Citation Nr: 0004675 Decision Date: 02/23/00 Archive Date: 02/28/00 DOCKET NO. 94-23 237 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to service connection for post-traumatic stress disorder (PTSD). 2. Entitlement to service connection for hemorrhoids. 3. A determination of the propriety of initial disability rating of 10 percent assigned to the veteran's service- connected bilateral hearing loss. 4. Entitlement to an effective date prior to July 18, 1997 for the grant of service connection for tinnitus. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Andrew E. Betourney, Associate Counsel INTRODUCTION The veteran served on active duty from July 1967 to April 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 1993 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri, which denied the veteran's claim for service connection for PTSD, and from a rating decision by this RO dated in October 1997, which granted the veteran's claim for service connection for bilateral hearing loss, and assigned a noncompensable (zero percent) disability rating thereto, and granted the veteran's claim for service connection for tinnitus, effective July 18, 1997. The veteran filed timely appeals to the denials of service connection for PTSD and hemorrhoids, the disability rating assigned to his service-connected hearing loss, and the effective date assigned to his service-connected tinnitus. When this matter was previously before the Board in April 1997 it was remanded to the RO for further development, which has been accomplished. The case is now before the Board for appellate consideration. The claim for service connection for PTSD shall be addressed in the REMAND portion of this decision. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the appeal has been obtained by the RO. 2. The veteran has not presented competent medical evidence that his current hemorrhoids are etiologically related to an injury or disease incurred in service. 3. The veteran has level I hearing in the right ear and level I hearing in the left ear. 4. The veteran's informal claim for service connection for tinnitus was received by VA on July 17, 1997. CONCLUSIONS OF LAW 1. The veteran's claim for service connection for hemorrhoids is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 2. The schedular criteria for a compensable rating for bilateral hearing loss have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.321, 4.1-4.3, 4.7, 4.85, Diagnostic Code 6100 (1999). 3. The criteria for an effective date of July 17, 1997 for the grant of service connection for tinnitus have been met. 38 U.S.C.A. §§ 5107, 5110 (West 1991); 38 C.F.R. § 3.400 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Service connection for hemorrhoids In order to establish service connection for a claimed disability, the facts, as shown by the evidence, must demonstrate that a particular injury or disease resulting in a current disability was incurred in or aggravated coincident with service in the Armed Forces. 38 U.S.C.A. § 1110 (West 1991); 38 C.F.R. § 3.303(a) (1999). However, the first step in this analysis is to determine whether the veteran has presented a well-grounded claim for service connection. In this regard, the veteran bears the burden of submitting sufficient evidence to justify a belief by a fair and impartial individual that the claim is well grounded. 38 U.S.C.A. § 5107(a); Robinette v. Brown, 8 Vet. App. 69, 73 (1995). Simply stated, a well-grounded claim must be plausible or capable of substantiation. Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). Where the determinative issue involves medical etiology or a medical diagnosis, competent medical evidence that a claim is "plausible" or "possible" is required for the claim to be well grounded. See Epps v. Gober, 126 F.3d 1464 (Fed. Cir. 1997); Heuer v. Brown, 7 Vet. App. 379, 384 (1995); Grottveit, 5 Vet. App. 91 (1993). This burden may not be met merely by presenting lay testimony, because lay persons are not competent to offer medical opinions. See Epps, supra; Grottveit, supra; Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). Service connection generally requires: (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of inservice incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed inservice disease or injury and the present disease or injury. See Epps, supra; Caluza v. Brown, 7 Vet. App. 498 (1995); see also Heuer, supra and Grottveit, both supra; Savage v. Gober, 10 Vet. App. 488, 497 (1997). In addition, a well-grounded claim may be established under the provisions of 38 C.F.R. § 3.303(b) when the evidence, regardless of its date, shows that a veteran had a chronic condition in service or during an applicable presumption period and still has such a condition. Such evidence must be medical unless it relates to a condition as to which, under the case law of the United States Court of Appeals for Veterans Claims (known as the United States Court of Veterans Appeals prior to March 1, 