement to service connection for a chronic kidney disorder, claimed as a residual of Agent Orange herbicide exposure. 3. Entitlement to service connection for a chronic blood disorder, claimed as a residual of Agent Orange herbicide exposure. 4. Entitlement to service connection for headaches, claimed as a residual of service-connected cervical spine disorder and as a residual of Agent Orange herbicide exposure. 5. Entitlement to an increased evaluation for arthritis of the lumbosacral spine with herniated nucleus pulposus, currently rated as 40 percent disabling. 6. Entitlement to an increased evaluation for post-operative residuals of a cervical spine disorder with radiculopathy of the left arm, currently rated as 30 percent disabling. 7. Entitlement to an increased evaluation for surgical scar residuals of the bone graft site at the right ilium, currently rated as 10 percent disabling. 8. Entitlement to an increased evaluation for chronic gastritis with reflux, currently rated as 10 percent disabling. 9. Entitlement to an increased evaluation for hypertension, currently rated as 10 percent disabling. 10. Entitlement to a total rating based on individual unemployability due to service-connected disability. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Michael A. Pappas, Counsel INTRODUCTION The appellant-veteran had active service from September 1944 to March 1947, from June 1947 to June 1949, from September 1949 to December 1952, and from August 1955 to September 1977. This matter is before the Board of Veterans’ Appeals (Board) on appeal of rating decisions in January 1996 and June 1996, of the Reno, Nevada, Department of Veterans Affairs (VA) Regional Office (RO). In March 1997, the RO transferred the veteran’s claims file to the Board. In April 1997, the RO received additional argument from the veteran and forwarded the argument to the Board that same month. In May 1997, the Board received additional argument and evidence directly from the veteran. 38 C.F.R. § 19.37(b). There was no waiver of the procedural right to have the evidence initially considered by the RO. The evidence consists of statements and copies of letters from the veteran relating specifically to previous unsuccessful attempts to obtain employment, and a letter from the appellant’s spouse on the same subject. This evidence is deemed solely pertinent to the issue of entitlement to a total rating based on individual unemployability due to service-connected disability, and is not pertinent to the other issues currently on appeal. For these reasons, the evidence need be referred to the RO for review and preparation of a supplemental statement of the case only as to the total rating issue. 38 C.F.R. § 20.1304(a)-(c). In previous decisions of the Board in August 1993 and October 1994, it was noted that the Court of Veterans Appeals had referred the veteran’s claim for reimbursement of expenses related to medical treatment provided in June 1991 to the RO for further development. As was also noted, there appeared to be an ongoing review of the matter by the RO, but no final disposition. There is still no final disposition of record. As this issue is not inextricably intertwined with any matter now under consideration, it is again referred to the RO for further action. It is specifically directed that the disposition of the matter be documented in the veteran’s claims file. The issues of entitlement to service connection for headaches, claimed as a residual of service-connected cervical spine disorder and/or as a residual of Agent Orange herbicide exposure, and entitlement to a total disability rating for compensation based on individual unemployability are addressed in the REMAND section of this decision. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends, essentially, that his lumbosacral and cervical spine disabilities, his bone graft surgical scar, his chronic gastritis, and his hypertension are more disabling than indicated by the evaluations assigned. He further argues that his chronic gastritis, kidney disorder, and blood disorder are directly attributable to his exposure to herbicide agents, specifically Agent Orange, during his service in Vietnam during the Vietnam war. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991 & Supp. 1997), has reviewed and considered all of the evidence and material of record in the veteran's claims files. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the preponderance of the evidence is against the claims for increased rating for arthritis of the lumbosacral spine with herniated nucleus pulposus, increased rating for post-operative residuals of a cervical spine disorder with radiculopathy of the left arm, increased rating for surgical scar residuals of the bone graft site at the right ilium, and increased rating for hypertension. It is further the decision of the Board that the veteran has not met the initial burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that the claims for service connection for a chronic prostate disorder, a chronic kidney disorder, and a chronic blood disorder, claimed as secondary to Agent Orange herbicide exposure are well grounded. The evidence, however, supports an increased rating to 20 percent for service-connected chronic gastritis with reflux. FINDINGS OF FACT 1. Neither unfavorable ankylosis nor pronounced intervertebral disc syndrome of the lumbosacral spine, considering functional loss due to pain, reduction of normal excursion of movements, including pain on movement, and painful motion with arthritis, is demonstrated. 2. Neither unfavorable ankylosis nor severe intervertebral disc syndrome of the cervical spine, considering functional loss due to pain, reduction of normal excursion of movements, including pain on movement, and painful motion with arthritis, is demonstrated. 3. Surgical scar residuals of the bone graft site at the right ilium are tender and painful, but not ulcerated, moderately disfiguring, or productive of limitation of function. 4. Chronic gastritis with reflux is manifested by episodes of pain occurring daily, 365 days per year, gastroesophageal reflux described as severe, but without disabling symptoms productive of considerable impairment of health, including anemia or loss of weight, dysphagia, pyrosis, and regurgitation, substernal or arm or shoulder pain. 5. The veteran's diastolic blood pressure is predominantly below 100. 6. The veteran had active service in Vietnam during the Vietnam era. 7. No competent evidence of a nexus between an in-service disease or injury and a prostate disorder, a kidney disorder or a blood disorder, claimed as residuals of Agent Orange herbicide exposure, has been presented. The veteran has not submitted evidence of a plausible claim for service connection for those disorders. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 40 percent for arthritis of the lumbosacral spine with herniated nucleus pulposus have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5292, 5293, 5295 (1996). 2. The criteria for a rating in excess of 30 percent for post-operative residuals of a cervical spine disorder with radiculopathy of the left arm have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5287, 5290, 5293 (1996). 3. The criteria for a rating in excess of 10 percent for surgical scar residuals of the bone graft site at the right ilium have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. § 4.14, 4.118, Diagnostic Codes 7803, 7804, 7805 (1996). 4. An evaluation of 20 percent, but no more, for chronic gastritis with reflux is warranted. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.1, 4.2, 4.7, Part 4, Diagnostic Codes 7305, 7346 (1996). 5. The criteria for a rating in excess of 10 percent rating for hypertension have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.321, 4.7, 4.104, Diagnostic Code 7101 (1996). 6. The claim for service connection for residuals of Agent Orange herbicide exposure, to include a prostate disorder, a kidney disorder, and a blood disorder, is not well grounded. 38 U.S.C.A. § 5107 (West 1991). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Increased Ratings As a preliminary matter, the Board finds that the veteran's claims of entitlement to increased ratings for the various service-connected disabilities at issue are well grounded. Murphy v. Derwinski, 1 Vet.App. 78 (1990), Proscelle v. Derwinski, 2 Vet.App. 629 (1992). The Board is satisfied that all relevant facts have been properly developed and that no further duty to assist exists in respect to the claims. Pursuant to 38 U.S.C.A. § 1155, disability ratings are rendered based upon VA’s Schedule for Rating Disabilities (Schedule) as set forth at 38 C.F.R. Part 4. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity in civil occupations and the disability must be viewed in relation to its history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: Interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; evaluation of the evidence in light of the established policies of VA, 38 C.F.R. § 4.6; where there is a question as to which of two evaluations apply, assigning the higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; evaluating functional impairment on the basis of lack of usefulness, and the medical examiners must furnish a full description of the effects of disability upon the person’s ordinary activity, 38 C.F.R. § 4.10; and, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function is expected, 38 C.F.R. § 4.21. In evaluating disabilities of the musculoskeletal system, such as may be found in the lumbosacral and cervical spine, additional rating factors included functional loss due to pain supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion, 38 C.F.R. § 4.40, reduction of normal excursion of movements, including pain on movement, 38 C.F.R. § 4.45, and painful motion with any form of arthritis, 38 C.F.R. § 4.59. Sections 4.41 and 4.42 of 38 C.F.R. require the tracing of the medical-industrial history from the original injury and the importance of the completeness of the initial VA medical examination. 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. The recorded history is reviewed in order to make a more accurate evaluation, see 38 C.F.R. §§ 4.1, 4.2, 4.41, but the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Lumbosacral Spine and Cervical Spine Factual Background Initially, with respect to the veteran’s lumbosacral spine, the Board observes that in December 1977, the RO granted service connection for the lumbar spine disability and assigned a zero percent rating, effective from October 1977. A 10 percent rating was later made effective in July 1984, and a 20 percent evaluation was made effective in May 1987. In August 1993, the veteran underwent a neurological examination that confirmed scattered bilateral disseminated sensory impairment of the lower extremities without obvious motor impairment. In September 1993, an orthopedic examination report indicated that the veteran walked with a limp on the right and that he complained of constant back pain and bilateral leg pain. The range of motion obtained showed forward flexion of 70 degrees, extension of 10 degrees, abduction of 30 degrees bilaterally and rotation of 60 degrees bilaterally. The sensory examination was reported to be normal. The diagnosis was spinal stenosis at L4-L5 and restricted range of motion of the lumbar spine with no neurological findings. On reexamination by an orthopedist in March 1994, the veteran complained of buttock, thigh, calf and low back pain. The range of motion showed forward flexion (sacral hip) to 67 degrees, extension to 5 degrees, lateral bending to 15 degrees bilaterally, and rotation to 20 degrees bilaterally. The straight leg raising exercise was negative in sitting and recumbency. It was reported that the veteran had some mild variable sensory radicular changes that were extremely mild. The neurologic examiner reported that there had been no essential change from the August 1993 examination. It was noted by the orthopedist and the neurologist that the veteran did not have any bowel or bladder dysfunction. The 1991 MRI study was reviewed. Based upon the foregoing evidence, in October 1994, the Board determined that persistent neurologic symptoms had been shown to be related to the service-connected low back disability, that limitation of motion was no more than moderate; and that muscle spasm had not been confirmed. The Board concluded that those findings more nearly approximated the criteria for a 40 percent evaluation for intervertebral disc syndrome in view of the persistence of neurologic symptoms and the overall picture, but that the criteria for a 60 percent evaluation had not been met since the neurologic and overall findings were clearly not pronounced. As to the veteran’s cervical spine, the Board initially observes that upon retirement from service in 1977, there was found postoperative residuals of a 1976 anterior cervical diskectomy and fusion at C5-7, consisting of mild residual radiculopathy affecting the neck and left arm. A December 1977 rating decision awarded service connection for a cervical spine disorder and assigned a 10 percent rating. An October 1978 rating decision awarded a 20 percent evaluation for the cervical spine disorder based primarily upon the results of an August 1978 VA examination that had revealed moderate limitation of cervical spine motion with pain with extremes of motion and palpable posterior muscle spasm. Thereafter, a January 1985 rating decision assigned a 30 percent evaluation for the cervical spine disorder based primarily upon the results of a September 1984 VA examination that had revealed significant painful limitation of motion of the cervical spine with muscle atrophy of the neck and left upper extremity, and arthrodeses shown by X-rays. In a March 1992 Board decision, it was found that the veteran’s cervical spine disorder was evaluated at the maximum schedular rating for limitation of cervical spine motion under Diagnostic Code 5290, and that intervertebral disc syndrome productive of severe impairment manifested by recurring attacks with intermittent relief had not been demonstrated. Based upon that finding, it was concluded that a disability evaluation in excess of 30 percent for the veteran’s postoperative residuals of a cervical spine disorder with radiculopathy of the left arm, was not warranted. The veteran appealed that determination, inter alia, to the Court of Veterans Appeals (Court). The decision of the Board with respect to the evaluation of the veteran’s cervical spine disorder was upheld by the Court in a January 1993 decision. The veteran’s current claim for increased compensation for his lumbosacral spine and cervical spine disorders was received in March 1995. A summary of the pertinent more recent evidence of record follows. In March 1994, the veteran was involved in a motor vehicle accident and received an injury to his neck. He was admitted to physical therapy in April 1994. He continued in physical therapy through June 1994 and was referred for a neurosurgery evaluation. The examiner’s impression following a May 1994 magnetic resonance imaging scan was status post C5 through C7 vertebral body fusion; abnormal cervical spine curvature with mild reversal of curvature at C6 level; mild narrowing of the spinal canal at C5-6 due to bony growth with narrowing of the canal on the left lateral aspect with narrowing of left L5 neural foramen; and cervical spondylosis involving C3-4, C4- 5, and C7-T1 discs. Neurosurgery consultation in June 1994 yielded an assessment, in pertinent part, of left cervical radiculitis due to stretch injury. Continued physical therapy was recommended and provided. The veteran was seen again by the neurosurgery staff in November 1994. It was noted that the veteran had experienced left arm pain at about the C6 level. The veteran reported that his muscles were tight and swollen. He was noted to be walking “ok” except for some low back pain. He also reported some mild soreness in the back of his head. It was noted that the veteran did not want surgery, that he felt that he was slowly getting better, and that he was worried that he had hurt his neck bones. X-rays were reported to show no fracture. The examiner’s impression was “stable.” The examiner’s impressions following a December 1994 magnetic resonance imaging scan of the cervical spine were 1) Fusion of C5 through C7; 2) Congenital spina bifida at C6, no evidence of enhancing mass in the region of the neural arch defect; 3) Left paracentral C6-7 moderate marginal osteophyte indents the thecal sac and displaces the cord posteriorly and to the right without compressing the cord; moderate narrowing of the left C6-7 neural foramen due to uncinate spurring; 4) Mild disc bulge with associated osteophytes at C3-4 and C4-5, mildly contours the ventral thecal sac without compressing the cord. No evidence of spinal stenosis. 