Citation Nr: 0001665 Decision Date: 01/20/00 Archive Date: 01/28/00 DOCKET NO. 96-48 400 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUES 1. Whether new and material evidence has been submitted to reopen a claim of entitlement to service connection for a back disorder. 2. Entitlement to service connection for a bilateral hip disorder. 3. Entitlement to service connection for a stomach disorder. 4. Entitlement to service connection for a headache disorder. 5. Entitlement to service connection for post-traumatic stress disorder. 6. Entitlement to a temporary total evaluation under 38 C.F.R. § 4.29 (1999) for a period of hospitalization in November and December 1995. 7. Entitlement to a compensable evaluation for fibrocystic disease of both breasts. 8. Entitlement to an evaluation in excess of 10 percent for residuals of a neck injury C5-C6, including chronic muscular strain superimposed on degenerative instability. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and her spouse INTRODUCTION The appellant had active service from April 1979 to June 1981. This matter comes to the Board of Veterans' Appeals (Board) from a May 1996 rating decision of the Department of Veterans Affairs (VA) Portland Regional Office (RO). In that determination, the RO declined to reopen previously denied claims of service connection for leg, hip, and back disorders; denied claims of service connection for post- traumatic stress disorder (PTSD), a stomach disorder, and migraine headaches; denied a claim for a temporary total evaluation for a period of hospitalization under 38 C.F.R. § 4.29; denied a claim for a compensable evaluation for fibrocystic disease of both breasts; and granted a 10 percent evaluation (increased from noncompensable) for residuals of a neck injury C5-C6, including chronic muscular strain superimposed on degenerative instability. The appellant perfected an appeal as to each of these determinations, including the 10 percent evaluation assigned to the cervical spine disability. See AB v. Brown, 6 Vet. App. 35, 38-39 (1993) (claimant presumably seeks maximum benefit allowed). As discussed below, the additional evidence received since March 1985 regarding the claim of service connection for a bilateral hip disorder is new and material. Thus, the issue is as styled on the title page of this decision. The RO developed for appellate review the issue of whether new and material evidence was submitted to reopen a claim of service connection for a bilateral leg disorder. In a March 1983 rating decision, the RO denied the claim of service connection for leg pain and cramps and was notified of that determination in an April 5, 1983 letter from the RO. In May 1983, she filed a notice of disagreement with other determinations addressed in the March 1983 rating decision, but failed to indicate any disagreement with the denial of service connection for leg pain and cramps. In an August 1983 statement, however, she indicated that the muscles in her calves developed knots and swelling and alluded to injuries in the lower legs during service. This statement, liberally construed and coming within one year of notification of the March 1983 adverse rating decision, is a valid notice of disagreement. See 38 C.F.R. §§ 20.201, 20.300, 20.301(a), 20.302(a) (notice of disagreement must be filed within one year of notice of decision). Thus, the March 1983 rating decision denying service connection for leg pain and cramps is not final and the Board does not have jurisdiction to determine whether new and material evidence has been submitted to reopen the claim. Action required to redress this procedural error is set forth in the Remand section of this decision. FINDINGS OF FACT 1. The claim of entitlement to service connection for a back disorder was denied by decision in March 1983; the appellant was notified by the RO thereof on April 5, 1983; she did not initiate an appeal of that issue. 2. The additional evidence concerning a back disorder received into the record after March 1983 is not probative and material, nor does it bear directly and substantially on the specific matter at hand. 3. The claim of entitlement to service connection for a bilateral hip disorder was denied by Board decision in March 1985. 4. The additional evidence concerning a bilateral hip disorder received into the record after March 1985 is new and material, as it bears directly and substantially on the specific matter at hand. 5. No competent evidence has been submitted linking the post-service findings of a bilateral hip disorder to service. 6. Competent evidence has been submitted linking the post- service findings of a stomach disorder to service. 7. Competent evidence has been submitted linking the post- service findings of a headache disorder to service. 8. Competent evidence has been submitted linking the post- service findings of PTSD to service. CONCLUSIONS OF LAW 1. The appellant has not submitted new and material evidence to reopen a claim of entitlement to service connection for a back disorder. 38 U.S.C.A. § 5108 (West 1991); 38 C.F.R. § 3.156(a) (1999). 2. The appellant has submitted new and material evidence to reopen a claim of entitlement to service connection for a bilateral hip disorder. 38 U.S.C.A. § 5108 (West 1991); 38 C.F.R. § 3.156(a) (1999). 3. The claim for service connection for a bilateral hip disorder is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 4. The claim for service connection for a stomach disorder is well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 5. The claim for service connection for a headache disorder is well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 6. The claim for service connection for PTSD is well grounded. 38 U.S.C.A. § 5107(a) (West 1991). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Claims to Reopen Final Back and Bilateral Hip Claims A. Pertinent Law and Regulations In a March 1983 rating decision, the RO denied the appellant's claim of service connection for a back disorder and a bilateral hip disorder. She filed an August 1983 statement that could be construed as a notice of disagreement with the denial of the back claim. However, in an April 1984 statement she informed the RO that she was "canceling" her claim for a back disorder. That communication is a valid withdrawal of the claim under 38 C.F.R. § 20.204(c). The March 1983 rating decision became final at the expiration of the one-year period following the April 5, 1983 notice of that determination. The appellant did perfect an appeal as to the claim of service connection for a bilateral hip disorder, which was denied by the Board in a March 1985 decision. Decisions of the Board are final. 38 U.S.C.A. § 7105(c). Final decisions, whether of the Board or the RO, may not be reopened in the absence of new and material evidence. If new and material evidence is submitted, the claim will be reopened and adjudicated on the merits. 