Citation Nr: 0028292 Decision Date: 10/26/00 Archive Date: 11/01/00 DOCKET NO. 90-01 753 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUES 1. Entitlement to service connection for multiple sclerosis. 2. Whether new and material evidence has been submitted to reopen a claim for service connection for hydrocephalus. REPRESENTATION Appellant represented by: Paralyzed Veterans of America, Inc. WITNESSES AT HEARING ON APPEAL Appellant and his wife ATTORNEY FOR THE BOARD Nancy S. Kettelle, Counsel INTRODUCTION The veteran had active service from August 1963 to July 1966. He served on active duty for training from September 12 to September 27, 1981, and from July 7 to July 25, 1982. This matter previously came to the Board of Veterans' Appeals (Board) on appeal from a November 1987 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Indianapolis, Indiana. In a decision dated in September 1988, the Board denied the veteran's claims of entitlement to service connection for hydrocephalus and multiple sclerosis (MS). In a June 1989 rating decision, the RO continued the denial of service connection for hydrocephalus and MS. The veteran appealed, and in a decision dated in September 1990, the Board denied the veteran's claims. The veteran appealed to the United States Court of Veterans Appeals (United States Court of Appeals for Veterans Claims since March 1, 1999) (Court). In January 1992, the Court granted the unopposed motion of the Secretary of Veterans Affairs (Secretary) for remand of the case to the Board, and the Court vacated the September 1990 Board decision. In July 1992, the Board determined that the veteran had not submitted new and material evidence to reopen his claims of entitlement to service connection for hydrocephalus and MS. In May 1993, the Court granted a motion of the Secretary for remand in this case and vacated the 1992 Board decision. In March 1994, a Hearing Officer at the RO found that new and material evidence had been added to the record, and after review of all the evidence, denied the claims. The veteran continued his appeal. In a decision dated in May 1995, the Board determined that subsequent to its September 1988 decision, new and material evidence had not been submitted to reopen the veteran's claims. In its analysis, the Board used the criteria set forth by the Court in Colvin v. Derwinski, 1 Vet. App. 171, 174 (1991) for the test it applied to determine whether evidence was material. The veteran appealed the Board decision. In its October 1998 order, the Court noted that the opinion of the United States Court of Appeals for the Federal Circuit (Federal Circuit) in Hodge v. West, 155 F.3d 1356 (Fed. Cir. 1998) invalidated the Colvin criteria for determining materiality to reopen a previously denied claim. The Federal Circuit found that VA's regulation on reopening, 38 C.F.R. § 3.156(a), was a reasonable interpretation of the materiality requirement in 38 U.S.C.A. § 5108 and governed decisions on whether to reopen previously disallowed claims. The Court vacated the May 1995 Board decision and held that a remand was necessary in order for the Board to apply 38 C.F.R. § 3.156(a) and Hodge. In July 1999, the Board determined that new and material evidence relative to service connection for MS had been added to the record and found that the claim was plausible and thus well grounded. The Board remanded the claim for service connection for MS to the RO for additional development and, because not all evidence added to the record had been considered by the RO, remanded for readjudication the issue of whether new and material evidence had been submitted to reopen the claim of entitlement to service connection for hydrocephalus. FINDINGS OF FACT 1. The veteran's MS was present prior to July 1982 and increased in severity during his active duty for training in July 1982. 2. In a decision dated in September 1988, the Board denied service connection for hydrocephalus. 3. Evidence added to the record since the September 1988 Board decision includes new evidence, but it is not so significant that it must be considered to fairly decide the merits of the claim for service connection for hydrocephalus. CONCLUSIONS OF LAW 1. MS was aggravated in active service. 38 U.S.C.A. §§ 101(24), 1131, 1153 (West 1991 & 2000); 38 C.F.R. §§ 3.6, 3.303, 3.306 (2000). 2. Evidence received since the September 1988 Board decision denying entitlement to service connection for hydrocephalus is not new and material, and the claim for service connection for hydrocephalus is not reopened. 38 U.S.C.A. § 5108 (West 1991); 38 C.F.R. § 3.156(a) (2000). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The veteran contends that clinically significant manifestations of his MS were first present during his active duty for training in July 1982 thereby warranting the conclusion that his MS was incurred in service. The veteran has reported that he is not aware of when hydrocephalus was initially manifested, but he assumes it was present at the same time that his MS had its inception during active duty for training in the summer of 1982. I. Background At the time of the September 1988 Board decision, the record included the veteran's service medical records for his active service from 1963 to 1966. Those records included no complaint, finding or diagnosis related to MS or hydrocephalus. Other evidence of record included clinical records from a Dr. Hansen dated from April 1978 to March 1981 showing that the veteran complained of malaise and feeling tired in the morning after having worked 60 hours a week over the past month. Dr. Hansen listed malaise and depression as among the veteran's problems, and in August 1978 prescribed Elavil. The veteran was off work for approximately 3 weeks. Those records show that in early 1981 the physician talked with the veteran concerning decreased libido. Also of record was a statement dated in September 1987 from Gary A. Babcoke, M.D., who reported that he first treated the veteran in September 1982 and the veteran's problems from then to September 1983 were weight loss and loose stool. Dr. Babcoke stated that he noted a neurological disorder in late November 1983 and referred the veteran to a Dr. Cohen. Also of record was a December 1983 letter from Hyman L. Cohen, M.D., in which he stated he had examined the veteran the previous day. He said the veteran had ataxia, walked on a broad base and had difficulty with tandem walking. He also noted the optic discs were slightly pale. The record also included two pages of a history and physical examination report form Porter Memorial Hospital concerning hospitalization in December 1983 wherein Dr. Cohen stated that he had initially examined the veteran on the day prior to admission. He stated the veteran gave a history of difficulty in walking for about two years. The veteran said his legs gave out and his right leg kicked out to the right involuntarily at times. The veteran said he had occasional trouble with control of bowel and bladder during the past year and had increased frequency. The veteran reported he had noted a memory deficit and his mood was reportedly different in that his affect seemed to be more flattened. On examination, the veteran walked on a broad base. He had difficulty with tandem walking, and the right foot turned out somewhat. Examination of the cranial nerves revealed that the disks were slightly pale. Dr. Cohen stated that a computed tomography (CT) scan the day prior to the office visit had revealed a hydrocephalus, most likely of the obstructive type. He stated that the veteran's hospitalization was for further evaluation and therapy. Also of record was a letter dated in February 1984 in which Antonio D. Zelaya, M.D., reported to Dr. Babcoke that the veteran had a ventriculoperitoneal shunt put in mid-December 1983 because of adult onset hydrocephalus. He said there was no clear etiology for this so it was assumed it was aqueductal stenosis. The physician stated the veteran's ataxia was a lot better, but weak legs were still a significant problem and were most likely secondary to stretching of the cortex spinal tracts by the enlarged ventricles. In a March 1984 letter, Dr. Zelaya said that the strength in the veteran's legs was better and his general neurological examination was unremarkable. The record also included a February 1985 letter from Lalit B. Savla, M.D., who stated that he had examined the veteran in December 1984. Dr. Savla noted gait abnormality and the veteran's reported symptoms of frequency of urination and dribbling and memory lapses. Dr. Savla stated the veteran's present symptomatology raised the question regarding adequate functioning of the shunt or that one should consider the etiology of demyelinating diseases. Also of record was a May 1985 letter from Frederick E. Pfeiffer, M.D., of the Mayo Clinic who reported that he had conducted an evaluation of the veteran in April 1985. Dr. Pfeiffer noted that the veteran had developed symptoms of depression, impotence and fatigue three years earlier. He also noted that two years earlier progressive right leg incoordination developed and that a CT scan ultimately revealed evidence of hydrocephalus. Dr. Pfeiffer noted that shunting did not improve the veteran's symptoms and that since that time he had developed difficulty in controlling his right arm and urinary urgency. He stated that test results taken together with the veteran's clinical findings were all diagnostic of demyelinating disease and that the most likely cause of such a demyelinating disease would be multiple sclerosis. Dr. Pfeiffer stated that he thought that the hydrocephalus had been asymptomatic and was only discovered because CT scanning was performed