1999) (Court), lay observation is competent. If the chronicity provision is not applicable, a claim may still be well grounded on the basis of § 3.303(b) if the condition observed during service or any applicable presumption period still exists, continuity of symptomatology is demonstrated thereafter, and competent evidence relates the present condition to that symptomatology. Savage, 10 Vet. App. at 498. In the absence of evidence of a well-grounded claim, there is no duty to assist the claimant in developing the facts pertinent to the claim, and the claim must fail. Gregory v. Brown, 8 Vet. App. 563, 568 (1996) (en banc); Slater v. Brown, 9 Vet. App. 240, 243 (1996); Grivois v. Brown, 6 Vet. App. 136, 140 (1994); Grottveit, supra. Evidence relevant to the veteran's claim for service connection for hemorrhoids includes his service medical records, which are negative for any reported complaint or diagnosis of, or treatment for, hemorrhoids. Relevant post-service evidence includes the report of a VA examination conducted in October 1982. At that time, the veteran reported that he was raped in 1968, while in Vietnam, and had had rectal bleeding off and on ever since that time. However, a rectal examination was not performed during this examination, and no relevant diagnosis was rendered. The first post-service evidence of hemorrhoids is found in a VA operation report dated in April 1991. At that time, the veteran reported that he was healthy until 1969, when he was raped by men while serving in Vietnam. He stated that he first saw a doctor for complaints of rectal prolapse in 1988, but until that time had treated himself. He reported having undergone surgery in April 1990, at which time part of his colon was removed. However, this surgery was reportedly unsuccessful, and required additional surgery in May 1990. Following a proctoscopy, the examiner determined that the veteran's complaints were due more to hemorrhoids than to a complete rectal prolapse, and thus it was determined that the veteran should return for a hemorrhoidectomy, rather than undergo a repeat lower anterior resection. Therefore, a few weeks later, the veteran underwent a hemorrhoidectomy. The operation report for this procedure, dated in April 1991, indicated that the veteran's hemorrhoidectomy was without complication, and he was discharged in good condition. In April 1997, the Board remanded the veteran's case to the RO for further development. Specifically, the Board noted the veteran's assertion that his hemorrhoids were caused by an incident in service in which he was gang raped by other soldiers. The Board thus determined that a medical opinion on the subject would be helpful in determining whether the veteran's post-service hemorrhoids were in any way related to his alleged inservice rape. Therefore, in July 1997 the veteran underwent a VA examination. At that time, the veteran reported that he was raped by two men in 1968. He stated that immediately after the rape he had a tear in the rectum which healed within a few weeks. He also reported that approximately one year after the reported rape, be began to have hemorrhoids, which had continued intermittently ever since. He stated that he was found to have a rectal prolapse and hemorrhoids in 1989, at which time he underwent the surgical removal of part of his rectum and a hemorrhoidectomy. He stated that he still had problems after this surgery, and that his hemorrhoids had progressively worsened. He also reported one or two episodes of rectal bleeding per month, with each incident lasting one to two days. On examination of the rectum and anus, post-surgical changes were noted. However, there were no internal or external hemorrhoids, no rectal prolapse, and no anal fissures. There was no significant tenderness on digital rectal examination. The examiner diagnosed no evidence of hemorrhoids or rectal prolapse on physical examination, and a prior history of rectal prolapse and hemorrhoids, with no residuals at this time. In response to the RO's request for a medical opinion, the examiner stated that "[i]t is not more likely than not that the veteran's claimed in-service rape could have contributed in any way to his post-service hemorrhoids including his rectal prolapse and hemorrhoidectomy." A review of this evidence reveals that there is some question whether the veteran currently suffers from a hemorrhoid disorder, since the most recent VA examination in July 1997 found no evidence of either internal or external hemorrhoids. Nevertheless, given the intermittent nature of this disorder, as reported by the veteran, as well as the diagnoses of this disorder in the early 1990's, the Board finds that the veteran does indeed suffer from current hemorrhoids. However, the Board has found no medical evidence which relates this disorder to service, some 20 years before the first post-service medical treatment for hemorrhoids. On the contrary, the only medical evidence which discusses the etiology of the