Citation Nr: 0210547 Decision Date: 08/27/02 Archive Date: 09/05/02 DOCKET NO. 98-16 263 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston- Salem, North Carolina THE ISSUES 1. Whether new and material evidence has been submitted to reopen a claim for service connection for a skin disorder. 2. Whether new and material evidence has been submitted to reopen a claim for service connection for malaria. 3. Entitlement to service connection for a skin disorder due to Agent Orange exposure. 4. Entitlement to service connection for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL Appellant, his wife, and a friend ATTORNEY FOR THE BOARD Phillip L. Krejci, Counsel INTRODUCTION The veteran had active service from April 1963 to February 1965. In May 1965, he claimed service connection for a skin disorder, and the claim was denied by a regional office (RO) decision rendered later that month. In a June 1982 letter and an August 1982 statement, the veteran claimed service connection for malaria and a skin disorder caused by exposure to Agent Orange. Both claims were denied by a November 1982 RO decision. In a July 1996 letter, the veteran claimed service connection for a skin disorder which he seemed to attribute to Agent Orange exposure, for malaria, and for PTSD. This case comes to the Board of Veterans' Appeals (Board) from a June 1997 decision by the Winston-Salem, North Carolina, RO that denied the claims. The veteran requested a hearing before a member of the Board though he, his wife, and a friend, testified at a June 1998 RO hearing. However, according to a letter from his representative, the veteran elected not to appear for the February 1999 travel Board hearing scheduled at his request. FINDINGS OF FACT 1. The veteran's claim for service connection for a skin disorder was denied by a May 1965 RO decision. He was notified of the decision and advised of his right to appeal, but he did not appeal, and the decision became final. 2. Evidence received since the May 1965 RO decision is duplicative or cumulative, or it does not bear directly or substantially upon the specific matters under consideration, or it is not so significant that it must be considered in order to fairly decide the merits of the claim for service connection for a skin disorder. 3. The veteran's claim for service connection for malaria was denied by a November 1982 RO decision. He was notified of the decision and advised of his right to appeal, but he did not appeal, and the decision became final. 4. Evidence received since the November 1982 RO decision is duplicative or cumulative, or it does not bear directly or substantially upon the specific matters under consideration, or it is not so significant that it must be considered in order to fairly decide the merits of the claim for service connection for malaria. 5. The veteran's medical records do not reflect diagnosis or treatment of a skin disorder caused by Agent Orange exposure. 6. The veteran did not engage in combat with the enemy, and there is little credible supporting evidence that he experienced a traumatic event in service. 7. The veteran does not have a clear diagnosis of PTSD. CONCLUSIONS OF LAW 1. Evidence received since the May 1965 RO decision is not new and material, and the claim for service connection for a skin disorder is not reopened. 38 U.S.C.A. §§ 5108, 7105(c) (West 1991 & Supp.); 38 C.F.R. §§ 3.104(a), 3.156(a), 20.1103 (2001). 2. Evidence received since the November 1982 RO decision is not new and material, and the claim for service connection for malaria is not reopened. 38 U.S.C.A. §§ 5108, 7105(c) (West 1991 & Supp.); 38 C.F.R. §§ 3.104(a), 3.156(a), 20.1103 (2001). 3. The veteran does not have a skin disorder caused by Agent Orange exposure. 38 U.S.C.A. §§ 1110, 1116 (as amended by the Veterans Education and Benefits Expansion Act of 2001, Pub. L. 107-103, 115 Stat. 976 (Dec. 27, 2001)), 5107 (West 1991 & Supp. 2001); 38 C.F.R. §§ 3.303(a), 3.307(a)(6), 3.309(e) (2001). 4. The veteran does not have PTSD that was incurred in military service. 38 U.S.C.A. §§ 1110, 5107 (West 1991 & Supp. 2001); 38 C.F.R. §§ 3.303(a), 3.304(f) (1998 & 2001). REASONS AND BASES FOR FINDINGS AND CONCLUSION Factual Background The veteran's service medical records consist of a January 1962 pre-induction examination, an April 1963 induction examination, a May 1963 eye examination, outpatient treatment records reflecting June 1964 and January 1965 complaints unrelated to any claims here at issue, and a February 1965 separation examination. As part of the separation examination, the veteran prepared a Report of Medical History. Though he gave a history of several disorders, he did not mention a skin disorder, and his skin was normal by clinical evaluation made at the examination. In May 1965, the veteran was seen in a VA dermatology clinic with an eczematous, confluent, papillomacular dermatitis of the face and upper extremities. He said it had appeared three times during the preceding year, that it worsened in sunlight, and that he was taking no medication currently save for an antimalarial one. The impression was light-sensitive dermatitis or dermatitis externa. An appointment was made for him for the following day with a private dermatologist. The day after the VA dermatology consult, the veteran claimed service connection for a skin disorder, but cited only the VA examination of the day before, and did not indicate he had seen a private dermatologist. A May 1965 RO decision denied the claim, a June letter notified the veteran of the RO decision