38 U.S.C.A. § 5108. New and material evidence means evidence not previously submitted to agency decisionmakers which bears directly and substantially on the specific matter under consideration, which is neither cumulative nor redundant, and which by itself or in connection with evidence previously assembled is so significant that it must be considered in order to fairly decide the merits of the claim. 38 C.F.R. § 3.156(a). Whether new and material evidence is submitted is a jurisdictional test, with the Board being required to reopen if such evidence is submitted and prohibited from reopening and considering the claim if such evidence is not submitted. Barnett v. Brown, 83 F.3d 1380, 1383-84 (Fed. Cir. 1996); Winters v. West, 12 Vet. App. 203, 206-07 (1999). In addressing whether new and material evidence has been submitted, the Board must review the evidence before VA at the time of the prior decision, identify any additional evidence now before VA, and determine whether that additional evidence is both new and material. If so, then the claim will be reopened for adjudication on the merits. If not, that is where the analysis must end as the Board lacks jurisdiction to review the merits of the claim. See Barnett, 83 F.3d at 1383-84. In a September 1995 statement, the appellant filed claims to reopen these determinations. The RO declined to reopen the prior final decisions in a May 1996 rating decision. The appellant disagreed, and the RO developed the claims for appellate review. The analysis required to adjudicate the application to reopen the previously denied claims requires three steps as set forth in Elkins v. West, 12 Vet. App. 209, 214 (1999). VA must (1) determine whether the [appellant] has presented new and material evidence under 38 C.F.R. § 3.156(a) in order to have a finally denied claim reopened under 38 U.S.C.A. § 5108; (2) if new and material evidence has been presented, determine whether, based upon all the evidence of record in support of the claim, presuming its credibility, the reopened claim is well grounded; and (3) if the claim is well grounded, evaluate the merits of the claim after ensuring that the duty to assist under 38 U.S.C.A. § 5107(b) has been fulfilled. Winters, 12 Vet. App. at 206-07. Thus, the first determination is whether the appellant has submitted new and material evidence. New evidence that was not likely to convince the Board to alter its previous decision could be material if it provided a more complete picture of the circumstances surrounding the origin of an injury or disability, even where it would not eventually convince the Board to alter its rating decision. Hodge v. West, 155 F.3d 1356, 1363 (Fed. Cir. 1998); Elkins, 12 Vet. App. at 214. The reopening standard provides for judgment as to whether new evidence bears directly or substantially on the specific matter and is so significant that it must be considered to fairly decide the merits of the claim. Fossie v. West, 12 Vet. App. 1, 4 (1998). The new and material evidence must be presented or secured since the time the claim was finally disallowed on any basis. Evans, 9 Vet. App. at 285. The newly presented evidence need not be probative of all the elements required to award the claim, but only as to each element that was a specified basis for the last disallowance. Id. at 284. Prior evidence of record is important in determining whether evidence is new for purposes of deciding whether to reopen a claim. Id. B. Back Disorder At the time of the March 1983 rating decision, the evidence of record included the service medical records. These records showed that the appellant complained of low back pain following a fall in November 1979. Mild low back strain without radiculopathy was noted. She was given a physical profile with low back strain. January and March 1980 service clinical record entries showed a normal back and a back examination within normal limits, respectively. In August 1980, she complained of extreme low back pain for three days, with mild spasm and no radiation. A March 1981 separation examination included her complaints of recurrent back pain and showed a normal back clinical evaluation. The examiner noted as history low back pain that was muscular in origin. Thereafter, a May 1981 clinical record entry indicate sacroiliac strain and a June 1981 entry noted minimal low back pain muscular in origin. VA examinations in January and February 1983 included diagnoses of history of back pain and recurrent low back pain without explanation. An x-ray of the lumbar spine was normal. In March 1983, the RO denied the claim because the evidence did not show any link between a current back disorder and that shown in service. The additional evidence of record received after the March 1983 rating decision includes the following: ? Transcripts of a November 1983 hearing and an April 1997 hearing, at which the appellant testified that she injured her low back in a fall down a flight of stairs in service. She also attributed the current back condition to strenuous running required during her service. ? A March 1983 private x-ray report showing no significant abnormalities of the lumbar spine and an undated private clinical record revealed complaints of low back pain. ? VA physical therapy records in January and February 1995 indicating that the appellant received physical therapy for right paraspinal muscle spasm in the lumbar region. ? VA hospital records in November and December 1995 noting that the appellant had low back pain secondary to degenerative arthritis. ? A March 1985 clinical record entry showing chronic radiating low back pain. ? A September 1987 clinical record indicating acute low back pain secondary to degenerative joint disease, a January 1995 clinical record revealed low back pain and paraspinal muscle spasm, and an October 1995 x- ray report noted mild arthritic changes at the lower lumbar spine. ? Private clinical records from July 1989 to February 1996 noting treatment for low back pain and a history of a fall in 1979. ? An article from THE MERCK MANUAL discussing fibromyalgia. ? Private clinical records from March 1996 to April 1997 showing treatment for low back pain and a history of a fall in 1979. ? VA clinical records from July through October 1997 indicating a history of back injury in 1979, low back pain and arthritic changes with disc bulging at L4- S1, and physical therapy prescribed to address these symptoms. None of this additional evidence even discusses a potential link between the current findings and service, the basis for the prior denial in March 1983. The March 1983 private x-ray report and an associated private clinical record showed no more than simply complaints of low back pain; neither record included any discussion as to a link to service. The March 1985 private clinical record entry noted low back pain and did not connect that pain to service. VA hospital