due to the symptoms of multiple sclerosis. At a VA examination in October 1987, the veteran related a history of progressive weakness of his lower extremities for years. He said he later had easy fatigability and loss of coordination and balance. He reported that he had been diagnosed with early multiple sclerosis and hydrocephalus. He also related that work-up at Mayo Clinic had confirmed the diagnosis of multiple sclerosis. On examination, the veteran's gait was ataxic and broad based. He had difficulty tandem walking, and his balance and coordination were poor. Strength in the lower extremities was 3/5. The diagnoses were multiple sclerosis and hydrocephalus, post operative (shunt 12/83). At a hearing at the RO in March 1988, the veteran testified that he went on a two-week National Guard active duty drill in the summer of 1982. He testified that during a four-mile march he noticed extreme fatigue and incoordination in his right leg, with his right leg kicking out to the side. He testified that he had difficulty completing the march. He testified that he did not report for treatment at that time because he thought the weakness and problems with his right leg were due to a fracture many years earlier. He testified that after the two-week drill, he continued with a fitness program, but instead of getting stronger, he continued to have problems with weakness in his legs and the turning out to the side. He testified that he went inactive with the National Guard in 1983 because of problems with his right leg incoordination and extreme fatigue. He testified that at that time he saw an orthopedic doctor, Dr. Olsen, who took an X-ray and noted a healed compound fracture of his leg. He testified that in the summer of 1984, Dr. Savla diagnosed him as having multiple sclerosis. At the hearing, the veteran testified that prior to his active duty period in 1982 he had not noticed the fatigue, weakness and incoordination of his right leg, but had noticed it constantly since then. The veteran testified there was no doubt in his mind that multiple sclerosis manifested itself while he was serving on active duty with the National Guard in the summer of 1982. His representative argued that the veteran's active duty for training in the National Guard either hastened the onset of the veteran's multiple sclerosis or severely aggravated any multiple sclerosis that might have been developing at the time. At the March 1988 hearing, the veteran's wife testified that when he came back from his two weeks of active duty in 1982, the veteran's leg was weak and he could not walk. She testified that after the veteran's drill period she sometimes participated with him in his fitness program. She testified that the veteran complained of fatigue and she noticed problems with his leg, including a limp. She testified that she noticed this from the time he came back in 1982 until the veteran stopped his fitness program. In its September 1988 decision, the Board denied entitlement to service connection for MS and hydrocephalus. Relative to the hydrocephalus claim the Board found that hydrocephalus was not present in service or during active duty for training and was initially documented many years after active service. Evidence added to the record since the September 1988 Board decision includes a report of medical history and physical examination report for National Guard enlistment dated in August 1980. Those records show a history of leg cramps, but no complaint, finding or diagnosis of MS or hydrocephalus. Also added were a report of medical history and a National Guard quadrennial physical examination report, both dated in January 1985. The veteran reported an extensive medical and surgical history with a recent history of hydrocephalus with shunt placement in December 1983. The veteran was found not qualified for active duty due to a history of MS. The veteran submitted a May 1989 decision of the Social Security Administration (SSA), which awarded him SSA disability benefits. The SSA found the medical evidence established the veteran had severe multiple sclerosis and depression. In October 1993, SSA furnished an additional copy of its May 1989 decision along with its June 1989 determination and transmittal form. Among the records provided by SSA was a disability report dated in August 1988 in which the veteran stated that MS was his disabling condition and it first bothered him in "1978?" The SSA also furnished copies of medical records obtained in connection with the veteran's SSA disability claim. Those records included documents from Porter Memorial Hospital concerning the veteran's hospitalization in December 1983. In addition to the two pages of the history and physical examination report previously of record, the added documents include another page of the physical examination report, the discharge summary, operative