and of his right to appeal it, but he did not appeal the decision and it became final. In a letter received in May 1982, the veteran reported significant dates, locations, and units of assignment in his military history. He then said that, while in Florida in July 1965, he developed hives, or a rash, on areas of his skin exposed to sunlight. In addition, he said that, every summer since his return from Vietnam, he developed "spells" of headaches, dizziness, and musculoskeletal pain. At first the "spells" occurred in August but, during the preceding three years, they occurred in May as well. He said that, in Vietnam, he had contact with a defoliant on at least one occasion when an Air Force C130 with bullet holes landed at his unit's airfield. He assisted a welder with repairs, and they were told the aircraft had been spraying defoliant when it was hit by enemy small arms fire. In a July 1982 letter, the RO asked for evidence of continuity of disability since his separation from service. In an August response, the veteran repeated the story about his 1965 trip to Florida, and said he saw a VA doctor upon his return. He said that the VA doctor told him that his skin disorder was related to excess vitamin C, but the doctor was unable to treat him because a skin disorder was not reflected in his service medical records. He said that, some time after he saw the VA doctor, he developed boils and saw a private doctor who treated them, but he was not sure he could get a statement from that doctor. In addition, the veteran said that, while visiting relatives in 1968, he developed a fever, shortness of breath, swollen joints, and pain in joints, muscles, head, and chest. A relative gave him some malaria medication he had, and the symptoms subsided. He said that, except for a doctor he saw for headaches in 1977, diagnosed as neuritis, he had not seen a doctor since he saw the VA doctor in 1965. The "attacks" had occurred mainly in August but, in recent years, had occurred in May as well. The last "attack" was from August 23 to 25 during which time he had fever and chills, headaches, muscle and joint pain, nausea, and diarrhea. At an October 1982 VA examination, the veteran gave a history of severe malaria in service with recurrent bouts, three during the preceding year, of joint and muscle pain, chills and fever, and shortness of breath. He said that, in service, he worked on an aircraft that had reportedly sprayed defoliant. He said he did not develop a skin disorder at that time, but he had a skin rash in 1965 diagnosed then as sensitivity to sunlight. His skin was currently clear, but there was a transient dermographia that faded in five minutes. There was full range of motion of all joints. The examiner expressed concern regarding febrile attacks because malaria did not often continue that way. He also noted that the veteran's exposure to Agent Orange was minimal, and that he had none of the standard residuals, such as chloracne, and concluded there was no current evidence of Agent Orange exposure. Diagnoses included febrile attacks with malaise, shortness of breath, and history of malaria, and a skin disorder manifested by photosensitive eruptions, eczematoid eruptions, and furunculosis, but no current evidence of a skin disorder. A November 1982 RO decision denied service connection for malaria and for a skin disorder due to Agent Orange exposure, a letter later that month notified the veteran of the decision and of his right to appeal it, but he did not appeal the decision and it became final. In a letter received in June 1996, the veteran claimed service connection for malaria, PTSD, chloracne, porphyria, and Agent Orange exposure. He asserted that his service medical records show that, while in Vietnam, he was treated for a skin disorder on February 2, 1964, that he contracted malaria, and that he was exposed to Agent Orange which cause porphyria and chloracne. He contended that he had "malaria attacks" every August and, since 1982, every May as well and also, since 1989, every February. He said these "attacks" were manifested by chest pain, weakness, and shortness of breath. He said he was treated for a skin rash and boils in Vietnam in February 1965. Since then, he had been treated at VA hospitals in Brecksville, Ohio, in May 1965, and in Johnson City, Tennessee, in October 1982. In addition, he said he had been treated by Dr. Charles Phillips in Gibsonville, North Carolina, in September 1993, and by the Moses Cone Family Practice Center in Greensboro, North Carolina, in May 1996. He said PTSD cost him jobs and caused depression, aggression, an inability to make friends, and a September 1969 flashback. In a September 1996 reply to an RO query about traumatic events in service, the veteran said he had seen body bags and reported two Viet Cong mortar attacks and two occasions when he had "routine guard duty at POL and ammo dump." He said he did not remember the names of any casualties, but he named three friends from Vietnam and their hometowns. In December 1996, the RO obtained the veteran's service personnel records and records from private health care providers. According to the veteran's service personnel records, he was a helicopter mechanic, arrived in Vietnam on December 15, 1963, was assigned to the 80th and, later, the 150th Transportation Detachments, and he left Vietnam on January 27, 1965. The records did not show his receipt of awards or decorations indicating that he had engaged in combat, nor did they otherwise suggest that he had done so. Indeed, the