veteran's hemorrhoids is the July 1997 VA examiner's opinion, which indicates that "[i]t is not more likely than not that the veteran's claimed in-service rape could have contributed in any way to his post-service hemorrhoids." Indeed, there is nothing in the veteran's claims file, other than the veteran's own contentions, which would tend to establish that his current hemorrhoids are related to his active military service, to include his alleged rape. The Board does not doubt the sincerity of the veteran's belief in this claimed causal connection. However, as the veteran is not a medical expert, he is not qualified to express an opinion regarding any medical causation of his hemorrhoids. As it is the province of trained health care professionals to enter conclusions which require medical expertise, such as opinions as to diagnosis and causation, Jones v. Brown, 7 Vet. App. 134, 137 (1994), the veteran's lay opinions cannot be accepted as competent evidence to the extent that they purport to establish such medical causation. See Espiritu v. Derwinski, 2 Vet. App. 492, 494-5 (1992). See also Heuer v. Brown, 7 Vet. App. 379, 384 (1995), citing Grottveit, in which the Court held that an appellant does not meet his or her burden of presenting evidence of a well-grounded claim where the determinative issue involves medical causation and the appellant presents only lay testimony by persons not competent to offer medical opinions. Thus, the Board finds that the veteran's contention that his current hemorrhoids are related to his reported rape while in the military cannot be accepted as competent evidence. Accordingly, it is the decision of the Board that the veteran has failed to meet his initial burden of submitting evidence of a well-grounded claim for entitlement to service connection for hemorrhoids, and the claim must be denied on that basis. As the duty to assist is not triggered here by the submission of a well-grounded claim, the Board finds that VA has no obligation to further develop the veteran's claim. See Epps, supra; Grivois v. Brown, 5 Vet. App. 136, 140 (1994). In reaching this determination, the Board recognizes that this issue is being disposed of in a manner that differs from that employed by the RO. The RO denied the veteran's claim on the merits, while the Board has concluded that the claim is not well grounded. The Board has therefore considered whether the veteran has been given adequate notice to respond, and if not, whether he has been prejudiced thereby. Bernard v. Brown, 4 Vet. App. 384, 394 (1993). Since the Court has held that "when an RO does not specifically address the question whether a claim is well grounded but rather, as here, proceeds to adjudication on the merits, there is no prejudice to the veteran solely from the omission of the well-grounded-claim analysis," the Board finds no prejudice to the veteran in this case. Meyer v. Brown, 9 Vet. App. 425, 432 (1996). In addition, in reaching this determination the Board notes that it has not been made aware of any outstanding evidence which could serve to well ground his claim for service connection for hemorrhoids. Accordingly, there is no further duty on the part of VA to inform the veteran of the evidence necessary to complete his application for this benefit. 38 U.S.C.A. § 5103 (West 1991); McKnight v. Gober, 131 F.3d 1483, 1484-85 (Fed. Cir. 1997). As a final note, the Board observes that the fact that the RO requested a special examination to determine the etiology of the veteran's claimed hemorrhoids does not mean that the claim was well grounded. See Slater v. Brown, 9 Vet. App. 240 (1996) (explaining that although certain exceptions have been provided by VA to excuse a claimant from the need to submit evidence fulfilling all of the requirements for a well-grounded claim, this does not mean that any claimant who does not fulfill these requirements is entitled to the duty to assist). II. Disability rating for bilateral hearing loss The veteran has claimed entitlement to a compensable rating for his service-connected bilateral hearing loss. This is an original claim placed in appellate status by a notice of disagreement (NOD) taking exception to the initial rating award dated in October 1997. Accordingly, his claim must be deemed well grounded within the meaning of 38 U.S.C.A. § 5107(a), and VA has a duty to assist the veteran in the development of the facts pertinent to his claim. See Fenderson v. West, 12 Vet. App.119, 127 (1999) (applying duty to assist under 38 U.S.C.A. § 5107(a) to initial rating claims); cf. Caffrey v. Brown, 6 Vet. App. 377, 381 (1994) (increased rating claims). Under these circumstances, VA must attempt to obtain all such medical evidence as is necessary to evaluate the severity of the veteran's disability from the effective date of service connection to the present. Fenderson, supra., citing Goss v. Brown, 9 Vet. App. 109, 114 (1996); Floyd v. Brown, 9 Vet. App. 88, 98 (1996); Green v. Derwinski, 1 Vet. App. 121, 124 (1991). See also 38 C.F.R. § 4.2 (ratings to be assigned "in the light of the whole recorded history"). This obligation was satisfied by the various examinations and treatment reports described below, and the Board is satisfied that all relevant facts have been properly and sufficiently developed. Disability evaluations are determined by the application of the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, 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 (1999). Any reasonable doubt regarding the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3 (1999). Evaluations of bilateral hearing loss range from noncompensable to 100 percent based on organic impairment of hearing acuity as measured by the results of speech discrimination tests, together with the average hearing threshold levels as measured by pure tone audiometry tests in the frequencies 500, 1,000, 2,000, 3,000 and 4,000 cycles per second. To evaluate the degree of disability for bilateral service connected hearing loss, the rating schedule has established eleven (11) auditory acuity levels, designated from level I for essentially normal acuity through level XI for profound deafness. 38 C.F.R. § 4.85, Codes 6100-6110 (1999). The assignment of disability ratings for hearing impairment are derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are rendered. Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). Evidence relevant to the current level of severity of the veteran's bilateral hearing loss includes the report of an audiological examination conducted in July 1997. At that time, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 10 10 65 75 LEFT 5 10 15 20 50 Pure tone threshold levels averaged 40 decibels for the right ear and 24 decibels for the left ear. Speech audiometry revealed speech recognition ability of 96 percent in the right ear and of 96 percent in the left ear. Under the criteria in effect at the time the veteran perfected his appeal, these results equate to level I hearing in the right ear and level I hearing in the left ear, which warrants a noncompensable rating under 38 C.F.R. § 4.87a, Diagnostic Code (DC) 6100. At the time of a subsequent VA audiological evaluation in March 1999, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 15 15 65 75 LEFT 15 15 20 35 60 Pure tone threshold levels averaged 43 decibels for the right ear and 33 decibels for the left ear. Speech audiometry revealed speech recognition ability of 96 percent in the right ear and of 100 percent in the left ear. These results also equate to level I hearing in the right ear and level I hearing in the left ear, which again warrants a noncompensable rating under 38 C.F.R. § 4.87a, DC 6100. In making this determination, the Board has considered the previous evidence of record, which consists of multiple VA audiograms since the veteran's separation from service in April 1970. Such evidence is consistent with the hearing acuity reflected on the most recent VA examinations in July 1997 and March 1999. The Board has also considered the veteran's contention that his hearing loss has increased in severity because he wears hearing aids, and that the noncompensable rating in effect does not adequately reflect the severity of his bilateral hearing loss. Although the veteran's contention is credible, it may not serve to establish entitlement to a higher rating for hearing loss because "...disability ratings for hearing impairment are derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are rendered." Lendenmann v. Principi, 3 Vet. App. at 349. Here, such mechanical application establishes that a noncompensable rating is warranted. Furthermore, the evidence with respect to the service- connected bilateral hearing loss does not present such an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards and thus warrant assignment of an extraschedular evaluation under 38 C.F.R. § 3.321(b)(1) (1999). The veteran has not required frequent periods of hospitalization for his service-connected disability, and he has presented no evidence to show that the disability has resulted in marked interference with employment. As a final matter, the Board observes that effective June 10, 1999, certain regulatory changes were made to the criteria for evaluating audiological disabilities, as included in 38 C.F.R. §§ 4.85-4.87 (1999). See 64 Fed. Reg. 25202- 25210 (1999). Generally, when the laws or regulations change while a case is pending, the version most favorable to the claimant applies, absent congressional intent to the contrary. Karnas v. Derwinski, 1 Vet. App. 312-13 (1991). But see Rhodan v. West, 12 Vet. App. 55, 57 (1998). The Board observes that summary information accompanying the regulatory changes to the rating criteria for evaluating audiological disabilities specifically indicates that, except for certain "unusual patterns of hearing impairment," the regulatory changes do not constitute liberalizing provisions. 