and physical therapy records in September 1987 and in 1995 indicated various current symptomatology, but did not link those symptoms to service. Because none of these records included any discussion of the etiology of the current back symptoms, they cannot serve as material evidence to reopen the claim. Several of the records received after March 1983 include discussion of the appellant's history of a fall during service in 1979. Private clinical records from July 1989 to April 1997 showed treatment for low back pain and a noted history of a fall in 1979. VA clinical records from July through October 1997 also showed a history of back injury in 1979. The service medical records include documentation of a fall in November 1979 and resulting mild low back strain. Thus, the history of this fall is not new evidence. Most importantly, these private and VA clinical records only note this history of a back injury in 1979. They do not indicate that the 1979 fall was the etiologic source of the appellant's current back symptoms. Thus, these records cannot serve as material evidence to reopen the claim. The only remaining evidence presented to reopen the claim is a copy of an article from THE MERCK MANUAL discussing fibromyalgia and the appellant's contentions and arguments at the November 1983 and April 1997 hearings. The evidence of record does not refer to fibromyalgia. Thus, the article from THE MERCK MANUAL is not material to the claim. As to the appellant's contentions, her testimony in November 1983 and April 1997 simply duplicates the contentions advanced at the time of the March 1983 rating decision. Moreover, even if these contentions and arguments were new and material, thereby reopening the claim, statements prepared by lay persons ostensibly untrained in medicine generally cannot constitute competent medical evidence to render a claim well grounded. A layperson can certainly provide an eyewitness account of an appellant's visible symptoms. Layno v. Brown, 5 Vet. App. 465, 469 (1994). However, the capability of a witness to offer such evidence is different from the capability of a witness to offer evidence that requires medical knowledge. For the most part, a witness qualified as an expert by knowledge, skill, experience, training, or education must provide medical testimony. Espiritu v. Derwinski, 2 Vet. App. 492, 494-95 (1992). The record does not indicate that the appellant possesses this requisite expertise. Thus, her testimony as to the etiology of her back symptomatology cannot serve as competent medical evidence to well ground the claim. Since the additional evidence presented since March 1983 is not probative on the element of the claim forming the basis of the prior denial, it is not material. Thus, the appellant's application to reopen the previously denied claim of service connection for a back disorder is denied. With new and material evidence not having been submitted, this is where the analysis must end. VA cannot reach the question of whether the claim is well grounded. Barnett, 83 F.3d at 1383-84. Nor, without determining if the claim is well grounded, may VA exercise its statutory duty to assist the claimant in developing facts pertinent to the claim. Morton v. West, 12 Vet. App. 477, 485 (1999). However, VA may be obligated under 38 U.S.C.A. § 5103(a) to advise a claimant of evidence needed to complete the application. This obligation depends on the particular facts of the case and the extent to which VA has advised the claimant of the evidence necessary to be submitted with a claim. Graves v. Brown, 8 Vet. App. 522 (1996). In this case, the RO fulfilled its obligation under § 5103(a) in the September 1996 statement of the case and in the September 1997 and July 1999 supplemental statements of the case in which the appellant was informed that the reason for the denial of the claim was the lack of evidence connecting the back symptomatology to service. Thus, to the extent possible, VA has complied with its obligations under 38 U.S.C.A. § 5103(a). C. Bilateral Hip Disorder At the time of the Board's March 1985 decision, the evidence relevant to the right hip claim included the service medical records. Clinical records from May to July 1979 showed that the appellant complained of bilateral hip pain secondary to running. A bone scan and x-ray were normal. A September 1979 record noted hip stress and poor physical conditioning. A January 1980 x-ray showed a slight irregularity of the pubic symphysis. A March 1980 examination was normal. A May 1980 record showed pain in the pelvic girdle and discounted any dislocation. A March 1981 separation examination revealed the appellant's complaints of swelling for the previous two years and a normal musculoskeletal clinical evaluation. Also before the Board in March 1985 was the following: ? January and February 1983 VA examinations, which included a diagnosis of history of hip pain. ? A March 1983 private clinical record that described an x-ray of the pelvis as showing no significant abnormality. ? The transcript of a November 1983 hearing, at which the appellant testified that she was placed on physical profile during service and was informed that she would probably require artificial hip joints. The Board denied the claim in March 1985, finding that the evidence of record did not show a current bilateral hip disorder. The additional evidence received after March 1985 included the following: ? A November 1985 VA x-ray of the hips showing mild arthritic changes and no disease demonstrated. ? A December 1985 private clinical record diagnosing bilateral hip arthrosis. ? A September 1987 VA clinical record noting a history of hip pain for seven years and an assessment of osteoarthritis of both hips. An x-ray showed minimal degenerative spurring. ? An October 1987 VA clinical record indicating minimal osteoarthritis of both hips. ? A June 1996 statement by the appellant's mother, who stated that the appellant's hip symptoms were due to drills conducted during her military service. ? VA hospital records in November and December 1995 indicated that the appellant had arthritis in her hips. ? The transcript of a hearing in April 1997, at which the appellant testified that she had a bilateral hip disorder that was related to a fall in 1979 and to the activities required of her during her active service. ? VA clinical records in July 1997 showed mild degenerative joint disease involving the hips. The Board denied the claim in its March 1985 decision because the evidence did not show a current bilateral hip disorder. The additional evidence received since then, summarized above, indicates that the appellant was treated for arthritis of both hips. The newly presented evidence need not be probative of all the elements required to award the claim, but only as to each element that was a specified basis for the last disallowance. Evans, 9 Vet. App. at 284. Since the