5) Moderate narrowing of the bilateral C3- 4, C4-5 neural foramina. Mild to moderate narrowing of the bilateral C5-6 neural foramina; 6) No significant change from the CT of the cervical spine from October 19, 1994 or the MRI of the cervical spine from May 25, 1994. In May 1995, the veteran underwent a magnetic resonance imaging scan of his lumbar spine. The examiner’s impression was that there was shown: 1) severe degenerative spinal stenosis at L4-5 due to mild diffuse disc bulge, moderate facet disease, and severe thickening of the ligamentum flavum; 2) mild degenerative spinal stenosis at L2-3, L3-4, and L5-S1 due to mild disc bulges, mild thickening of the ligamentum flavum, and moderate facet disease; 3) no evidence of nerve root compression at the superior aspect of the neural foramina. Nerve root compression was noted to be probably related to central spinal stenosis at L4-5; and 5) Disc protrusion and associated osteophytes noted at the anterior aspect of the vertebral bodies at L2-3 and L3-4, were deemed by the examiner as not clinically significant. In September 1995, the veteran underwent VA orthopedic examination of the spine that included an examination of both the cervical and lumbosacral spine. By medical history, it was noted that the cervical spine underwent surgery for herniated nucleus pulposus in 1976 with a cervical fusion. It was further noted that the veteran has residual weakness, pain, and numbness of the left arm into the left hand. With respect to the lumbosacral spine, it was noted that the onset of the low back disability was in the pre-1970’s on, and that the diagnosis was spinal stenosis and degeneration. The veteran’s subjective complaints were noted to be weakness, pain and numbness in the left arm; constant pain in the lower back; an inability to sit very long; and radiation down both legs to the calves. Objective findings with respect to the cervical spine was that there was almost complete loss of motion of the cervical spine. There was a loss of the normal lordotic curve. It was noted to be tender over the neck scar from the surgery; tender over the spinous processes, and over the paraspinal muscles. Objective findings with respect to the lumbosacral spine included a loss of the normal lordotic curve; tenderness over the lumbosacral joint and both sciatic notches; tenderness over the paraspinal muscles; supine straight leg raising was 60 degrees for both legs; Patrick test was positive; and range of motion was decreased. Specific evaluation showed postural abnormalities to include a loss of lordotic curve in the cervical and lumbar spine; fixed deformity in the cervical spine; and a normal musculature of the back. Range of motion of the cervical spine as measured with a goniometer showed forward flexion to 10 degrees; backward extension from 0 to 5 degrees; left lateral flexion to 0 degrees; right lateral flexion to 0 degrees; rotation to the left to 5 degrees; and rotation to the right to 5 degrees. There was pain noted with all movements. Range of motion of the lumbar spine as measured with a goniometer showed forward flexion to 50 degrees; backward extension to 15 degrees; left lateral flexion to 20 degrees; right lateral flexion to 20 degrees; rotation to the left to 20 degrees; and rotation to the right to 20 degrees. There was pain noted with all movements. In terms of identifying any evidence of neurological involvement, the examiner noted that there was no foot drop or muscle atrophy. The examiner’s diagnoses were degenerative disc/joint disease of the cervical and lumbosacral spine; severe. On neurological examination by a private neurologist provided on a fee basis in August 1995, it was noted that the veteran had multiple complaints, including symptoms of headaches, weakness, generalized aches and pains, numbness in the left hand, spinal stenosis, neck pain, arm pain, back pain, and leg pain. Although the veteran’s claims file was not presented at the time of the examination, the examiner noted that he was able to review a number of documents from previous evaluations that the veteran had presented. These documents included past neurological consultations, electomyograph studies, nerve conduction studies, an intravenous urogram, a May 1994 cervical spine magnetic resonance imaging scan, cervical spine films from September 1994, a computed tomography scan of the cervical spine from October 1994, a December 1994 cervical spine magnetic resonance imaging scan, and a lumbosacral spine magnetic resonance imaging scan taken thereafter. The examining neurologist reported that he reviewed the results of these examinations. Upon neurological examination, the veteran was described as alert and oriented times three with normal speech and recall. There was no dysarthria or aphasia present. Cranial nerves II through XII were intact. Fundoscopic examination revealed the veteran to have flat discs bilaterally. Motor exam revealed the veteran to have no fix or drift. The veteran did have give-way weakness of his upper extremities. There was some give-way in the proximal lower extremities as well. The examiner noted that the veteran belched almost continuously during the history gathering process and during the examination. Fine motor coordination was described as equal bilaterally. Cerebellar examination was normal with respect to finger-to-nose and rapid tap testing. Sensation was normal to light touch bilaterally. Vibratory sensation was described as mildly reduced at both ankles. Temperature sensation was found to be symmetric. The veteran’s gait was described as normal with respect to heel, toe and tandem walking except that the gait had a right antalgic quality. Reflexes were noted to be 2+ and symmetric throughout. The examiner’s impression was that the veteran had multiple complaints of pain and other neurologic symptoms, but that there had been no real changes in the last 12 to 15 months. The examiner opined that the veteran was not felt to be a surgical candidate. According to the examining neurologist, the examination revealed the veteran to have essentially normal findings except for some give-way weakness, which suggested some augmentation. The neurological examiner noted further, that with respect to the veteran’s herniated nucleus pulposus of the lumbosacral spine, the veteran appeared more likely to have chronic degenerative joint disease and arthritis in his lumbar spine. It was speculated that it was probably unrelated to the veteran’s previous tour of duty. The examiner noted the possibility that the veteran may benefit from lumbar surgery to correct spinal stenosis, but the examiner doubted that the veteran would improve long-term since the veteran had such an unfavorable response to a previous cervical laminectomy. The examiner concluded that the veteran did not appear to have any long-standing neurologic disorder at the time of the examination, noting that all reflexes were physiologic, and that there was no objective evidence of muscle weakness. In November 1995, the neurologist who had examined the veteran in August 1995 presented a statement indicating that the veteran’s claims file had been reviewed, without further comment. Analysis Lumbosacral Spine Analysis The service-connected arthritis of the lumbosacral spine with herniated nucleus pulposus is currently rated as 40 percent disabling under Diagnostic Code 5003, pertaining to degenerative arthritis, that is rated on the basis of limitation of motion under the appropriate diagnostic code for the specific joint involved. Limitation of motion of the lumbar spine is rated under Diagnostic Code 5292 that provides a 40 percent rating for severe limitation of motion. The next higher rating based on limitation of motion is 50 percent under Diagnostic Code 5289 that requires unfavorable ankylosis of the lumbar spine. The Board has also considered the disability under Diagnostic Code 5295 (lumbosacral strain), where the 40 percent rating is the maximum schedular rating under this Diagnostic Code. Lastly, the Board has considered the disability under Diagnostic Code 5293 (intervertebral disc syndrome), where the 40 percent rating equates to severe recurring attacks with little intermittent relief. The criteria for the next higher rating, 60 percent, under the same Diagnostic Code are pronounced impairment with persistent symptoms compatible with sciatic neuropathy with characteristic pain and demonstrable muscle spasm, absent ankle jerk, or other neurological findings appropriate to the site of the diseased disc with little intermittent relief. On review of the record favorable to the veteran, there emerges from the evidence a disability picture characterized by persistent pain on all motions, a loss of the normal lordotic curve; tenderness, chronic joint degeneration, magnetic resonance imaging scan findings of mild to severe degenerative spinal stenosis. In addition, the record is consistent in documenting the veteran’s chronic low back pain over many years. When the evidence against the claim is considered, the medical evidence does not support a finding of unfavorable ankylosis either historically or currently. In the absence of a finding of unfavorable ankylosis of the lumbosacral spine, considering disabling pain, applying 38 C.F.R. §§ 4.40 (functional loss due to pain), 4.45 (reduction of normal excursion of movements, including pain on movement), and 4.59 (painful motion with arthritis), the schedular criteria for a rating in excess of 40 percent on the basis of limitation of motion, applying 38 C.F.R. § 4.7 (higher of the two where the disability picture more nearly approximates the criteria for the next higher rating), of the lumbosacral spine have not been met. As for persistent symptoms compatible with sciatic neuropathy, there was no evidence of peripheral nerve involvement on neurological examination in August 1995. The examiner concluded that the veteran did not appear to have any long-standing neurologic disorder at the time of the examination, noting that all reflexes were physiologic, and that there was no objective evidence of muscle weakness. The examiner’s impression was that the veteran had multiple complaints of pain and other neurologic symptoms, but that there had been no real changes in the last 12 to 15 months. With respect to the veteran’s herniated nucleus pulposus of the lumbosacral spine, the neurologist stated that the veteran appeared more likely to have chronic degenerative joint disease and arthritis in his lumbar spine. Considering disabling pain as a factor, applying 38 C.F.R. §§ 4.40, 4.45, 4.59, the medical evidence does not more nearly approximate or equate to the criteria of pronounced impairment in the absence of persistent symptoms compatible with sciatic neuropathy or other neurological findings appropriate to the site of the diseased disc, with little intermittent relief. For these reasons, the preponderance of the evidence is against a rating in excess of 40 percent. Cervical Spine Analysis The service-connected cervical spine disorder with radiculopathy of the left arm is currently rated as 30 percent disabling under Diagnostic Codes 5290 and 5293. Limitation of motion of the cervical spine is rated under Diagnostic Code 5290 that provides a 30 percent rating for severe limitation of motion. The next higher rating based on limitation of motion is 40 percent under Diagnostic Code 5287 that requires unfavorable ankylosis of the cervical spine. The Board has also considered the disability under Diagnostic Code 5293 (intervertebral disc syndrome), where a 40 percent rating equates to severe recurring attacks with little intermittent relief. The criteria for a 60 percent rating under the same Diagnostic Code are pronounced impairment with persistent symptoms compatible with sciatic neuropathy with characteristic pain and demonstrable muscle spasm, absent ankle jerk, or other neurological findings appropriate to the site of the diseased disc with little intermittent relief. On review of the record favorable to the veteran, there emerges from the evidence a disability picture characterized by almost a complete loss of motion; persistent pain on all motions; a loss of the normal lordotic curve; tenderness; pain and numbness in the left arm; magnetic resonance imaging scan findings of status post C5 through C7 vertebral body fusion, abnormal cervical spine curvature, mild narrowing of the spinal canal with narrowing of neural foramen; and cervical spondylosis. In addition, the record is consistent in documenting the veteran’s chronic cervical spine pain over many years. When the evidence against the claim is considered, the medical evidence does not support a finding of unfavorable ankylosis either historically or currently. In the absence of a finding of unfavorable ankylosis of the cervical spine, considering disabling pain, applying 38 C.F.R. §§ 4.40 (functional loss due to pain), 4.45 (reduction of normal excursion of movements, including pain on movement), and 4.59 (painful motion with arthritis), the schedular criteria for a rating in excess of 30 percent on the basis of limitation of motion, applying 38 C.F.R. § 4.7 (higher of the two where the disability picture more nearly approximates the criteria for the next higher rating), of the lumbosacral spine have not been met. As for persistent symptoms compatible with sciatic neuropathy, there was no evidence of peripheral nerve involvement on neurological examination in August 1995. The examiner concluded that the veteran did not appear to have any long-standing neurologic disorder at the time of the examination, noting that all reflexes were physiologic, and that there was no objective evidence of muscle weakness. The examiner’s impression was that the veteran had multiple complaints of pain and other neurologic symptoms, but that there had been no real changes in the last 12 to 15 months. Considering disabling pain as a factor, applying 38 C.F.R. §§ 4.40, 4.45, 4.59, the medical evidence does not more nearly approximate or equate to the criteria of severe impairment in the absence of persistent symptoms compatible with sciatic neuropathy or other neurological findings appropriate to the site of the diseased disc with little intermittent relief. For these reasons, the preponderance of the evidence is against a rating in excess of 30 percent. Surgical Scar Residuals of the Bone Graft Site at the Right Ilium Factual Background The veteran underwent a cervical diskectomy and fusion in 1976 while in service. Following service, the veteran was examined by the VA in August 1978. Upon examination, there was noted to be a 3 1/2 inch scar at the donor bone graft site just superior and parallel to the anterior crest of the ilium. It was noted to be sore and tender; there was a bone defect deeply. Based upon that examination, service connection was granted for a residual tender surgical scar at the bone graft donor site in a November 1978 rating decision, and evaluated as 10 percent disabling effective from October 1977. VA examination in September 1982 revealed a 6 centimeter long diagonal scar at the right iliac that was found to be well- healed and supple with only slight induration, but tender to deep palpation. The pertinent diagnosis was residuals of a cervical fusion C5-6-7, with bone graft from the right iliac crest. Based upon that examination, a January 1983 rating decision reduced the disability evaluation of the right iliac scar from 10 percent to zero percent. Following the noted reduction, the veteran filed for the restoration of the 10 percent evaluation. In a February 1984 decision, the Board found that the continuation of the 10 percent rating was warranted based upon a finding that the scar was tender on deep palpation. The evaluation for the bone graft scar was returned to 10 percent. The veteran filed for an increased evaluation in March 1995, complaining that the scar at the bone graft site at the right ilium had never healed properly, that it will always be sore and tender, and that in conjunction with his other disorders, walking is made very difficult. Service connection is also in effect for two other scars, including a post-operative scar at the right flank and a residual surgical scar of the cervical spine fusion. These scars are evaluated as noncompensable. There are no recent treatment records referable to the treatment of the veteran’s service-connected scars. VA examination of the veteran’s scars were conducted in September 1995. Medical history noted surgical scars at the neck, right hip, and mid-left back. Status-post cervical disc, right hip for cervical fusion, and the back for excision of lipoma were noted. Subjectively, the veteran complained that the right hip scar was always sore, and that there was a pulling sensation from the scar in the right neck. Pertinent objective findings upon examination was an eight centimeter linear right lower quadrant scar that was extremely tender to palpation. There was noted no keloid formation, adherence, herniation, inflammation, swelling, depression, vascular supply, or ulceration. There was noted to be no limitation of parts affected. The diagnosis was post-surgical scars. Analysis Scars may be evaluated on the basis of any related limitation of function of the body part which they affect. 38 C.F.R. § 4.118, Diagnostic Code 7805. Scars which are superficial, and poorly nourished with repeated ulceration, will be evaluated as 10 percent disabling under Diagnostic Code 7803. Scars which are superficial, tender and painful on objective demonstration will be evaluated as 10 percent disabling under Diagnostic Code 7804. In every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. A review of the objective medical evidence reveals that the criteria for a compensable 10 percent rating for surgical scar residuals of the bone graft site at the right ilium have been met. The September 1995 examination report shows that there is present an eight centimeter linear right lower quadrant scar that was extremely tender to palpation. There was noted, however, no keloid formation, adherence, herniation, inflammation, swelling, depression, vascular supply, or ulceration. Significantly, although the veteran has complained that the scar in conjunction with his low back disorder makes it difficult for him to walk, there was noted to be no limitation of parts affected upon objective clinical examination of the scar. In view of the foregoing, it is clear that an evaluation in excess of 10 percent is not warranted under all appropriate diagnostic codes. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 4.31, 4.118, Diagnostic Codes 7803, 7804, 7805. Any limitation of motion of the lumbosacral spine complained of by the veteran has been more significantly attributed from a clinical perspective to the veteran’s service-connected disorder of the lumbosacral spine and rated in conjunction with that disorder. It cannot also be rated under the diagnostic code for scars without violating the restriction against the pyramiding of the same disability under more than one diagnostic code. 38 C.F.R. § 4.14 (1996). Chronic Gastritis with Reflux Factual Background Service medical records reveal that the veteran was treated with antacids for various complaints of dyspepsia from 1970. From August to October 1977, the veteran was seen for complaints of regurgitation, bloating, and belching. The examiner’s impression following endoscopy in October 1977, was superficial gastritis with hypertonicity and irritability of the gastroesophageal junction with friability of uncertain etiology. Service connection for chronic gastritis with reflux was granted in a December 1977 rating decision, and assigned a 10 percent evaluation effective from October 1977. That rating has been in effect since that time. VA examination in September 1980 revealed that the veteran’s complaints included gastritis for which he indicated that he was receiving “Bethanecol” and “Titralac” tablets. The veteran at the time was noted to weigh 180.2 pounds. It was also noted that the veteran had gastritis and nausea at the time of the examination. Examination of the digestive system revealed some obesity, but no enlargements, masses, tenderness or rigidity. Pertinent diagnosis was reflux esophagitis. VA examination in August 1984 revealed that the veteran’s complaints included gastritis for which he indicated that he took Gaviscon tablets. The orthopedic examination report noted that the veteran’s gastritis was not too severe, but that Motrin aggravated it. VA examination in March 1988 included a consultation relative to the veteran’s digestive system. The veteran’s weight was noted to be 171 pounds. The digestive system evaluation noted that the veteran developed belching and heartburn in the service which had continued. It was noted to be mild to moderate in intensity. The veteran was told to continue on Gaviscon. An H2 blocker was suggested to see if additional relief could be given. It was noted that an upper gastrointestinal test had been reviewed and showed a little hiatus hernia and the duodenal bulb was deformed but there was no definite ulcer. Pertinent diagnosis was status gastritis. The veteran underwent a VA digestive examination on September 1995. It was reported, by history, that the onset of stomach distress occurred while the veteran was in Vietnam. Reported were excessive gas, belching, constant barborygnius, in spite of medication. Diagnosis was of esophago-gastro intestinal reflux. The veteran’s subjective complaints included constant belching every few minutes. Objective findings included tympanitis abdomen. Liver and spleen were not enlarged. There was right lower quadrant tenderness over the bone graft procureal scar. Bowel sounds were normal. It was noted that the veteran belched constantly, and that he appeared to the examiner to be an air swallower. The veteran’s weight was noted to be 175 pounds, which was also noted to be his maximum weight over the past year. The veteran was noted to not be anemic. There was no periodic vomiting or recurrent hematemesis or melena. The area of pain was noted to be epigastric and chest. Episodes of pain occurred daily, 365 days per year. The diagnosis was gastroesophageal reflux; severe. Recent treatment records fail to reveal the veteran being seen clinically for complaints specific to his digestive system. Complaints of “gas in the abdomen” were reported in conjunction with a September 1996 cardiology examination. The veteran’s weight at the time was 180.5 pounds. Analysis When an unlisted condition is encountered, it is permissible to rate under a closely related disease or injury. 38 C.F.R. § 4.20 (1996). The veteran's chronic gastritis with reflux has been rated by analogy to a hiatal hernia, due to a similarity in anatomical location and symptomatology. 38 C.F.R. § 4.20, Part 4, Diagnostic Code 7346 (1996). The rating criteria for hiatal hernia include pyrosis and dysphagia. A 30 percent evaluation is warranted for persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A 10 percent evaluation is warranted where the disorder is manifested by two or more of the symptoms for the 30 percent evaluation of less severity. The veteran's chronic gastritis with reflux could also be rated by analogy to a duodenal ulcer, due to a similarity in anatomical location and symptomatology. 38 C.F.R. § 4.20, Part 4, Diagnostic Code 7305 (1995). A 10 percent evaluation is warranted for a mild disorder, with recurring symptoms once or twice yearly. A 20 percent evaluation is warranted for a moderate disorder, with recurring episodes of severe symptoms two or three times a year averaging 10 days in duration, or with continuous moderate manifestations. A 30 percent evaluation is warranted for a moderately severe disorder that is less than severe but with impairment of health manifested by anemia and weight loss; or recurrent incapacitating episodes averaging 10 days or more in duration at least four or more times a year. When there is a question as to which of two evaluations should be applied to a disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (1996). Following a review of the record, the Board finds that the evidence suggests that symptoms of chronic gastritis with reflux are of such severity and frequency as to be considered analogous to "moderate" in nature under Diagnostic Code 7305. That is, the evidence does indicate recurring episodes of severe symptoms or continuous moderate manifestations. Upon VA examination in September 1995, episodes of pain occurred daily, 365 days per year, and the examiner’s diagnosis was gastroesophageal reflux; severe. What has not been shown, however, was impairment of health manifested by anemia and weight loss; or recurrent incapacitating episodes averaging 10 days or more in duration at least four or more times a year. Anemia has never been diagnoses, and the veteran’s weight has remained relatively stable over the years. Incapacitating episodes associated with his gastritis have not been demonstrated in the overall clinical record. Therefore an evaluation greater than 20 percent is not warranted under Diagnostic Code 7305. What has also not been demonstrated in the clinical record are persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. Therefore, an evaluation greater than 20 percent is also not warranted under Diagnostic Code 7346. In addition, the provisions of 38 C.F.R. § 4.114 provide that separate evaluations cannot be assigned under Codes 7305 and 7346. Section 4.114 provides that the predominant disorder will be evaluated, with elevation to the next higher rating where the severity of the overall disability picture warrants such elevation. Here, evaluation under Diagnostic Code 7305 results in an evaluation of 20 percent while an evaluation under Diagnostic Code 7346 results in an evaluation of 10 percent. Given the overall picture of the veteran’s gastric disability, in that recent treatment records fail to reveal the veteran being seen clinically for complaints specific to his digestive system, and that his symptoms have been treated conservatively through the years with antacid medication, elevation to the next higher evaluation under either Code is clearly not warranted. Hypertension Factual Background Service connection was granted for hypertension by a January 1983 decision of the Board based upon findings that the veteran had exhibited an abnormal blood pressure (164/94 in August 1977) shortly before his separation from service, that he had exhibited abnormally high blood pressure readings with a resulting diagnosis of essential hypertension following service (156/108 in December 1980), and that the veteran’s then current diagnosis could not be disassociated from service. A January 1983 rating decision that followed assigned a 10 percent