64 Fed. Reg. 25202- 25210. The "unusual patterns of hearing impairment" include cases where the pure tone thresholds at each of the four specified frequencies (1,000, 2,000, 3,000 and 4,000 Hertz) is 55 decibels or more, or where the pure tone thresholds are 30 decibels or less at 1,000 Hertz and 70 decibels or more at 2,000 Hertz. Neither hearing loss pattern is evident in the current case; as such, the Board finds that its action on the veteran's claim at this time will not result in any prejudice to him even though the agency of original jurisdiction (here the RO) had not yet had an opportunity to apply these regulatory changes to the veteran's claim. See generally Bernard v. Brown, 4 Vet. App. 384 (1994). In fact, the Board notes that in the present case, the assigned levels and evaluation for the veteran's left ear hearing loss would be exactly the same for the veteran under the old or the new criteria. III. Earlier effective date for grant of service connection for tinnitus In October 1997, the RO granted the veteran service connection for tinnitus, evaluated as 10 percent disabling "from July 18, 1999, the date of the current diagnosis." The RO noted that this diagnosis, rendered at the time of a VA examination, described bilateral, constant tinnitus, secondary to the veteran's service-connected bilateral hearing loss, and thus established that his tinnitus was related to his military service. The veteran asserts that the effective date should be May 18, 1994, the effective date of service connection for bilateral hearing loss, since he has had a diagnosis of tinnitus since that time. The Board observes that the veteran's notice of disagreement (NOD), received by VA in November 1997, was somewhat unclear in its wording, and appeared to evince a desire to seek an earlier effective date for bilateral hearing loss. Therefore, the RO's subsequent statement of the case (SOC), issued in December 1997, listed an earlier effective date for the grant of service connection for bilateral hearing loss as the issue on appeal. However, in his substantive appeal, received by VA in January 1998, the veteran clarified that "I agree with the effective date of hearing [loss] to be May 18, [19]94, but the tinnitus should be the same date," thus indicating that he was seeking an earlier effective date for tinnitus, not hearing loss. However, despite the RO's error in listing hearing loss instead of tinnitus, the Board finds no prejudice to the veteran in this case, as the SOC clearly set out the law and regulations pertaining to effective date claims, which apply equally to all service connection effective date determinations. Therefore, the Board finds that adjudication of this issue by the Board at this time is proper. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). Under governing law, the effective date of an award of disability compensation, in conjunction with a grant of entitlement to service connection on a direct basis, shall be the day following separation from active service or the date entitlement arose, if the claim is received within one year of separation from service; otherwise, the effective date shall be the date of receipt of the claim, or the date entitlement arose, whichever is later. 38 U.S.C.A. § 5110(a); 38 C.F.R. § 3.400(b)(2). In this case, a review of the veteran's claims file does not reveal that the veteran ever claimed entitlement to service connection for tinnitus. His request to reopen his claim for service connection for hearing loss, received by VA on May 18, 1994, did not mention tinnitus, and a subsequent VA audio-ear disease examination conducted in October 1994 indicated that "the patient has no other symptoms in reference to this except for loss of hearing. He has no vertigo, dizziness, or ringing in the ears." The first evidence of the existence of tinnitus is found in an October 1994 VA audiological examination, at which time the veteran reported periodic bilateral tinnitus since 1968. However, the veteran did not indicate anything which would indicate a desire to seek service connection for this disorder. On July 17, 1997, the veteran underwent a VA audio-ear disease examination. At that time, the veteran complained of tinnitus, which he described as a buzzing in both ears. He stated that this problem began in Vietnam, when he was exposed to artillery fire. Following an examination, the examiner diagnosed sensorineural hearing loss, right greater than left, stable, and "tinnitus - due to #1 [hearing loss]." The veteran also underwent an audiological examination the next day, July 18, 1997, at which time the veteran reported experiencing constant bilateral high-pitched ringing since 1970. However, this examiner did not diagnose tinnitus or relate it to the veteran's hearing loss. Although the RO was not explicit on this point, it appears that it construed the audio-ear examiner's July 17, 1997 statement as an informal claim for service connection for tinnitus, presumably based on the theory that the veteran's entitlement to this benefit was