records did not suggest that he had any duties other than those of a helicopter mechanic. A September 1989 record by Jeffrey Katz, MD, noted the veteran's complaints of chest tightness and some diaphoresis after having eaten ham, beef, macaroni, and a McDonald's. The symptoms were relieved in the emergency room with a "GI cocktail." Records by Charles Phillips, MD, dating from November 1983 to September 1993, consisted of one page of notes. A November 1983 record addressed an ear disorder. A May 1992 record noted a two-day history of "stomach problems," including gas, treated with Donnatal and Zantac. A September 1993 record noted a skin rash and referral to a dermatologist. A February 1994 letter to Dr. Phillips from James Patterson, MD, a dermatologist, reported the results of his consult with the veteran. Dr. Patterson said the veteran gave a history of a rash on the hands, worse in the summer. Examination revealed no hives currently, but there was onycholysis of the toenails, dermatographia, a "branny" erythema of the palms and soles, and a peeling of the left hand that tested positive for fungus. The assessment included tinea manus, pedis, and unguium, dermatographism, and probable urticaria. Records by the Family Practice Center at Moses H. Cone Hospital begin with one dated in February 1995. On that record, the veteran had a complaint unrelated to these claims, but the doctor noted that his hands were very dry and scaly and scrapings tested positive for fungus. The assessment included fungal dermatitis. On an April 1996 record, the veteran voiced several complaints, including low back pain, but none of them related to claims here at issue. A May 1996 record reflected a complete physical examination, but noted that the veteran had "no concerns today." He gave a history of malaria which he said flared up in August, May, and, sometimes, February. Symptoms were "hot and cold sensitivity," weakness, dizziness, joint pain, and eyeball pain. He also gave a history of light-sensitive dermatitis and a skin disorder from exposure to Agent Orange. He complained of chest pain, with some left arm radiation, during the preceding year, but he denied abdominal pain, nausea, diarrhea, and shortness of breath. Examination of the skin revealed multiple cherry angioma, and some fungus between the toes, but was otherwise benign. The assessment did not include relevant diagnoses. At a March 1997 VA dermatologic examination, the veteran gave a history of a skin disorder in service and since. He said it was manifested by itching, blisters, and wheals, and appeared on the front and back of the torso. Summer sunlight seemed to trigger an outbreak. On examination, his skin was free of dermatitis or abnormal lesions. The diagnosis was recurrent urticaria not present on that examination. At a March 1997 VA psychiatric examination, the veteran said he had been a helicopter mechanic and door gunner in service. He gave a long history of depression, sleep disturbance with frequent nightmares, intrusive thoughts of his Vietnam experiences, and marked irritability and anger. Objective findings were unremarkable and the veteran was referred for a psychological evaluation. After the psychological evaluation, the examiner annotated the report with "PTSD not diagnosed on this examination." The veteran underwent an April 1997 in-depth psychological evaluation conducted for VA by Thomas Holm, PhD, that included, in addition to a clinical interview, administration of the Minnesota Multiphasic Personality Inventory-2 as well as the Mississippi Scale for Combat-Related PTSD. The interview included the veteran's earliest recollections from his childhood, his education, his employment and life before service, his service experiences including duty as a helicopter mechanic, and his employment and experiences since service. He said he had "limited combat exposure" in service and noted only some sniping and nighttime indirect fires. When asked how he reexperienced events in service, he said he often reflected upon them and sometimes liked doing so. Occasionally, he had had some bad feelings, but those had been less frequent of late. He did not think he had frequent or disruptive anxiety and any sadness he felt was brief. He had some dreams, occasionally about the military particularly after having seen movies with that theme, but he also had dreams about other subjects including current events in his life. He expressed considerable concern with his physical condition, and said he was often weak and tired, and the examiner suggested that the veteran may have an underlying somatoform disorder. The examiner said the veteran showed some features of PTSD, but not persistent avoidance of stimuli associated with traumatic events, and not a numbing of general responsiveness. Dr. Holm concluded that a diagnosis of PTSD would not be appropriate, and that the veteran's responses did not otherwise indicate a specific psychiatric/psychological disorder. The June 1997 RO decision denied service connection for a skin disorder due to Agent Orange exposure, for malaria, and for PTSD. In a July 1997 Notice of Disagreement, the veteran contended that he had had malaria in service and submitted, in support of his contention, a copy of the first page of the report, with the history he gave then of severe malaria in service underlined, of the October 1982 VA examination. He also contended that he was treated for a skin disorder in service and within three months of his return from Vietnam, and submitted, in support of his contention, a