evaluation for the veteran’s hypertension from October 1977, based upon VA examination in September 1982 that found the veteran’s blood pressure to be controlled with a reading of 130/80. The evaluation has remained in effect since that time. VA examination in March 1988 noted the veteran’s blood pressure to be 123/94 (systolic/diastolic). There was found to be good thrust in a normal cardiovascular system. VA examination for hypertension in September 1995 noted a 20 year history of hypertension for which medication had been taken since first noted. The veteran’s hypertension was noted to have been controlled on different medications since onset. The veteran’s subjective complaints included headaches and vertigo. There were no objective findings other than high blood pressure. Blood pressure readings were as follows: Sitting - 160/100; Lying - 160/98; and Standing - 158/98. The veteran’s medication was noted to be Procardia. There was no enlarged heart confirmation or apex beat beyond the midclavicular line. The diagnosis was hypertensive vascular disease. The veteran was seen between September and October 1995 for complaints relative to his hypertension that included general weakness. In September 1995, his blood pressure was measured to be 140/80. The medication Procardia was discontinued and Cardura was prescribed. In a follow up examination in October 1995, it was noted that the veteran’s blood pressure was well-controlled. His blood pressure reading was 157/87. He was continued on Cardura. The veteran was seen in the VA cardiology department in September 1996 for complaints of being tired all the time over the prior two years. His blood pressure was measured to be 162/92. Following examination, the examiner’s impression was cardiac arrhythmia and depressive reaction. Analysis 38 C.F.R. § 4.104, Diagnostic Code 7101 provides a 10 percent rating for hypertension when diastolic pressure is predominantly 100 or more or when continuous medication is shown necessary for control of hypertension with a history of diastolic blood pressure predominantly 100 or more. The veteran meets this latter criteria. However, under the schedular criteria, in order to warrant a 20 percent rating, the next higher rating, diastolic pressure predominantly 110 or more with definite symptoms must be shown. The service medical records and VA medical records from 1977 to 1996 show that the veteran's diastolic pressure is predominantly below 100. Clearly, the blood pressure readings do not more nearly reflect diastolic pressure predominantly 110 or more, the criteria for the next higher rating of 20 percent. In fact, a diastolic reading of 110 or more can not be found in the veteran’s available medical records. Elevation to the next higher evaluation under the Diagnostic Code for the evaluation of hypertension is not warranted. Service Connection for Chronic Prostate Disorder, Chronic Kidney Disorder and Chronic Blood Disorder Pertinent Law and Regulations Service connection may be established for a disability resulting from personal injury suffered or disease contracted in the line of duty or for aggravation of a preexisting injury suffered or disease contracted in the line of duty. 38 U.S.C.A. §§ 1110, 1131 (West 1991). Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (1996). A disease associated with exposure to certain herbicide agents, listed in 38 C.F.R. § 3.309 (1996) will be considered to have been incurred in service under the circumstances outlined in that section even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307(a) (1995). If a veteran was exposed to an herbicide agent during active military, naval, or air service, the following diseases shall be service-connected if the requirements of 38 C.F.R. § 3.307(a)(6) (1996) 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) (1996) are also satisfied: Chloracne or other acneform disease consistent with chloracne; Hodgkin's disease; Non-Hodgkin's lymphoma; Porphyria cutanea tarda; multiple myeloma, respiratory cancers (cancers of the lung, bronchus, larynx, or trachea), and soft-tissue sarcoma. 38 C.F.R. § 3.309(e) (1996). These diseases shall have become manifest to a degree of 10 percent or more at any time after service, except that chloracne, or other acneform disease consistent with chloracne, and porphyria cutanea tarda shall have become manifest to a degree of 10 percent or more within a year, and respiratory cancers within 30 years, after the last date on which the veteran was exposed to an herbicide agent during active military, naval, or air service. 38 C.F.R. § 3.307(a)(6)(ii) (19965). The Secretary has also determined that there was 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. 59 Fed. Reg. 341-46 (January 4, 1994). The threshold question that must be resolved with regard to each claim is whether the appellant has presented evidence that the claim is well grounded; that is, that the claim is plausible. If he has not, his appeal fails as to that claim, and the Department of Veterans Affairs (VA) is under no duty to assist him in any further development of that claim. 38 U.S.C.A. § 5107(a) (West 1991); Murphy v. Derwinski, 1 Vet.App. 78 (1990). Case law provides that, although a claim need not be conclusive to be well grounded, it must be accompanied by evidence. A claimant must submit supporting evidence that justifies a belief by a fair and impartial individual that the claim is plausible. Dixon v. Derwinski, 3 Vet.App. 261, 262 (1992); Tirpak v. Derwinski, 2 Vet.App. 609, 611 (1992). In order for a claim to be well grounded, there must be competent evidence of current disability (a medical diagnosis); of incurrence or aggravation of a disease or injury in service (lay or medical evidence); and of a nexus between the in-service injury or disease and the current disability (medical evidence). Caluza v. Brown, 7 Vet.App. 498 (1995). One element of a well-grounded claim is a presently existing disability stemming from the disease or injury alleged to have begun in or been aggravated by service. Brammer v. Derwinski, 3 Vet.App. 223 (1992); Rabideau v. Derwinski, 2 Vet.App. 141 (1992). 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). Lay assertions of medical causation cannot constitute evidence to render a claim well grounded under 38 U.S.C.A. § 5107(a) (West 1991); if no cognizable evidence is submitted to support a claim, the claim cannot be well grounded. Id. Factual Background Initially, the Board notes that the veteran had previously filed claims of entitlement to service connection for a chronic prostate disorder and a chronic kidney disorder which were denied in a December 1977 rating decision. That decision was not timely appealed and became final. 38 U.S.C.A. § 7105 (West 1991). The veteran’s only contention currently at issue is that his prostate disorder, kidney disorder, and blood disorder are the result of his exposure to Agent Orange while serving in Vietnam during the Vietnam war. Since that contention is potentially based upon a presumptive, and therefore, liberalizing law, with respect to the issues of entitlement to service connection for a prostate disorder and kidney disorder, there is now presented a new basis for entitlement, thus constituting a new claim. Ashford v. Brown, 10 Vet.App. 120 (1997). As such, the claims under that theory are not subject to the new and material evidence requirements as set out in 38 C.F.R. § 3.156 (1996). The Board, therefore, will review the decision on appeal with respect to the prostate disorder and kidney disorder solely on that basis. In terms of the veteran’s claim of service connection for a blood disorder, the Board notes that the veteran’s available service medical records are negative for the complaints, treatment or diagnosis of a blood disorder. Post-service medical records reveal that the veteran was referred to the Internal Medicine Clinic at the Nellis Air Force Base Hospital in August 1988 with a provisional diagnosis of leukopenia following a long history of a low white blood cell count on complete blood count testing. The examiner’s assessment was leukopenia with relative neutropenia without clear cut etiology. It was recommended among other things that the veteran stop Motrin and Hydrochlorothiazide. It was noted that the veteran was found to have leukopenia on routine complete blood count that dated back to 1981 and that he had been on Motrin and Hydrochlorothiazide since that time. The veteran was hospitalized and treated by a private physician in September 1990 for nausea, fever, stomach pains and a temperature of 101.7. It was noted that he had been on Hydrochlorothiazide, Motrin, and Gaviscon. Following testing that included a complete blood count, the examiner’s assessment was neutropenia of