reasonably raised by the record. See 38 C.F.R. § 3.155. Since the audio-ear disease examination which indicated the positive relationship between the veteran's tinnitus and his service-connected hearing loss was clearly dated July 17, 1997, the Board finds that the RO erred in assigning the date of July 18, 1997, the date of the audiological examination, as the effective date for service connection for tinnitus. To this extent, the veteran's claim for an earlier effective date for the grant of service connection for tinnitus is granted. However, as noted above, the relevant VA regulation states that the effective date of a grant of service connection shall be the date of receipt of the claim, or the date entitlement arose, whichever is later. In this case, there is nothing in the claims file dated prior to July 17, 1997, which can be construed as a claim for service connection for tinnitus, or which showed entitlement to service connection for tinnitus. Neither the veteran nor his service representative submitted any correspondence which could be construed as seeking such a benefit, and no medical evidence was received prior to that date which indicated that the veteran suffered from tinnitus which was related to service or to a service-connected disorder. Although the examiner who performed the October 1994 audiological examination did note the veteran's report that he had suffered from periodic bilateral tinnitus since 1968, this notation appears to merely reflect a recordation of historical information relayed by the veteran, rather than being based on a review of the veteran's medical record. In any case, "[e]vidence which is simply information recorded by a medical examiner, unenhanced by any additional medical comment by that examiner, does not constitute 'competent medical evidence...'" LeShore v. Brown, 8 Vet. App. 406, 409 (1995); see also Reonal v. Brown, 5 Vet. App. 458, 461 (1993); Elkins v. Brown, 5 Vet. App. 474, 478 (1993). In any case, this examiner neither diagnosed tinnitus, nor related it medically to the veteran's service or to his service- connected hearing loss. Therefore, the Board can find no basis for the assignment of an effective date prior to July 17, 1997, for the grant of service connection for tinnitus. ORDER Evidence of a well-grounded claim having not been submitted, service connection for hemorrhoids is denied. A compensable rating for bilateral hearing loss is denied. An effective date of July 17, 1997, for the grant of service connection for tinnitus is granted. REMAND In order to establish service connection for a claimed disability, the facts, as shown by the evidence, must demonstrate that a particular injury or disease resulting in a current disability was incurred in or aggravated coincident with service in the Armed Forces. 38 U.S.C.A. §§ 1110, 1131 (West 1991); 38 C.F.R. § 3.303(a) (1999). Service connection for PTSD requires medical evidence establishing a clear diagnosis of the condition, credible supporting evidence that the claimed inservice stressor actually occurred, and a link, established by medical evidence, between current symptomatology and the claimed inservice stressor. 38 C.F.R. § 3.304(f) (1999); Cohen v. Brown, 10 Vet. App. 128 (1997). Under the new Cohen criteria, the veteran has met his burden of submitting a well-grounded PTSD claim because he has submitted medical evidence of a current disability; lay evidence (presumed to be credible to establish well- groundedness) of an inservice stressor, which in a PTSD case is the equivalent of in-service incurrence or aggravation; and medical evidence of a nexus between service and the current PTSD disability, in the form of diagnoses by VA medical personnel. Cohen v. Brown, 10 Vet. App. 128, 137 (1997), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir. 1996) (table); Heuer v. Brown, 7 Vet. App. 379, 384 (1995); and King v. Brown, 5 Vet. App. 19, 21 (1993). Because the claim is well grounded, the VA has a duty to assist the veteran in the development of facts pertinent to his claim. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.103(a) (1996); EF v. Derwinski, 1 Vet. App. 324 (1991); Littke v. Derwinski, 1 Vet. App. 90 (1990). The veteran's claims file is replete with records containing diagnoses and treatment for various psychiatric disorders, including alcohol dependence, cocaine dependence, bipolar mood disorder, and major depression. However, the Board observes that these records also include multiple diagnoses of PTSD from 1993 until the present, including, most recently, a diagnosis of PTSD in November 1998. Many of these diagnoses were based on inservice stressors reported by the veteran at the time of examinations. Although the stressor information provided to examiners has changed somewhat over the years, and includes both combat and non- combat related incidents, the incident which was generally claimed to be the veteran's principal stressor, and, indeed, was often the only stressor mentioned by the