copy of the May 1965 VA dermatologic consult that diagnosed light-sensitive dermatitis or possible dermatitis externa. He contended that his history of frequent job changes proved that he had PTSD. In a letter received in July 1997, [redacted] said that he knew the veteran had Agent Orange rashes and "malaria syndrome," and that he had given the veteran "malaria pills" in 1967. With a November 1997 letter, the veteran enclosed photographs of himself, naked from the waist up, which he said depicted a skin rash. In the letter, he said that VA examinations had not been conducted during an outbreak of the rash. With a February 1998 letter, the veteran enclosed copies of two news articles. One, from USA Today, concerned a 74-year- old Greek woman who had malaria at age 3. At age 71, she was found to have anemia, weight loss, an enlarged spleen, and tested positive for the malaria parasite. She was treated and cured in three days. The other article, from Knight- Ridder News Service in 1996, was about Agent Orange in general and noted that prostate cancer and peripheral neuropathy had recently been added to the list of disorders presumed to be due to Agent Orange exposure. In a letter received in May 1998, the veteran's son-in-law said he had seen the veteran with a skin disorder consisting of "sploches [sic] common with other veterans I know caused by fungis [sic] picked up in Vietnam." He said he had also seen the veteran having "attacks of what I consider malaria." During the preceding two years, he had worked at the same warehouse as the veteran and had seen him fly into rages during which he threw 55-gallon drums and heavy doors at other persons including his bosses. In another letter received in May 1998, his wife said that she married the veteran in 1972, and soon noticed that he had a lot of anger, that he destroyed things in their home, and that he often lost his job. She described an incident in 1969 when someone shot at members of her family and the veteran, armed with a firearm, kicked in the door of an apartment and threatened the occupants. She said she had seen his skin rash and had taken pictures of it. She also said he had "spells of weakness" and joint pain and referred to these as malaria attacks. At a June 1998 hearing, the veteran testified that he and two of his friends had a skin eruption in February 1964 that looked like poison ivy or hives. He said his service medical records show that he was treated for chloracne in Vietnam in 1964, but he also said that VA doctors would not treat him for a skin disorder in 1965 because his service medical records did not show that he had one in service. After VA doctors refused to treat him in May 1965, he went to a private doctor who gave him a solution to mix in his bath. He did not recall that that doctor diagnosed a specific skin disorder. He later learned that the private doctor had died and he was unable to get his records. He said he took malaria prophylaxis pills in service but, in May 1964, developed fever and chills and doctors told him he had malaria. He said, however, that he was not given treatment in May 1964. He had a recurrence in August 1964 and another in January 1965, both of which were treated. In January 1965, he was given two shots per day for a week and was told it was for malaria. When asked to identify specific traumatic events in service, he said that the whole Vietnam experience was traumatic, but specifically mentioned watching the fall of Saigon, apparently on television, in 1973. He said that, since service, he had been mentally unstable and also had recurring malaria attacks, but had not missed any work due to physical or mental disorders. His wife testified that the veteran had had skin rashes and had been ill with malaria. She also said that, though he had never abused her, he had demonstrated rage, did not sleep well, and had lost several jobs. A friend testified that he had worked with the veteran for several years, and had seen him kick and throw things and get fired or quit. He also said he had seen the veteran with a skin rash. In an August 1998 Substantive Appeal, VA Form 9, the veteran said he had no medical evidence of his PTSD, but he recited misbehavior on his part and suggested that it was a product of PTSD. He said his service medical records do not show malaria because he did not trust doctors and did not seek medical attention for it while in service. However, he then contended that malaria is reflected in his service medical records. In addition, he contended that his service medical records show that he was treated for a skin disorder in February 1964, but he then said he had not been treated for urticaria, which he said appeared in February 1964, at any time while he was in Vietnam. In a February 1999 letter, Rosalyn Harris-Offutt, BS, CRNA, LPC, ADS, reported that she evaluated the veteran in September 1998. She said the veteran "admitted" to recurring rage and flashbacks and that he carried a gun for many years because it made him feel safer. She noted hypervigilance, exaggerated startle response, sleep disturbed by recurring nightmares, avoidance of situations that might trigger fear or rage, survivor guilt, depression, history of heavy drinking, and history of paranoia. She opined that the veteran had chronic and persistent PTSD and recommended that he continue in therapy. In July 2000, the RO submitted copies of the veteran's statements and service personnel records to the US Armed Services Center for Research of Unit Records (USASCRUR), and asked for relevant