acute onset since admission and febrile illness. VA compensation examination in September 1995 included several pertinent examinations to the specific disabilities currently at issue. VA examination in September 1995 included an examination for systemic conditions. Medical history noted a low white cell count. The veteran’s sole subjective complaint was weakness. There were no objective findings. It was noted, in pertinent part, that the veteran had a renal stone and no anemia. The diagnosis was Leukopenia. Examination for hematologic disorders noted by history a low white blood cell count that had been present for years. There were no subjective complaints. The sole objective finding was a white blood cell count of 3.9. It was noted that the veteran was weak in terms of his physical activity. The diagnosis was Leukopenia, mild. VA examination in September 1995 included an examination for residuals of dioxin exposure (Agent Orange). By history it was noted that the veteran served in the United States Air Force in Vietnam during the Vietnam war period. In terms of medical history, it was noted that the veteran attributed no symptoms to Agent Orange at the time of exposure, but that he now attributes his stomach problems, including excessive belching, and his kidney infection to the exposure. Objectively, the pertinent examination noted the veteran’s prostate to be smooth and enlarged, 1-2+, with no nodules palpated. The veteran’s lymphatics were not enlarged. There was no evidence of neoplasia or infertility. There was no diagnosis provided. Laboratory work was not available at the time of the examination. VA examination in September 1995 of the pyelitis, nephrolithiasis, ureterolithiasis, ureteral stricture and hydronephrosis noted a kidney stone by medical history, first noted in 1986 or 1987, and passed, which was a uric stone. It was also noted that the veteran had a kidney infection while in service in Thailand. The second stone of 7 millimeters in 1992 was not passed and was broken up by Lithotripsy. It was noted further that the veteran had a right upper pole renal stone. Subjective complaints included back soreness in the right mid-back. Objectively, there was noted mild costovertebral tenderness on the right side. A right upper pole renal stone was reported to be present. It was noted that previous stones were from the left kidney which were passed or broken up by Lithotripsy. The diagnosis was right renal stone. VA examination in September 1995 for disorders including disorders of the prostate, bladder and urethra, noted by medical history that the veteran had urological problems for the past 20 years. It was noted that he had a bladder infection in Vietnam and Thailand. He recently was noted to have had urgency and frequency, dribbling, and minor incontinence. Subjective complaints included urgency, dribbling, and incontinence. There were no objective findings noted. Frequency of urination was nocturia times 3. There was no pyuria, pain or tenesmus. Incontinence occasionally required pads or appliance. Diagnostic or clinical tests included a prostate-specific antigen. The diagnosis was benign prostatic hypertrophy. Analysis The Board may concede that the veteran currently has a blood disorder, kidney disorder, and prostate disorder. As indicated above, service connection for a kidney disorder and prostate disorder were previously denied in a 1977 rating decision that had become final The Board also notes that there was no evidence of a blood disorder in service, and the veteran does not contend otherwise. The veteran has claimed entitlement to service connection for a blood disorder, kidney disorder, and prostate disorder, as the result of exposure to Agent Orange, and that is the issue currently on review by the Board. The new regulations pertaining to Agent Orange, now expanded to include all herbicides used in Vietnam, provide for a presumption of exposure to herbicide agents for veterans who served on active duty in Vietnam during the Vietnam era. 38 C.F.R. § 3.307(a)(6) (1996). The regulations also stipulate the diseases for which service connection may be presumed due to an association with exposure to herbicide agents. 38 C.F.R. § 3.309(e) (1996). Further, the Secretary of Veterans Affairs formally announced in the Federal Register on January 4, 1994, that a presumption of service connection based on exposure to herbicides used in Vietnam was not warranted for certain conditions, to specifically include circulatory disorders or for "any other condition for which the Secretary has not specifically determined a presumption of service connection is warranted." 59 Fed. Reg. 341 (1994). Neither leukopenia, kidney stones, nor prostatic hypertrophy are included among the diseases stipulated in 38 C.F.R. § 3.309(e). Notwithstanding the foregoing, the United States Court of Appeals for the Federal Circuit recently determined that the Veteran's Dioxin and Radiation Exposure Compensation Standards (Radiation Compensation) Act, Pub. L. No. 98-542, § 5, 98 Stat. 2725, 2727-29 (1984) does not preclude a veteran from establishing service connection with proof of actual direct causation. Combee v. Brown, 34 F.3d 1039 (Fed.Cir. 1994). However, the United States Court of Veterans Appeals has held that where the issue involves medical causation, competent medical evidence which indicates that the claim is plausible or possible is required to set forth a well- grounded claim. Grottveit v. Brown, 5 Vet.App. 91, 93 (1993). In this case, although the veteran did serve in Vietnam during the Vietnam era, there is no competent medical evidence suggesting a connection between his presumed herbicide exposure while in Vietnam and the subsequent development of a blood disorder, kidney disorder, or a prostate disorder. Once again, his assertions of medical causation alone are not probative because lay persons (i.e., persons without medical expertise) are not competent to offer medical opinions. Moray v. Brown, 5 Vet.App. 211 (1993); Grottveit v. Brown, 5 Vet.App. 91 (1993); Espiritu v. Derwinski, 2 Vet.App. 492 (1992). In order for a claim to be well grounded, there must be competent evidence of current disability (a medical diagnosis), of incurrence or aggravation of a disease or injury in service (lay or medical evidence), and of a nexus between the in-service injury or disease and the current disability (medical evidence.) Caluza v. Brown, 7 Vet. App. 498 (1995). In the absence of credible evidence that the veteran currently has a blood disorder, kidney disorder, or a prostate disorder, that was incurred or aggravated in service, or was causally or etiologically related thereto, the Board finds that the claim is not well-grounded. See Grivois, 6 Vet.App. at 140. Accordingly, the claim must be denied. See 38 U.S.C.A. § 7105(d)(5). ORDER Entitlement to an increased evaluation for arthritis of the lumbosacral spine with herniated nucleus pulposus, is denied. Entitlement to an increased evaluation for post-operative residuals of a cervical spine disorder with radiculopathy of the left arm, is denied. Entitlement to an increased evaluation for surgical scar residuals of the bone graft site at the right ilium, is denied. Entitlement to an increased evaluation to 20 percent for chronic gastritis with reflux, is granted, subject to the laws and regulations governing the award of benefits. Entitlement to an increased evaluation for hypertension is denied. Entitlement to service connection for a chronic prostate disorder, claimed as a residual of Agent Orange herbicide exposure, is denied. Entitlement to service connection for a chronic kidney disorder, claimed as a residual of Agent Orange herbicide exposure, is denied. Entitlement to service connection for a chronic blood disorder, claimed as a residual of Agent Orange herbicide exposure, is denied. REMAND The veteran has submitted on at least two occasions a copy of page 2 of VA Form 10-9009, purported to be a report of an Agent Orange examination that had taken place on October 3, 1990 at the VA outpatient clinic in Las Vegas, Nevada. The document, which appears to be executed by an examining physician, provides a diagnosis of headaches, and an indication that the diagnosed headaches were caused by Agent Orange exposure. The Board notes, however, that a rationale for that opinion was not offered, and that the complete report of the examination has not been sought or otherwise associated with the claims folder. Secondly, as indicated in the Introduction section of this decision, following the RO’s issuance of a supplemental statement of the case, the veteran submitted evidence that was deemed pertinent to the issue of entitlement to a total rating based on individual unemployability due to service- connected disability. Consequently, it is necessary that such evidence be referred to the RO for review and preparation of a supplemental statement of the case as to the total rating issue. 