veteran at the time of psychiatric evaluation and treatment, involved an alleged rape in 1968. More specifically, the veteran has alleged that on or about May 15, 1968, while at LZ Ozzie, he was drugged and raped by two fellow soldiers. He stated that when he told his captain, he did not believe the veteran's report, accusing him of lying and trying to get out of Vietnam. In addition, he stated that later that day he was told by a friend that if he told anyone, he would be killed by the perpetrators, so he never reported the incident to any other authorities. The Board observes that the RO has expended considerable effort in attempting to assist the veteran in the development of his claim by attempting to verify the veteran's claimed stressors. In this regard, the Board notes that the evidence necessary to establish the occurrence of a recognizable stressor during service to support a diagnosis of PTSD will vary depending upon whether the veteran was engaged in combat with the enemy. Where it is determined, through recognized military citations or other supportive evidence, that the veteran engaged in combat with the enemy and the claimed stressor is combat-related, the veteran's lay testimony may be sufficient to establish the occurrence of such stressor, provided such testimony is credible and consistent with the circumstances, conditions, and hardships of service. However, where the veteran did not engage in combat or the claimed stressor is non combat-related, the record must contain service records which corroborate the veteran's testimony as to the occurrence of the claimed stressor. Id.; Zarycki v. Brown, 6 Vet. App 91, 98 (1993). In this case, the Board notes that the veteran's principal claimed stressor, the inservice rape in May 1968, is not a combat-related stressor, and, thus, the record must contain evidence which corroborates the veteran's claim as to the occurrence of this claimed stressor. In this regard, the Board observes that, during the pendency of the veteran's appeal, the Court issued a decision in Patton v. West, in which it noted that in the particular case of claims of PTSD due to a personal assault, VA has established special procedures for evidentiary development. Patton v. West, 12 Vet. App. 272, 277 (1999). These procedures, which became effective in February 1996, take into account the fact that since personal assault is an extremely sensitive issue, many incidents of personal assault are not officially reported, and victims of this type of inservice trauma may find it difficult to produce evidence to support the occurrence of the stressor. These procedures thus acknowledge the difficulty veterans face in establishing the occurrence of the stressor through standard evidence, and the need for development of alternate sources of evidence. See VA Adjudication Procedure Manual M21-1 (hereinafter Manual M21-1), Part III, paragraph 5.14c (Feb. 20, 1996) (substantially enlarging on the former Manual M21-1, Part III, paragraph 7.47c(2) (Oct. 11, 1995)). Alternate sources that may provide credible evidence of an in-service personal assault include medical or counseling treatment records following the incident, military or civilian police reports, reports from crisis intervention or other emergency centers, statements from confidants or family, copies of diaries or journals, or behavior changes documented or observed at the time of the incident, such as obsessive behavior at the time of the incident, pregnancy tests, increased interest in test for sexually transmitted diseases, termination of primary relationships, or alcohol and drug abuse. Evidence that documents any such behavioral changes may require interpretation by a VA neuropsychiatric physician to determine whether such evidence bears a relationship to the medical diagnoses. See M21-1, Part III, para. 5.14(c)(9). Furthermore, these provisions recognize that the standard PTSD stressor letter may be inappropriate for this type of PTSD claim, and thus state that if the claimed stressful incident is a personal assault, a stressor development letter specifically tailored for personal assault cases should be sent to such veterans. See M21-1, Part III, para. 5.14(c)(6). In addition, the Court in Patton noted that in two places the MANUAL M21-1, Part III, 5.14(c)(3) and (9), appears improperly to require that the existence of an in-service stressor be shown by "the preponderance of the evidence" and holds that any such requirement, however, would be inconsistent with the benefit of the doubt, or equipoise, doctrine contained in 38 U.S.C. § 5107(b). Therefore, the evidence need only be in relative equipoise to prevail on the question of the existence of the stressor. The Court has held that the provisions in M21-1, Part III, 5.14(c), which address PTSD claims based on personal assault are substantive rules which are the equivalent of VA regulations, and are binding on VA. Cohen; YR v. West, 11 Vet. App. 393, 398-99 (1998); Patton, 12 Vet. App. at 