Board denied the claim based on a lack of evidence of a current disorder, and the additional evidence addresses that basis, the additional evidence is new and material. Thus, the appellant's application to reopen the claim is granted. II. Service Connection Claims A. Pertinent General Law and Regulations Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Because the appellant served continuously for 90 days or more during a period of war or during peacetime after December 31, 1946, arthritis and "other organic diseases of the nervous system" (such as headaches) manifest to a degree of 10 percent within one year from the date of termination of such service shall be presumed to have been incurred in service, even without evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. The threshold question that must be resolved with regard to a claim is whether the appellant has presented evidence of a well-grounded claim. See 38 U.S.C.A. § 5107(a); Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). A well-grounded claim is a plausible claim that is meritorious on its own or capable of substantiation. See Murphy, 1 Vet. App. at 81. An allegation of a disorder that is service connected is not sufficient; the appellant must submit evidence in support of a claim that would "justify a belief by a fair and impartial individual that the claim is plausible." 38 U.S.C.A. § 5107(a); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992). The quality and quantity of the evidence required to meet this statutory burden of necessity will depend upon the issue presented by the claim. Grottveit v. Brown, 5 Vet. App. 91, 92-93 (1993). In order for a claim to be well grounded, there must be competent medical evidence of a current disability, lay or medical evidence of incurrence or aggravation of a disease or injury in service, and competent medical evidence of a nexus, or link, between the in-service injury or disease and the current disability. Epps v. Gober, 126 F.3d 1464, 1468 (Fed. Cir. 1997); Caluza v. Brown, 7 Vet. App. 498, 506 (1995). See Grottveit, 5 Vet. App. at 93 (lay assertions of medical causation cannot constitute competent medical evidence). If no cognizable evidence is submitted to support a claim, the claim cannot be well grounded. B. Bilateral Hip Disorder Because the appellant has submitted new and material evidence to reopen the claim of service connection for a bilateral hip disorder, the Board must determine whether, based upon all the evidence of record in support of the claim, presuming its credibility, the claim is well grounded. Only then may the Board then proceed to evaluate the merits of the claim. Winters, 12 Vet. App. at 206-07. The evidence summarized above with respect to a bilateral hip disorder contains competent medical evidence of a current bilateral hip disorder. VA and private clinical records prepared from 1985 through 1997 indicate that the appellant's hips have undergone arthritic changes over the years. This evidence satisfies the initial element of a well-grounded claim. In addition, the service medical records indicate that the appellant complained of bilateral hip pain and swelling, that examiners noted hip stress, and that an x-ray showed slight irregularity of the pubic symphysis. This evidence satisfies the second element of a well-grounded claim. As for the third element of a well-grounded claim, requiring competent medical evidence linking the current disorder to service, the evidence of record is silent. Despite the complaints and symptomatology noted in the service medical records, the separation examination in March 1981 showed a normal musculoskeletal clinical evaluation. January and February 1983 VA examinations, conducted about 18 months after separation from service in June 1981, included only a diagnosis of history of hip pain; there was no finding of current symptomatology. The March 1983 pelvis x-ray showed no abnormality. Thus, the first finding of hip symptomatology after service was noted in a November 1985 x- ray report showing mild arthritic changes. The key consideration here is whether the remaining evidence links the arthritic changes noted in November 1985 to service or the one-year period after separation from service. The December 1985 private clinical record, the October 1987 VA clinical record, the November and December 1995 VA hospital records, and the July 1997 VA clinical records all showed arthritic findings, but none addressed whether those findings were related to service. The September 1987 VA clinical record as well included a finding of arthritic changes, but also contained a notation of a history of hip pain for the previous seven years, which would place the onset of the pain in about 1980 during service. This evidence, though, represents information simply recorded by a medical examiner and unenhanced by any additional medical comment by that examiner. Therefore, it cannot constitute competent medical evidence. LeShore v. Brown, 8 Vet. App. 406, 410 (1995). Thus, to the extent that this clinical record based a finding on a recitation by the appellant of her own medical history, the information is not probative evidence as to the etiology of the disorder. As the evidence is not probative, it cannot form the basis of competent medical evidence. The only remaining evidence concerning the etiology of the bilateral hip disorder is the June 1996 statement by the appellant's mother and the appellant's own testimony at hearings in November 1983 and April 1997. However, because the record does not show that the appellant or her mother possess medical expertise, this material cannot constitute competent medical evidence to render a claim well grounded. Espiritu, 2 Vet. App. at 494-95. For these reasons, the evidence of record does not satisfy the third and final element of a well-grounded claim. Because the claim is not well grounded, VA is under no duty to assist the appellant in further development of the claim. 