information in support of his claim for service connection for PTSD. In a January 2001 response, USASCRUR reported that it had been unable to locate archived records of the transportation detachments to which the veteran had been assigned in Vietnam, but submitted the 1964 History of the 121st Aviation Company, the unit supported by the transportation detachments to which the veteran had been assigned. That lengthy and detailed document described the base camp and listed supporting units, including the transportation detachment to which the veteran had been assigned, and their duties. There followed a month-by-month account of significant events. Noteworthy events included the death in January of a door gunner (door gunners were provided, according to the History, by door-gunner platoons) killed during an insertion operation. In April, the installation received 34 Viet Cong mortar rounds and sustained some equipment damage but no casualties. The unit history did not refer to the veteran or, save for the references described above, the transportation detachments to which he had been assigned. Analysis There has been a change in the law during the pendency of this appeal, and we first turn briefly to that change. The Veterans Claims Assistance Act of 2000 (VCAA) was enacted on November 9, 2000. 38 U.S.C. §§ 5100, 5102, 5103, 5103A, and 5107 (West Supp. 2001). VCAA eliminates the requirement for a well-grounded claim. 38 U.S.C.A. § 5107(a). It also identifies and describes duties on the part of VA to advise a claimant of the evidence needed to substantiate a claim and to help a claimant obtain that evidence. 38 U.S.C.A. §§ 5103, 5103A. All claims filed on or after November 9, 2000, or filed before that date but not final by that date, are subject to VCAA. Veterans Claims Assistance Act of 2000, Pub. L. No. 106-475, § 7(a), 114 Stat. 2099 (2000); 38 U.S.C.A. § 5107, Historical and Statutory Notes (Effective and Applicability Provisions). The duties to notify and assist claimants have been implemented by a new regulation. Duty to Assist, 66 Fed. Reg. 45620, 45630-2 (Aug. 29, 2001) (to be codified at 38 C.F.R. § 3.159). Before proceeding to the evidence, it is appropriate to review the record for VA compliance with VCAA. In addition to the June 1997 decision, the RO sent the veteran an August 1998 Statement of the Case (SOC), and a December 2001 Supplemental Statement of the Case (SSOC), all of which set out the evidentiary shortcomings of the veteran's claims, while the SOC and the SSOC also set out the applicable law. In addition, the claim file includes the veteran's military personnel and medical records, VA treatment records and examination reports, treatment records and correspondence from health care providers the veteran identified, written statements from the veteran and some of his friends and relatives, the transcript of a June 1998 hearing attended by the veteran, his wife, and a friend, and archived information obtained by USASCRUR in support of the veteran's claim for service connection for PTSD. Finally, in a March 2002 letter, the RO advised the veteran that his case was being sent to the Board, and invited him to submit any additional evidence he had directly to the Board. In view of the foregoing, the Board finds that VA has satisfied the notice and duty-to-assist provisions of VCAA and 38 C.F.R. § 3.159, and we turn now to an analysis of the evidence and the applicable law. Service connection is granted for disability resulting from disease or injury incurred or aggravated in active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. To establish service connection, there must be evidence of an etiologic relationship between a current disability and events in service or an injury or disease incurred there. Cuevas v. Principi, 3 Vet. App. 542, 548 (1992), citing Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992). Here, the veteran has claimed service connection for PTSD, and he has submitted a report from Rosalyn Harris-Offutt, BS, CRNA, LPC, ADS, reflecting a diagnosis of PTSD. However, other reports in the file, one from Thomas Holm, PhD, and another from a VA psychiatrist, indicate that he does not have PTSD. It is the responsibility of the Board to weigh the evidence, including the medical evidence, and determine where to give credit and where to withhold the same. Evans v. West, 12 Vet. App. 22, 30 (1998), citing Owens v. Brown, 7 Vet. App. 429, 433 (1995). In so doing, the Board may accept one medical opinion and reject others. Id. At the same time, we are mindful that we cannot make our own independent medical determinations, and that we must have plausible reasons, based upon medical evidence in the record, for favoring one medical opinion over another. Evans, supra; Rucker v. Brown, 10 Vet. App. 67, 74 (1997), citing Colvin v. Derwinski, 1 Vet. App. 171 (1991). Thus, we must determine the weight to be accorded the various items of evidence in this case. With regard to medical evidence, a diagnosis or opinion by a health care professional is not conclusive and is not entitled to absolute deference. Indeed, the Court of Appeals for Veterans Claims (Court) has provided guidance for weighing medical evidence. The Court has held, for example, that a postservice reference to injuries sustained in service, without a review of service medical records, is not competent medical evidence. Grover v. West, 12 Vet. App. 109, 112 (1999). Further, a bare conclusion, even one reached by a health care professional, is not probative unless there is