272. Therefore, in order to give the veteran every consideration with respect to the present appeal and to accord the veteran due process of law, the Board finds that further development with respect to the issue on appeal in this case is warranted. Accordingly, this case is REMANDED to the RO for the following actions: 1. The RO should provide the veteran with a personal assault letter and questionnaire to be filled out and returned, in accordance with M21-1, Part III, § 5.14(c), in order to obtain as much information as possible about the personal assault incident in service, to include a detailed description of the pertinent incident, with all pertinent dates and locations, as well as the complete names and unit designations of the assailant and others who were also assaulted or have knowledge of the incident. The RO should afford the veteran the opportunity to submit any additional evidence in support of his claim for service connection for PTSD, to include statements from relatives. He should be asked to provide any additional information possible regarding the stressful events claimed to have caused PTSD and to identify potential alternative sources for supporting evidence regarding the stressors he alleges occurred in service. In particular, the veteran should provide as much detailed information as possible including the dates, places, names of people present, and detailed descriptions of events. The veteran is advised that this information is necessary to obtain supportive evidence of the stressful events and that he must be as specific as possible because without such details an adequate search for verifying information can not be conducted. The RO should then request any supporting evidence from alternative sources identified by the veteran and any additional alternative sources deemed appropriate, including military police records, if the veteran has provided sufficiently detailed information to make such request feasible. 2. If the RO determines that there is evidence of behavior changes at the time of an alleged stressor which might indicate the occurrence of an in-service stressor, or if otherwise deemed necessary, the RO should obtain interpretation of such evidence by a clinician as provided in M21-1, Part III, 5.14(c)(9). 3. The RO should then review the file and make a specific written determination, in accordance with the provisions of 38 C.F.R. § 3.304(f) and M21-1, Part III, 5.14(c), with respect to whether the veteran was exposed to a stressor, or stressors, in service, and, if so, the nature of the specific stressor or stressors established by the record. In reaching this determination, the RO should address any credibility questions raised by the record. 4. Thereafter, if any claimed inservice stressor is corroborated by the evidence or if otherwise deemed warranted, the veteran should be afforded a VA psychiatric examination. The claims file, a separate copy of this remand, and a list of the stressor(s) found by the RO to be corroborated by the evidence must be provided to the examiner for review, the receipt of which should be acknowledged in the examination report. 5. The examiner must determine whether the veteran has PTSD and, if so, whether the in-service stressor(s) found to be established by the RO are sufficient to produce PTSD. The examiner should be instructed that only the verified events listed by the RO may be considered as stressors. The examiner should utilize the DSM-IV in arriving at diagnoses and identify all existing psychiatric diagnoses. If PTSD is diagnosed, the examiner must explain whether and how each of the diagnostic criteria is or is not satisfied. Also, if PTSD is diagnosed, the examiner must identify the stressor(s) supporting the diagnosis. A complete rationale must be given for any opinion expressed and the foundation for all conclusions should be clearly set forth. The report of the psychiatric examination should be associated with the veteran's claims folder. 6. The veteran's claim should then be readjudicated with consideration of all pertinent law, regulations, Court decisions and M21-1, Part III, 5.14(c). If the veteran's claim remains denied, he and his representative should be provided with a Supplemental Statement of the Case, which includes any additional pertinent law and regulations, specifically to include M21-1, Part III, 5.14(c). The applicable response time should be allowed. Thereafter, subject to current appellate procedures, the case should be returned to the Board for further appellate consideration, if appropriate. The purpose of this REMAND is to obtain additional development and adjudication, and the Board does not intimate any opinion as to the merits of the case, either favorable or unfavorable, at this time. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded to the regional office. Kutscherousky v. West, 12 Vet. App. 369 (1999). No action is required of the veteran until he is notified. WARREN W. RICE, JR. Member, Board of Veterans' Appeals