report and a CT scan report. The final diagnosis reported in the discharge summary was hydrocephalus of uncertain etiology. Other documents from SSA include a copy of Dr. Zelaya's February 1984 letter, a copy of Dr. Pfeiffer's May 1985 letter, a copy of the October 1987 VA examination report and private medical records and reports dated in 1988 and 1989. In a September 1988 letter to Dr. Babcoke, Richard Silberman, M.D., reported on a neurological consultation. Dr. Silberman noted the veteran's complaints including increased weakness in right extremities, uncontrolled spasm in lower extremities, right greater than left, bladder dysfunction for the past 10 years, especially urinary urgency and frequency, bowel dysfunction, occasional episodes of diplopia, fatigue, impotence, dull pains in extremities, and numbness in digits of the right upper extremity. Based on a review of the veteran's history and the results of the physical examination, Dr. Silberman concluded that the veteran was suffering from MS with multiple system complaints at this time. He said among the complaints, he had discussed with the veteran the possibility of treatment for his bladder dysfunction and impotence as well as the possible use of anti-spasmatics for increased tone and spasms in the lower extremities. Dr. Silberman recommended a urological consultation for a cystometrogram and cystectomy, and September 1988 hospital records concerning those procedures are in the file. In a letter dated in March 1989, Dr. Silberman reported concerning the veteran's current symptoms. Among the records from SSA is an October 1988 report of a special neurological examination by Yong C. Song, M.D. Dr. Song reported that the veteran gave a history of impotence in 1981. The veteran reported that during the following year, while he was active in the National Guard, he experienced right leg incoordination and extreme weakness in the right side of his body. Dr. Song also noted that the veteran's history included hospitalization for a shunt due to hydrocephalus of unknown origin, but probably aqueduct stenosis. After examination, the diagnostic impression was history of MS and status post J-V shunt for hydrocephalus. Clinical records from Porter/Starke show that the veteran was seen by a clinical psychologist in November and December 1988. He reported the veteran had a shunt placed in his head in 1983 for hydroencephalitis, and was diagnosed in 1984 with MS though he was beginning to have symptoms, including impotence, in 1980. In May 1993, the veteran submitted an excerpt from McAlpine's Multiple Sclerosis, 2ed (1991). The text describes environmental effects on MS and cites to several studies, which demonstrate that exercise and changes in environmental temperature exacerbate symptoms of MS. In a notarized sworn statement dated in December 1993, a fellow serviceman reported that he participated in National Guard annual training with the veteran. He stated that when they arrived the veteran looked very good and was a very capable person. He said that the veteran's health started to deteriorate after they took part in the PT test that was given each year. He said that the veteran's health continued to go down hill, until, at the end of annual training, the veteran told him that if the annual training were not over, he was going to have to go on sick call. At a hearing at the RO in February 1994, the veteran testified that prior to his two-week training in 1982 he had experienced double vision on a fleeting basis in 1975 or 1976. He also testified that he probably started experiencing bowel and bladder problems prior to 1982, but they were definitely present during his active duty for training in 1982. He also recalled being treated for fatigue and being diagnosed with depression by Dr. Hansen prior to 1982. The veteran testified he thought he was mis-diagnosed with depression when the symptoms were present for MS. The veteran testified that on the march in active duty for training he started experiencing extreme fatigue, right leg incoordination, weakness and urinary urgency. He testified that he had not paid attention to these symptoms, which were mild prior to 1982, attributing them to getting older, but they really manifested themselves during the four-mile march in the summer of 1982. The veteran testified that on the SSA form, his entry "1978?" for when MS first bothered him was because it had been so slowly progressive that he did not know when it first became apparent. The veteran testified that he was certain that hydroencephalitis was present during the four-mile march in 1982. At the hearing, the veteran confirmed that in the December 1993 statement, his fellow serviceman was referring to the summer training in 1982. At the hearing, the veteran's wife testified that she and the veteran were married in 1975. She testified