a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). A bare transcription of lay history, unenhanced by additional comment by the transcriber, is not competent medical evidence merely because the transcriber was a health care professional. LeShore v. Brown, 8 Vet. App. 406, 409 (1995). Moreover, a medical professional is not competent to opine as to matters outside the scope of his expertise. Id. citing Layno v. Brown, 6 Vet. App. 465, 469 (1994). A medical opinion based on speculation, without supporting clinical data or other rationale, does not provide the required degree of medical certainty. Bloom v. West, 12 Vet. App. 185, 187 (1999). Indeed, a medical opinion is inadequate if not supported by clinical evidence. Black v. Brown, 5 Vet. App. 177, 180 (1995). Finally, a medical opinion based on an inaccurate factual premise is not probative. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). In sum, the weight to be accorded the various items of medical evidence in this case must be determined by the quality of the evidence and not necessarily by its quantity or source. In order to weigh the evidence in this case, it is first necessary to determine the standard, or criteria, against which it should be measured. The regulatory criteria for service connection for PTSD are set forth in 38 C.F.R. § 3.304(f) while the diagnostic criteria are listed in the applicable edition of the American Psychiatric Association's Diagnostic and Statistical Manual (DSM). However, there have been changes in the applicable regulatory and diagnostic criteria and a chronological review of those changes, together with the relevant procedural events in this case, is in order. Regulatory criteria for service connection for PTSD were established when section 3.304(f) was added to title 38 of the Code of Federal Regulations. 58 Fed. Reg. 29109 (May 19, 1993). The criteria were: a clear diagnosis of PTSD, credible supporting evidence that claimed stressor events actually occurred, and medical evidence linking the traumatic events in service to the current disability. The diagnostic criteria were set out, actually listed, in the VA Adjudication Procedure Manual, M21-1, Part VI, chapter 7, paragraph 7.46, and were taken from the revised third edition of the DSM (DSM-III-R). Related regulatory criteria were 38 C.F.R. §§ 4.125 and 4.126. Section 4.125, entitled general considerations, provided that nomenclature relating to mental disorders used in VA regulations came from the third edition of the DSM (DSM-III). Section 4.126, entitled substantiation of diagnoses, provided that diagnoses must be made in accord with the DSM and must be supported by findings on examination; if either of those standards was not met, the RO was to return the report to the examiner for substantiation. On August 26, 1996, M21-1, Part VI, was amended by deleting paragraph 7.46 and adding chapter 11. In the new chapter 11, paragraph 11.38(a) merely prescribed DSM-III-R as the source for PTSD diagnostic criteria without actually listing the criteria as the deleted paragraph 7.46 had done. In 1995, VA proposed rules to revise relevant sections of part 4 of title 38 of the Code of Federal Regulations. 60 Fed. Reg. 54,825 (Oct. 26, 1995). On November 7, 1996, a final rule was adopted that, among other things, amended 38 C.F.R. § 4.125(a) to prescribe the fourth edition of the DSM (DSM- IV) as the source for diagnostic criteria for all mental disorders including PTSD. 61 Fed. Reg. 52695 (Oct. 8, 1996). On February 13, 1997, M21-1, Part VI, chapter 11, was amended to also prescribe DSM-IV as the source for PTSD diagnostic criteria. On March 7, 1997, the Court issued a decision in Cohen v. Brown, 10 Vet. App. 129 (1997). There the Court asserted that, in spite of the reference to DSM-IV in the amendment to 38 C.F.R. § 4.125, neither M21-1 nor 38 C.F.R. § 3.304(f) had been amended to establish DSM-IV as the source for PTSD diagnostic criteria. Thus, it appears that the Court was unaware of the February 13 amendment to M21-1 that established DSM-IV as the source for PTSD diagnostic criteria. In any event, the Court in Cohen held that both DSM-III-R and DSM-IV were in effect during the pendency of that veteran's claim, and the set of regulatory and diagnostic criteria most favorable to the claim was applicable. Cohen at 138-9; Karnas v. Derwinski, 1 Vet. App. 308, 312-3 (1991). What was thought by the Court in Cohen to have been a defect, i.e., the reference to DSM-IV in section 4.125 and the absence of a concomitant reference in section 3.304(f), was corrected by an amendment that required that PTSD diagnoses be made in accord with 38 C.F.R. § 4.125. 64 Fed. Reg. 32807 (Jun. 18, 1999). The effective date of the amendment was March 7, 1997, the date of the Cohen decision. The veteran's claim for service connection for PTSD was received in June 1996. Thus, the regulatory criteria of the amended and the unamended versions of 38 C.F.R. § 3.304(f) must be applied to determine which is most favorable. The unamended version of 38 C.F.R. § 3.304(f) provided, in pertinent part, as follows: Service connection for post-traumatic stress disorder 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. If the claimed stressor is related to combat, service department evidence that the veteran engaged in combat or that the veteran was awarded the Purple Heart, Combat Infantryman Badge, or similar combat citation will be accepted, in the absence of evidence to the contrary, as conclusive evidence of the claimed inservice stressor. The amended version of the