38 C.F.R. § 20.1304(a)-(c). Moreover, by virtue of the fact that an additional grant of benefits has been accorded the veteran in this decision, it would be appropriate for the RO to readjudicate the issue of total rating based on individual unemployability due to service- connected disability. In that regard, the Board is cognizant that as recently as September 1995, the veteran was afforded several VA examinations for rating purposes. Although those examinations appear thorough, "when a TDIU claim is presented, a VA examining physician should generally address the extent of functional and industrial impairment from the veteran's service-connected disabilities. See Martin (Roy) v. Brown, 4 Vet.App. 136, 140 (1993)." Gary v. Brown, 7 Vet.App. 229, 232 (1994). That question was not specifically addressed in the September 1995 VA examinations. The VA has the duty to assist the veteran in the development of facts pertinent to his claim. 38 U.S.C.A. § 5107(a). The United States Court of Veterans Appeals has held that the duty to assist the veteran includes obtaining medical records and medical examinations where indicated by the facts and circumstances of an individual case. Littke v. Derwinski, 1 Vet.App. 90 (1990). In order to clarify the veteran's disability picture, the Board concludes that the veteran should be afforded another VA examination. At that time, the examiner will have an opportunity to address the extent of functional and industrial impairment that can be exclusively attributed to the veteran's service connected disabilities. Gary v. Brown, 7 Vet.App. 229 (1994). On the basis of the above and pursuant to 38 C.F.R. § 19.9, the Board determines that further development of the evidence is essential for a proper appellate decision and, therefore, remands the matter to the RO for the following action: 1. The RO should ask the veteran to provide the names, addresses, and approximate dates of treatment of all VA and non-VA health care providers who have treated him for his service-connected disabilities since September 1996, the date of the most recent clinical evidence of record. After securing any necessary authorizations, the RO should request copies of all indicated records and associate them with the claims folder. The RO should also attempt to obtain a complete copy of the Agent Orange protocol examination that had reportedly taken place on October 3, 1990 at the VA outpatient clinic in Las Vegas, Nevada. 2. The RO should schedule the veteran for a VA orthopedic examination to determine the extent of his service- connected disabilities. All indicated tests, studies and X-rays should be performed. The examiner is requested to comment on the functional and industrial impairment caused by those disabilities. Finally, the examiner should provide an opinion as to whether it can be stated on a more likely than not basis that the veteran’s headaches disorder, if any, is caused by his cervical spine disorder or by his presumed exposure to Agent Orange during his tours of duty in Vietnam during the Vietnam war. Reasons and bases for all opinions are to be included. The claims folder and a separate copy of this remand must be made available to the examiner for review prior to the examination. The RO must inform the veteran of all consequences of his failure to report for the examination in order that he may make an informed decision regarding his participation in said examination. 3. The RO should schedule the veteran for a VA neurological examination to determine the extent of his service- connected disabilities, and the nature and extent of his non-service-connected headaches. All indicated tests and studies should be performed. The examiner is requested to comment on the functional and industrial impairment caused exclusively by the veteran’s service-connected disabilities and only those disabilities. The examiner should comment as to whether the veteran’s service-connected disabilities in and of themselves renders the veteran unable to secure or follow a substantially gainful occupation. If the examiner is unable to distinguish the occupational impact of the veteran’s nonservice-connected disorders from the veteran’s service- connected disorders, the examiner should so state that opinion. Finally, the examiner should provide an opinion as to whether it can be stated on a more likely than not basis that the veteran’s headaches disorder, if any, is caused by his cervical spine disorder or by his presumed exposure to Agent Orange during his tours of duty in Vietnam during the Vietnam war. Reasons and bases for all opinions are to be included. The claims folder and a separate copy of this remand must be made available to the examiner for review prior to the examination. The RO must inform the veteran of all consequences of his failure to report for the examination in order that he may make an informed decision regarding his participation in said examination. 4. Following the completion of the foregoing special orthopedic and neurological examinations and the association of the reports of those examinations in the claims folder, the RO should schedule the veteran for a general VA medical examination to determine the extent to which the veteran’s service- connected disabilities in total, and only those disabilities, impact the veteran’s ability to work. All indicated tests and studies should be performed. The examiner is requested to comment on the functional and industrial impairment caused solely by the veteran’s service- connected disabilities and whether those disabilities and only those disabilities render the veteran unable to secure and follow a substantially gainful occupation. If the examiner is unable to distinguish the occupational impact of the veteran’s nonservice-connected disorders from the veteran’s service- connected disorders, the examiner should so state that opinion. Reasons and bases for all opinions are to be included. The claims folder and a separate copy of this remand must be made available to the examiner for review prior to the examination. The RO must inform the veteran of all consequences of his failure to report for the examination in order that he may make an informed decision regarding his participation in said examination. 5. After the above examinations are conducted, the RO should review the claims folder and ensure that all of the foregoing development actions have been conducted and completed in full. If any development is incomplete, appropriate corrective action is to be implemented. Specific attention is directed to the reports of examination. If the reports do not include sufficient data or adequate responses to the specific opinions requested, the reports must be returned to the examiner for corrective action. 38 C.F.R. § 4.2. 6. Thereafter, the RO should readjudicate, in light of the additional evidence, the issue of service connection for headaches as secondary to the cervical spine disorder or as secondary to Agent Orange exposure and the issue of a total rating based on individual unemployability. If the benefit sought is denied, then the appellant and his representative should be provided a supplemental statement of the case which reflects RO consideration of all additional evidence, and the opportunity to respond. Thereafter, the case should be returned to the Board for further appellate review. The purpose of this REMAND is to obtain additional evidence and ensure that the veteran is afforded all due process of law. The Board intimates no opinion, either factual or legal, as to the ultimate conclusion warranted in this case. No action is required by the veteran until contacted by the RO. 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. 1997) (Historical and Statutory Notes). In addition, VBA’s ADJUDICATION PROCEDURE MANUAL, M21-1, Part IV, directs the ROs 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. V. L. JORDAN Member, Board of Veterans' Appeals NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991 & Supp. 1997), a decision of the Board of Veterans’ Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans’ Judicial Review Act, Pub. L. No. 100-687, § 402, 102 Stat. 4105, 4122 (1988). The date that appears on the face of this decision constitutes the date of mailing and the copy of this decision that you have received is your notice of the action taken on your appeal by the Board of Veterans’ Appeals. Appellate rights do not attach to those issues addressed in the remand portion of the Board’s decision, because a remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (1996). - 2 -