38 U.S.C.A. § 5107(a); Morton, 12 Vet. App. at 485. Although where claims are not well grounded VA does not have a statutory duty to assist the claimant in developing facts pertinent to the claim, VA may be obligated under 38 U.S.C.A. § 5103(a) to advise a claimant of evidence needed to complete the application. This obligation depends upon the particular facts of the case and the extent to which VA has advised the claimant of the evidence necessary to be submitted with a VA benefits claims. Robinette v. Brown, 8 Vet. App. 69 (1995). In this case, the RO fulfilled its obligation under § 5103(a) in the September 1996 statement of the case and in the September 1997 and the July 1999 supplemental statements of the case in which the appellant was informed that the reason for the denial of the claim was the lack of evidence linking a bilateral hip disorder to service. Furthermore, by this decision, the Board is informing the appellant of the evidence which is lacking and that is necessary to make the claim well grounded. When the Board addresses in its decision a question that has not been addressed by the RO, in this case well groundedness, it must consider whether the appellant has been given adequate notice to respond and, if not, whether she has been prejudiced thereby. Bernard v. Brown, 4 Vet. App. 384 (1993). The Board finds that the appellant has been accorded ample opportunity by the RO to present argument and evidence in support of her claim. Any error by the RO in deciding this case on the merits, rather than being not well grounded, was not prejudicial to the appellant. C. Stomach Disorder The first element of a well-grounded claim requires competent medical evidence of a current stomach disorder. A May 1996 VA clinical record noted that the appellant had irritable bowel syndrome. October 1996 VA clinical records also noted irritable bowel disorder with reflux and upper abdominal pain. March 1997 VA clinical records indicated that she had stomach problems and a history of irritable bowel syndrome. These findings satisfy the initial element of a well-grounded claim. The second element of a well-grounded claim requires lay or medical evidence of a disease or injury in service. The service medical records indicate that the appellant complained of abdominal pain, epigastric discomfort, and constipation. These symptoms were resolved with use of Milk of Magnesia. A clinical record entry also indicated a possible stomach ulcer. An upper gastrointestinal series and x-ray of the abdomen showed no abnormalities, although a barium enema indicated a redundant colon. The separation examination in March 1981 revealed a normal abdomen clinical evaluation and continuing complaints of stomach problems and coughed up blood. The findings of abdominal pain, epigastric discomfort, constipation, and a possible stomach ulcer satisfy the second element of a well-grounded claim. As for the third element of a well-grounded claim, requiring competent medical evidence linking the current findings to those in service, a September 1981 VA clinical record, within three months after separation from service, noted abdominal and epigastric pain and chronic constipation. The impression was irritable bowel syndrome. A February 1987 VA clinical record noted that the appellant complained of constipation. A December 1987 VA clinical record showed findings of diarrhea and stomach cramps. A January 1991 private emergency room report showed complaints of abdominal pain; assessment of constipation and possible re-entry gastroenteritis. March 1991 VA clinical records indicated abdominal complaints and gastroenteritis. A January 1994 VA clinical record noted abdominal pain. January 1994 VA hospital records included a diagnosis of gastroenteritis, a normal upper gastrointestinal series, and possible mild ileus secondary to gastroenteritis. February to June 1994 VA clinical records noted irritable bowel disorder versus inflammatory bowel syndrome. An October 1995 VA clinical record showed complaints of abdominal pain and a diagnosis of reflux esophagitis. November to December 1995 VA hospital records indicated constipation. An April 1996 upper gastrointestinal series was normal. An October 1996 VA clinical record indicated that the appellant had complained of upper abdominal pain "for years". The information on these documents does not actually link the current findings to service. The October 1996 VA clinical record indicated that the appellant complained of abdominal pain "for years", but that vague phrase does not necessarily indicate a link to service ending more than 15 years earlier. Thus, this evidence does not satisfy the third element of a well-grounded claim. See Epps, 126 F.3d at 1468. However, a claim may also be well grounded if the condition is observed during service or during any applicable presumptive period, if continuity of symptomatology is demonstrated thereafter, and if competent evidence relates the present condition to that symptomatology. 38 C.F.R. § 3.303(b); Savage v. Gober, 10 Vet. App. 488, 495 (1997). In this case, the evidence summarized above traces the appellant's stomach symptomatology from service through 1997, thereby satisfying the third element of a well-grounded claim. VA has a statutory obligation to assist the appellant in the development of facts pertinent to the claim. Actions pursuant to that obligation are addressed in the Remand section below. D. Headache Disorder The record includes VA and private treatment records noting the appellant's complaints of headaches, variously characterized as migraine, vascular, or tension, thereby satisfying the first element of a well-grounded claim. Although the service medical records silent as to migraine or other types of headaches, the record does indicate that the appellant fell and injured her cervical spine, a disorder that has been granted service connection. She argues in an April 1997 hearing that her headaches are related to service, including the fall in service resulting in a cervical spine disability. These findings of such a fall in service satisfy the second element of a well-grounded claim. As for the third element of a well-grounded claim, the record includes several clinical documents relating the headache symptomatology to the service-connected cervical spine disorder resulting from the fall in service. For example, a private clinical record in December 1992 revealed upper back and neck pain causing headaches. In addition, VA neurologic examination in March 1996 revealed continuing headaches that began in service, probably at least partly associated and/or cause by the cervical spine disability; a May 1996 VA physical therapy records showed therapy to the cervical spine helped to relieve the headaches; and a September 1996 VA physical therapy record showed that the length of the headaches was lessened by performing neck stretching exercises and that the headaches were secondary to stress and posture. While an April 1996 neurological consultation report indicated that there was no definite causal relationship between the mixed tension vascular headaches and the fall in service, the other evidence suggests such a relationship and is sufficient to satisfy the third element of a well-grounded claim. See Jones v. Brown, 7 Vet. App. 134, 137 (1994) (secondary service connection claim well grounded with medical evidence supporting alleged causal relationship between service-connected disorder and disorder for which secondary service connection is sought). VA has a statutory obligation to assist the appellant in the development of facts pertinent to the claim. Actions pursuant to that obligation are addressed in the Remand section below. E. PTSD A well-grounded claim of PTSD requires medical evidence of a current disorder, lay evidence, presumed credible, of an in- service stressor, and medical