that she remembered that when the veteran came home from summer training in 1982 he was having problems with his legs. In February 1994, the veteran submitted medical records from his former employer. They show that in October 1992 he received treatment for a possible chip fracture of the right thumb. The record shows the veteran gave a history of having slipped on oil and losing his balance. He said he caught himself by falling on his right hand. Records dated from January to April 1984 follow the veteran's status, including problems with weakness and unsteady walking, following placement of the shunt in December 1983. Records dated in July 1985 show the veteran was seen with complaints of pressure and discomfort at the outer aspect of the area of the shunt. It was noted that he had also been diagnosed as having MS In a notarized statement dated in February 1995, the veteran's former wife stated that she and the veteran were married from 1967 to 1971. She said that during the marriage the veteran often complained of fatigue and at times had difficulty maintaining an erection during intercourse. The evidence received since the September 1988 Board decision includes a May 1999 memorandum from Craig N. Bash, M.D., a neuroradiologist, who is Assistant Professor of Radiology at the Uniformed Services University of Health Sciences and Associate Director of Medical Services, Paralyzed Veterans of America. Dr. Bash stated that he had reviewed the veteran's claims file, including his service medical records and private and VA medical records. Dr. Bash then stated his impression and said that given the events described by the veteran and his witnesses, it appeared likely the exercise in the heat of July 1982 caused the veteran's multiple sclerosis to manifest and caused a chronic increase in the level of disability. Dr. Bash went on to say that one current theory suggested the predilection to develop multiple sclerosis might begin during the formation of the myelin sheath. He said that subsequent events then continually degrade the insulating effect of the myelin sheath producing debilitating symptoms that become clinically apparent. Dr. Bash stated it was therefore likely that multiple sclerosis was present when the veteran reported for training in 1982. Dr. Bash said that some of the veteran's symptoms reported prior to this time may or may not have been related to multiple sclerosis, but the diagnosis of multiple sclerosis would not then have been justified because symptoms would be sub-clinical and there was no clear documentation of neurologic dysfunction at different locations at different times. He then said it appeared the exercise in the heat of the July 1982 training period caused the multiple sclerosis to exacerbate and to remain at clinically significant levels which were noticeable by witnesses who observed weakness and gait alteration from that time forward. Dr. Bash said that the multiple sclerosis appeared to have progressed and subsequently led the veteran to seek medical care, leading to the diagnosis of multiple sclerosis. In September 1999, the veteran submitted clinical records from Dr. Silberman dated from September 1988 to August 1999. The records show that in September 1988 Dr. Silberman noted that the veteran's history included obstructive hydrocephalus in December 1983 requiring a shunt. It was also noted that for years prior to this the veteran had difficulty walking associated with uncontrolled weakness and spasm and that despite the shunt the symptoms became progressively worse. He further noted that work-up at Mayo Clinic in 1985 resulted in the MS diagnosis. It was also noted that the veteran reported various symptoms over the past few years including bladder difficulties for 10 years and impotence for 10 years. The remaining records from Dr. Silberman show treatment for MS. The veteran's submission in September 1999 also included copies of Dr. Cohen's December 1983 letter, Dr. Zelaya's letters dated in January, February and March 1984, Dr. Savla's February 1985 letter and Dr. Pfeiffer's May 1985 letter. In a VA examination report dated in December 1999, a VA physician, who is a neurology specialist, stated that he had reviewed the claims files including the veteran's service records. The physician noted that the veteran had a diagnosis of MS made at the Mayo Clinic in 1984-1985. The veteran's current complaints included significant gait difficulty, urinary urgency, constipation, right-sided numbness and significantly poor balance. The veteran stated that he felt his symptoms may have initially begun as early as the 1980s and he noted that during basic training while exercising he felt right-sided weakness and poor coordination and said he barely could make it throughout the exercises. He had a CAT scan in 1983, which suggested hydrocephalus and because of that had a