regulation provides, in pertinent part, as follows: Service connection for post-traumatic stress disorder requires medical evidence diagnosing the condition in accordance with Sec. 4.125(a) of this chapter; 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. If the evidence establishes that the veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. There are several differences between the unamended and the amended versions of 38 C.F.R. § 3.304(f). First, the amended version adopts, albeit indirectly, DSM-IV as the source for PTSD diagnostic criteria while the unamended version does not, by its terms, prescribe a source. As noted above, under the unamended version of the regulation, the diagnostic criteria for PTSD are found in DSM-III-R. Second, the unamended version of the regulation requires a "clear" diagnosis of PTSD while the word "clear" was omitted from the amended version. With regard to the use of the word "clear" in the unamended version, the Court has said that the word was not defined in the regulation but held that it required, at a minimum, that a diagnosis be an "unequivocal" one. Cohen at 139. The amended version of the regulation refers to 38 C.F.R. § 4.125(a) which provides: If the diagnosis of a mental disorder does not conform to DSM-IV or is not supported by the findings on the examination report, the rating agency shall return the report to the examiner to substantiate the diagnosis. Though the word "clear" is omitted from the amended version of the regulation, the Board is unwilling, in light of 38 C.F.R. § 4.125(a), to conclude that an equivocal diagnosis would be acceptable. Tirpak v. Derwinski, 2 Vet. App. 609 (1992). Finally, in both the unamended and amended versions of the regulation, evidence that the veteran engaged in combat with the enemy will generally suffice, if there is no evidence to the contrary and the claimed stressor is related to combat, to establish that the claimed stressor occurred. The difference, in this regard, between the unamended and the amended versions of the regulation, is the nature of the evidence needed to show that the veteran engaged in combat with the enemy. Under the unamended version of the regulation, the veteran must be shown to have received an award or decoration indicative of combat with the enemy, or other service department evidence is required to make that showing. The amended version of the regulation is not so limited. Under the amended version, the determination as to whether the veteran engaged in combat with the enemy must be based on all the evidence of record and not just service department evidence or awards and decorations. Cohen at 142- 3; Dizoglio v. Brown, 9 Vet. App. 163 (1996); see, also, VAOPGCPREC 12-99 (Oct. 18, 1999) (addressing the phrase "engaged in combat with the enemy" as used in 38 U.S.C.A. § 1154(b)). In addition, if the veteran engaged in combat with the enemy, the standard for evidence deemed to disprove the claim that the stressor occurred is, in the unamended version, "evidence to the contrary" while, in the amended version, the standard is "clear and convincing evidence to the contrary," seemingly a more stringent standard. As for the diagnostic criteria, we first turn our attention to DSM-III-R, which is linked to the unamended version of 38 C.F.R. § 3.304(f), and the description of PTSD found there: The person has experienced an event that is outside the range of usual human experience and that would be markedly distressing to almost anyone, e.g., serious threat to one's life or physical integrity; serious threat or harm to one's children, spouse, or other close relatives and friends; sudden destruction of one's home or community; or seeing another person who has recently been, or is being, seriously injured or killed as the result of an accident or physical violence. AMERICAN PSYCHIATRIC ASSOCIATION, DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS 250 (3rd ed. rev. 1987). In DSM-IV, which is linked to the amended version of 38 C.F.R. § 3.304(f), PTSD is described as follows: The person has been exposed to a traumatic event in which he experienced, witnessed, or was confronted with actual or threatened death or serious injury, or a threat to the physical integrity of self or others and his response to the event involved intense fear, horror, or helplessness. AMERICAN PSYCHIATRIC ASSOCIATION, DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS 424 (4th ed. 1994). In addition to a description of PTSD, each edition of the DSM provides diagnostic criteria for the disorder. In DSM-IV, the diagnostic criteria are: (1) the person was exposed to a traumatic event; (2) the traumatic event is persistently reexperienced; (3) there is persistent avoidance of stimuli associated with the traumatic event and numbing of general responsiveness; (4) there are persistent symptoms of increased arousal not present before the traumatic event; (5) the duration of symptoms is more than one month; (6) the symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. AMERICAN PSYCHIATRIC ASSOCIATION, DIAGNOSTIC AND STATISTICAL MANUAL 427-9 (4th ed. 1994). The diagnostic criteria in DSM-III-R are substantially similar. However, the third criterion uses the disjunctive rather than the conjunctive. Further, the sixth criterion is omitted though the discussion in the accompanying text refers to functional impairment. Finally, there are some minor differences in possible manifestations of the disorder. See AMERICAN PSYCHIATRIC ASSOCIATION, DIAGNOSTIC AND STATISTICAL MANUAL 250- 1 (3rd