evidence linking the two. Gaines v. West, 11 Vet. App. 353, 357 (1998); Cohen (Douglas) v. Brown, 10 Vet. App. 128, 136-37 (1997). The November to December 1995 VA hospital discharge summary included a diagnosis of PTSD based on a history of sexual assault. The appellant maintains that she was traumatized when her former spouse assaulted her during service. The truthfulness of this evidence must be presumed when determining whether a claim is well grounded. King v. Brown, 5 Vet. App. 19, 21 (1993). This evidence satisfies the three elements of a well-grounded claim for PTSD. Because the claim is well grounded, VA has a statutory obligation to assist the appellant in the development of facts pertinent to the claim. Actions pursuant to that obligation are addressed in the Remand section below. ORDER New and material evidence having not been submitted to reopen a claim of entitlement to service connection for a back disorder, the application to reopen the March 1983 rating decision is denied. New and material evidence having been submitted to reopen a claim of entitlement to service connection for a bilateral hip disorder, the application to reopen the March 1985 Board decision is granted. Entitlement to service connection for a bilateral hip disorder is denied. Entitlement to service connection for a stomach disorder is well grounded. Entitlement to service connection for a headache disorder is well grounded. Entitlement to service connection for PTSD is well grounded. REMAND Leg Pain and Cramps As noted in the Introduction to this decision, the RO's March 1983 rating decision denying the appellant's claim of service connection for a disorder characterized as leg pain and cramps is not final because an August 1983 statement constitutes a valid notice of disagreement. The RO has not issued a statement of the case as to this issue. Accordingly, a remand for this action is necessary. See 38 C.F.R. § 19.9; Manlincon v. West, 12 Vet. App. 238 (1999). Stomach Disorder and Headaches As noted above, the appellant has presented competent evidence showing that the claims of service connection for a stomach disorder and a headache disorder are well grounded. Because these claims have not been addressed by VA examinations designed to determine the nature and etiology of the disorders, they are remanded for such examinations. PTSD The appellant maintains that her former spouse sexually assaulted her during her period of service in the Federal Republic of Germany in 1980. She stated in various documents and testified at her April 1997 hearing that her former spouse raped her on at least two occasions. She did not assert that she ever engaged in combat. Service connection for PTSD requires medical evidence diagnosing the condition in accord with 38 C.F.R. § 4.125(a); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f) (1999). Prior to June 18, 1999, service connection for PTSD required medical evidence establishing a clear diagnosis of the condition, credible supporting evidence that the claimed in-service stressor actually occurred, and a link, established by medical evidence, between current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304(f) (1998). In approaching a claim of service connection for PTSD, the question of the existence of an event claimed as a recognizable stressor must be resolved by adjudicatory personnel. If the adjudicators conclude that the record established the existence of such a stressor(s), then and only then, should the case be referred for medical examination to determine the sufficiency of the stressor and as to whether the remaining elements required to support the diagnosis of PTSD have been met. In such a referral, the adjudicators should specify to the examiner(s) precisely what stressor or stressors has been accepted as established by the record, and the medical examiners must be instructed that only those events may be considered in determining whether the appellant was exposed to a stressor and what the nature of the stressor or stressors was to which the appellant was exposed. In other words, if the adjudicators determine that the record does not establish the existence of an alleged stressor or stressors in service, a medical examination to determine whether PTSD due to service is present would be pointless. Likewise, if the examiners render a diagnosis of PTSD that is not clearly based on stressors in service whose existence the adjudicators have accepted, the examination would be inadequate for rating purposes. West v. Brown, 7 Vet. App. 70 (1994); Zarycki v. Brown, 6 Vet. App. 91 (1993). See also Moreau v. Brown, 9 Vet. App. 389 (1996) (neither noncombat claimant's testimony alone nor medical statements finding a relationship between claimant's recitation of claimed stressors and a diagnosis of PTSD can qualify as corroborating evidence of a stressor). The provisions of VA ADJUDICATION MANUAL M21-1 (M21-1) dealing with PTSD are substantive rules and the equivalent of VA regulations. Cohen (Douglas), 10 Vet. App. 128, 139 (1997). In cases where available records do not provide objective or supportive evidence of the alleged in-service stressor, it is necessary to develop for this evidence. M21-1, Part III, 5.14b(3). Patton v. West, 12 Vet. App. 272, 278-80 (1999). As to personal-assault PTSD claims, M21-1, Part III, 5.14c specifies particular requirements.? Service personnel records indicate that the appellant and her former spouse married in Germany in January 1980. She testified that after six weeks of marriage, he raped her. She noted she did not report this incident. She also stated that in the summer of 1980 he raped her anally and that a military physician, Dr. Walker, treated her for injuries resulting from that incident. She also testified that Dr. Walker called her former spouse's commander, but the record is silent as to what action, if any, that commander took. She further reported that her former spouse was arrested in December 1980 by German police and later tried in the U.S. military justice system on charges of rape and murder of multiple German nationals. The appellant indicated she testified at her former spouse's courts-martial and, as far as she knew, he was still serving a sentence at a military prison in Leavenworth, Kansas. She stated the German police beat her during the arrest of her former spouse. She also testified that her former spouse locked her in her apartment and would not let her out, resulting in her missing assigned duty, an offense for which she was punished. In a March 1996 VA PTSD Questionnaire, the appellant noted that German police questioned and interrogated her extensively because they thought she might be an accomplice. She also reported that there were no private treatment records relevant to her claim. The service medical records include documentation from enlistment through separation. Service clinical records showing treatment