shunt placed. His symptoms did not improve, and he was eventually evaluated at the Mayo clinic. The diagnosis after the December 1999 examination was MS. The VA physician stated that in reviewing the veteran's chart there did not appear to be any objective evaluation by a physician until 1983 when ataxia was found. The physician noted that the veteran stated that he developed right-sided clumsiness and weakness during military training. The physician said these were common symptoms of MS and would suggest that the veteran's MS began about 1982. The physician said the veteran also had impotence and fatigue, which can be seen in MS. The physician said although it is always difficult to pinpoint exactly when MS begins, it is his opinion that it is at least as likely as not that the veteran's MS had its onset during his active duty training in 1982. The physician said that patients with MS are somewhat sensitive to exercising and thus the veteran's statement that he noted right-sided weakness upon a four-mile hike and run would not be unusual for somebody with MS. II. Analysis Multiple Sclerosis Under the law, service connection may be granted for disability resulting from disease or injury incurred in or aggravated during active military service. 38 U.S.C.A. §§ 1110, 1131 (West Supp. 2000). The term active service includes active duty and also includes any period of active duty for training during which the individual concerned was disabled or died from a disease or injury incurred or aggravated in the line of duty. 38 U.S.C.A. § 101(24) (West 1991); 38 C.F.R. § 3.6 (2000). The term "veteran" means a person who served in the active military, naval, or air service, and who was discharged or released therefrom under conditions other than dishonorable. 38 U.S.C.A. § 101(2) (West 1991). Where a veteran served continuously for 90 days or more and MS becomes manifest to a degree of 10 percent or more within seven years of termination of such service, MS shall be presumed to have been incurred in service. 38 U.S.C.A. §§ 1101, 1112 (West 1991); 38 C.F.R. §§ 3.307, 3.309 (2000). Service connection may also be established for disease initially diagnosed after discharge from service when all the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2000). A preexisting injury or disease will be considered to have been aggravated by active service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C.A. § 1153 (West 1991); 38 C.F.R. § 3.306 (2000). The claim for service connection for MS is plausible, and the Board is satisfied that the evidence of record is adequate for an equitable disposition of this claim. The post-service medical evidence described earlier shows that physicians first mentioned demyelinating disease in 1984 and that it was following the Mayo Clinic work-up in 1985 that the diagnosis of MS was made. The veteran does not contend, nor does the evidence show, that MS was present during his 1963 to 1966 active service or that it was manifest to a degree of 10 percent within 7 years of his separation from that period of service. The veteran contends that his MS had its onset during his active duty for training in July 1982, and a VA physician who reviewed the veteran's claims files has stated that it is his opinion that it is at least as likely as not that the veteran's MS had its onset during his active duty training in 1982. The VA physician referred to the veteran's accounts of having developed right-sided clumsiness and weakness during military training and said these were common symptoms of MS and would suggest that the veteran's MS began about 1982. Although the VA physician's opinion supports the veteran's contention of onset of the disease during active duty for training, the Board gives greater weight to the opinion of Dr. Bash that the veteran's MS was exacerbated during active duty for training in July 1982, which is more consistent with the medical record in its entirety. The record shows, for example, that in December 1983 the veteran gave a 2-year history of difficulty walking and that in April 1985 at the Mayo Clinic, he gave a 3-year history of symptoms of depression, impotence and fatigue while symptoms of malaise, depression and decreased libido were reported in clinical records dated from 1978 to 1981. Also, in September 1988, the veteran gave a history of bladder dysfunction over the past 10 years and in October 1988 gave a history of impotence in 1981. There is no indication that the veteran has medical training of any sort, nor does he claim medical expertise. However, even as a layman, he is competent to report observable symptoms, most notably gait abnormalities and bladder problems, which the collection of medical records consistently identify as symptoms of the veteran's MS. See Espiritu v. Derwinski, 2 Vet. App. 492, 494-95 (1992). The Board accepts the veteran's