by Dr. Walker, beginning in October 1980 and ending in April 1981, contain no reference to injuries or treatment as described by the appellant. The service personnel records include copies of counseling and nonjudicial punishment records. In June 1980, the appellant was counseled for a lack of motivation. In September 1980, she was punished for failing to report to an appointed place. In response, she contended that the duty roster was not posted prior to her being excused for medical reasons. In October 1980, she was again punished for failing to report to an appointed place. In December 1980, she received a letter of reprimand for missing duty. In February 1981, she again was counseled for a lack of motivation. These documents do not refer to her claimed stressors. In a June 1996 statement, the appellant's mother wrote regarding her relationship with the appellant during service. She indicated that after the former spouse's arrest, she spoke to the appellant by telephone often and also exchanged letters with her. She also noted that in 1995 the appellant began speaking more openly about her experiences in service. Amplification by the appellant's mother may assist the appellant's claim. On remand, the RO should ask the appellant's mother to fully discuss the nature and subjects of the telephone conversations between her and the appellant during the appellant's service, particularly the treatment of the appellant by her former spouse. In addition, the RO should ask the appellant and her mother to provide copies of any letters exchanged between them. In addition, as discussed below, the RO should ask the appellant to provide any further specific information as to her alleged stressors in accordance with the provisions of M21-1, Part III, 5.14; obtain from the service department or other appropriate agency the appellant's former spouse's service personnel records, including any DA Form 20, the record of trial of any courts-martial or other judicial records involving the appellant's former spouse, including any testimony by the appellant, and any record of investigation regarding the appellant or her former spouse; make a specific determination as to which stressor(s) are verified; and, only if a stressor is verified, have the appellant examined by a VA psychiatrist to determine any link between the diagnosis of PTSD and any verified stressor. Temporary Total Disability Under 38 C.F.R. § 4.29 A total disability rating will be assigned without regard to other provisions of the rating schedule when it is established that a service-connected disability required hospital treatment in a VA or an approved hospital for a period in excess of 21 days or hospital observation at VA expense for a service-connected disability for a period in excess of 21 days. 38 C.F.R. § 4.29. In December 1995, the appellant filed a claim for benefits under 38 C.F.R. § 4.29 for a period of hospitalization for PTSD beginning in November 1995. Service connection has not yet been established for PTSD, although the claim of service connection for PTSD is being remanded for additional development. Because the claim for benefits under 38 C.F.R. § 4.29 is dependent on the outcome of the claim of service connection for PTSD, these two claims are inextricably intertwined. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). The temporary total disability claim is, therefore, remanded without action so that it may be addressed by the RO after a determination is made on the PTSD claim. Fibrocystic Disease of Both Breasts and Residuals of a Neck Injury The claims of entitlement to a compensable evaluation for fibrocystic disease of both breasts and entitlement to an evaluation in excess of 10 percent for residuals of a neck injury C5-C6, including chronic muscular strain superimposed on degenerative instability, are well-grounded within the meaning of 38 U.S.C.A. § 5107(a); that is, they are not inherently implausible. See Drosky v. Brown, 10 Vet. App. 251, 254 (1997); Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992) (contention of an increase in disability severity renders claim well grounded). VA has a resulting statutory obligation to assist the appellant in the development of facts pertinent to the claims. 38 U.S.C.A. § 5107(a). The most recent VA examinations addressing the severity of these disabilities were conducted in April 1996. The Board is not required, pursuant to its duty to assist to remand solely because of the passage of time since the preparation of an otherwise adequate examination report. An exception to this general rule exists where the claimant asserts that the disability in question has undergone an increase in severity since the time of the examination. VA O.G.C. Prec. Op. 11- 95, slip op. at 10 (Apr. 7, 1995). In this case, the appellant so asserted in her April 1997 hearing testimony. The claims will be remanded for further development. See Caffrey v. Brown, 6 Vet. App. 377, 381 (1995) (VA required to afford a contemporaneous medical examination where examination report was approximately two years old). The case is REMANDED for the following development: 1. The RO should request that the appellant supply the names and addresses of any individuals or treatment facilities that have treated her for fibrocystic disease of both breasts and cervical spine disabilities since April 1996, and the dates of such treatment. The RO should also request that the appellant supply the names and addresses of any individuals or treatment facilities that have treated her for a stomach disorder, a headache disorder, and PTSD since December 1997, and the dates of such treatment. After securing any necessary releases, the RO should obtain complete clinical records of such treatment and associate them with the claims folder. 2. The RO should ask the appellant to provide any further specific information as to her alleged stressors in accordance with the provisions of M21-1, Part III, 5.14. 3. The RO should ask the appellant's mother to fully discuss the nature and subjects of telephone conversations between her and the appellant during the appellant's service, particularly the treatment of the appellant by her former spouse. In addition, the RO should ask the appellant and her mother to provide copies of any letters exchanged between them. 4. The RO should obtain from the service department or other appropriate agency the appellant's former spouse's service personnel records, including any DA Form 20; the record of trial of any courts-martial or other judicial records involving the appellant's former spouse, including any testimony by the appellant; and any record of investigation regarding the appellant or her former spouse. 5. After the above is accomplished, the RO must make a specific determination, based on the complete record, with respect to whether the appellant was exposed to a stressor or stressors in service, and if so, the nature of the specific stressor or stressors. If the RO determines that the record establishes the existence of stressor(s), the RO must specify what stressor or stressors in service it has determined the record establishes. In reaching this determination, the RO should address any credibility questions raised by the record. 6. Only if the RO determines that the record establishes the existence of a stressor or stressors, then the appellant should be afforded a VA psychiatric examination to determine the nature and etiology of all psychiatric disorders found to be present. The RO must specify for the examiner the stressor(s) that it has determined are established by the record and the examiner must be instructed that only those events may be considered for the purpose of determining whether the appellant was exposed to a stressor in service. The entire claims file and a copy of this REMAND must be made available to the examiner in conjunction with the examination, and the examination report should reflect review of pertinent material in the claims folder. If a diagnosis of PTSD is made, the examiner should specify (1) whether each alleged stressor found by the RO to be established in the record was sufficient to produce PTSD; (2) whether the remaining diagnostic criteria to support the diagnosis of PTSD have been satisfied; and (3) whether there is a link between the current symptomatology and one or more of the in-service stressors found to be established by the record by the RO and found to be sufficient to produce PTSD by the examiner. The examination report should include the rationale for all opinions expressed. All necessary special studies, to include psychological testing and evaluation, should be accomplished. 7. The RO should schedule the appellant for an examination to determine the nature and etiology of her claimed stomach disorder. The claims folder and a copy of this REMAND must be made available to the physician for review in conjunction with the examination. The examiner should obtain all pertinent history concerning the claimed disorder. All necessary tests and studies should be conducted. The report of examination should contain a detailed account of all manifestations found to be present. The examiner should be asked to identify any stomach disorder found and render an opinion as to whether it is at least as likely as not that any stomach disorder noted is related to service, based on the examination results and the examiner's review of the claims file. 8. The RO should schedule the appellant for a neurologic examination to determine the nature and etiology of her claimed headache disorder. The claims folder and a copy of this REMAND must be made available to the physician for review in conjunction with the examination. The examiner should obtain all pertinent history concerning the claimed disorder. All necessary tests and studies should be conducted. The report of examination should contain a detailed account of all manifestations found to be present. The examiner should be asked to identify any headache disorder found and render an opinion as to whether it is at least as likely as not that any headache disorder noted is related to service, based on the examination results and the examiner's review of the claims file. 9. The RO should schedule the appellant for an examination to determine the nature and severity of the fibrocystic disease of both breasts. The claims folder and a copy of this REMAND must be made available to the physician for review in conjunction with the examination. The pertinent history concerning the disabilities should be obtained and all necessary tests and studies should be accomplished. The report of examination should contain a detailed account of all manifestations of the disability found to be present. The examiner should be asked to determine whether there is any scarring or disfigurement associated with the disability, or any symptomatology consistent with eczema, including ulceration, exudation, exfoliation, itching, crusting, or systemic or nervous manifestations. 10. The RO should schedule the appellant for an examination to determine the nature and severity of the cervical spine disability. The claims folder and a copy of this REMAND must be made available to the physician for review in conjunction with the examination. The pertinent history concerning the disabilities should be obtained, and all necessary tests and studies, including x-ray studies and range of motion measurements, should be accomplished. The report of examination should contain a detailed account of all manifestations of the disability found to be present. The examiner should also be asked to express an opinion as to whether pain could significantly limit functional ability during flare-ups or with prolonged use and whether any pain or functional loss produced additional range-of-motion loss due to any weakened movement, excess fatigability, or incoordination. 11. The RO should issue a statement of the case to the appellant and her representative addressing the issue of entitlement to service connection for a bilateral leg disorder. The statement of the case should include all relevant law and regulations pertaining to the claim. The appellant must be advised of the time limit in which she may file a substantive appeal. 38 C.F.R. § 20.302(b). Then, if an appeal is perfected, this issue should be returned to the Board for further review. 12. When the aforementioned development has been completed, the RO should review the record to ensure it is in compliance with this REMAND. If not, the RO should undertake remedial action before returning the claim to the Board. See Stegall v. West, 11 Vet. App. 268, 270-71 (1998). After the development requested above has been completed to the extent possible, the RO should again review the record. If any benefit sought on appeal, for which a notice of disagreement has been filed, remains denied, the appellant and her representative should be furnished a supplemental statement of the case and given the opportunity to respond thereto. Thereafter, the case should be returned to the Board. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded to the RO. Kutscherousky v. West, 12 Vet. App. 369 (1999). 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 Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 1999) (Historical and Statutory Notes). In addition, VBA's Adjudication Procedure Manual, M21-1, Part IV, directs the 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. Jeffrey J. Schueler Acting Member, Board of Veterans' Appeals ? M21-1, Part III, 5.14(c)(3) and (9), improperly requires that the existence of an in-service stressor be shown by "the preponderance of the evidence." Any such requirement is inconsistent with the benefit of the doubt, or equipoise, doctrine contained in 38 U.S.C.A. § 5107(b). Patton v. West, 12. Vet. App. 272, 280 (1999).