statements as credible. The medical histories he provided for treatment purposes indicate that these symptoms predate the July 1982 active duty for training, and in his hearing testimony, he reported extreme fatigue and incoordination in his right leg during active duty for training in July 1982 and its persistence thereafter. The veteran's wife's hearing testimony and his fellow serviceman's statement corroborate the veteran's statements concerning the severity and disabling nature of those symptoms. Further, at the February 1994 hearing, the veteran testified that prior to July 1982 he had mild symptoms of fatigue, right leg incoordination, weakness and urinary urgency, but that they really became extreme during the four-mile march in the summer of 1982. The excerpt from McAlpine's Multiple Sclerosis supports the inference that the hot weather and unusual exertion the veteran experienced during active duty for training in July 1982 exacerbated MS symptoms that were previously present, and, according to Dr. Bash, caused a chronic increase in the level of the veteran's disability. The Board therefore finds that the veteran's MS was present prior to July 1982 and increased in severity during his active duty for training in July 1982. Based on this finding, the Board concludes that the veteran's MS was aggravated in active service. Hydrocephalus The veteran's claims include entitlement to service connection for hydrocephalus. As outlined earlier, in a decision dated in September 1988, the Board denied entitlement to service connection for hydrocephalus, and this decision was final. Generally, when a claim is disallowed by the Board, that claim may not thereafter be reopened and allowed, and a claim based upon the same factual basis may not be considered. 38 U.S.C.A. § 7104(b) (West 1991). The exception to this rule is 38 U.S.C.A. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. New and material evidence means evidence not previously submitted to agency decisionmakers which bears directly and substantially upon the specific matter under consideration, which is neither cumulative nor redundant, and which by itself or in connection with the 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). New evidence will be presumed credible solely for the purpose of determining whether the claim has been reopened. Justus v. Principi, 3 Vet. App. 510, 513 (1992). As described in detail earlier, evidence of record at the time of the September 1988 Board decision showed that the veteran's hydrocephalus was diagnosed and treated in December 1983, but did not relate it to any period of active service. The evidence added to the record includes duplicates of medical records and letters from physicians that were considered by the Board in September 1988, and this evidence is obviously not new. Medical evidence not previously of record includes the discharge summary from Porter Memorial Hospital concerning the veteran's hospitalization in December 1983. The final diagnosis of "hydrocephalus of uncertain etiology" was not previously of record and is therefore new, but neither it, nor post-September 1988 evidence added to the record relates the hydrocephalus to any period of service. The veteran's testimony at the February 1994 hearing that he was certain that "hydroencephalitis" was present during his four-mile march in July 1982 is also new, but the veteran, though competent to report symptoms, is not, as a layperson, competent to provide evidence concerning medical diagnosis or etiology. See Espiritu, 2 Vet. App. at 494-95. The veteran's testimony concerning medical etiology thus cannot constitute competent medical evidence with which to reopen a claim. See Moray v. Brown, 5 Vet. App. 211, 214 (1993). Therefore, his testimony is not, either alone or in connection with evidence previously assembled, so significant that it must be considered in order to fairly decide the merits of the claim. As a whole, the new evidence received in the veteran's claims file subsequent to the September 1988 Board decision does not tend to show that the veteran's hydrocephalus was incurred in or aggravated by service. Thus, in the Board's judgment, this evidence, when viewed by itself or in connection with the evidence previously assembled, is not so significant that it must be considered in order to fairly decide the merits of the claim. Accordingly, the Board concludes that the evidence submitted subsequent to the September 1988 Board decision that denied service connection for hydrocephalus is not new and material, and the claim for service connection for hydrocephalus is not reopened. ORDER Service connection for multiple sclerosis is granted. New and material evidence not having been submitted, reopening of the claim for service connection for hydrocephalus is denied. Shane A. Durkin Member, Board of Veterans' Appeals