ed. rev. 1987). We find that, except for the difference between the descriptions of PTSD, there is no significant difference between the diagnostic criteria of DSM-III-R and those of DSM-IV. A question arises as to the manner in which stressor events should be assessed and who it is that should make the assessment. In addressing that question, the Court said: [A] clear (that is, unequivocal) PTSD diagnosis by a mental-health professional must be presumed (unless evidence shows to the contrary) to have been made in accordance with the applicable DSM criteria as to both the adequacy of the symptomatology and the sufficiency of the stressor. Mental health professionals are experts and are presumed to know the DSM requirements applicable to their practice and to have taken them into account in providing a PTSD diagnosis. (Emphasis added.) Cohen at 140. Thus, the Court specifically provided that, where there is an unequivocal diagnosis of PTSD by a mental- health professional, it is presumed, unless evidence shows to the contrary, that the inservice stressor events were outside the range of usual human experience (DSM-III-R) or included an event in which the veteran experienced, witnessed, or was confronted with actual or threatened death or serious injury or a threat to the physical integrity of self or others (DSM- IV). However, before turning to the medical evidence here, we first consider the matter of whether the veteran engaged in combat with the enemy for, if he did, and if his claimed stressor events are related to combat, his word alone will establish their occurrence. If he did not, or if his claimed stressor events are not related to combat, then credible supporting evidence is needed to establish their occurrence. 38 C.F.R. § 3.304(f). The Court, in addressing the term "combat" and evidence that establishes it, has noted that service in a combat zone is stressful, to some degree, for everyone there regardless of their duties and experiences. Wood v. Derwinski, 1 Vet. App. 190, 192-3 (1991), reconsideration den., 1 Vet. App. 406 (1991). So evidence of mere service in a combat zone, in and of itself, will not support a diagnosis of PTSD. Zarycki v. Brown, 6 Vet. App. 91, 98-9 (1993). Combat, as the term is used in 38 C.F.R. § 3.304(f), means to fight in battle. WEBSTER'S II NEW COLLEGE DICTIONARY 223 (1995). The phrase "'engaged in combat with the enemy' requires that the veteran have personally participated in events constituting an actual fight or encounter with a military foe or hostile unit or instrumentality." (Emphasis added.) VAOPGCPREC 12- 99 (Oct. 18, 1999). Accordingly, in order to find that the veteran engaged in combat with the enemy, we look for evidence that he participated, in some meaningful way, in an actual confrontation with enemy forces. The veteran has not specifically contended that he engaged in combat with the enemy. Indeed, he told Dr. Holm that he was a helicopter mechanic, a report confirmed by his service personnel records, and that he had "limited combat exposure." At the March 1997 VA psychiatric examination, he told the doctor he had been a door gunner, but that claim is not credible in view of the facts that that duty was not reflected in his service personnel records, that the History of the 121st Aviation Company showed door-gunner platoons detailed to support it, and that the veteran never made the claim previously nor did he repeat it. He has referred to sniper fire and mortar attacks, but he has not said that he was a sniper target or that he was endangered by a mortar attack. Moreover, the recipient of incoming fire on an otherwise secure installation is merely a passive participant and, as such, has not "confronted" an enemy force so it could be said that he engaged in combat with the enemy. Accordingly, we find that the veteran did not engage in combat with the enemy, and service connection for PTSD cannot be granted here in the absence of credible supporting evidence that claimed inservice stressor events actually occurred. Cohen at 142; Moreau v. Brown, 9 Vet. App. 389, 394-5 (1996); 38 C.F.R. § 3.304(f). Having found that the veteran did not engage in combat with the enemy, we must next determine whether he has identified stressor events he experienced in service and, if he has, whether there is credible supporting evidence of such events. He said he had seen body bags, but did not suggest that he was in any way involved with them or their contents, and there is no credible supporting evidence of even that report. In his September 1996 reply to the RO query regarding stressor events in service, he reported two Viet Cong mortar attacks at Soc Trang in May 1964. The information provided by USASCRUR indicated that the 121st Aviation Company sustained a mortar attack on April 10, 1964, but there were no injuries, and the information did not indicate that the veteran was involved in the attack in any way. He also said that, on two occasions, he had "routine guard duty at POL and ammo dump," but did not indicate how such duty constituted a stressor event. In his August 1998 Substantive Appeal, he took issue with the RO finding that he had not experienced a stressor event in service and said: How about being surrounded by concertina wire, minefields, innumerable enemies even in your own ranks, stranded on an American island in a sea of chaos, filth, and death, being shot at, mortared, the angel of death constantly hovering over you, your food covered with bugs, constantly attacked by mosquitoes, hot and wet or hot and dry, never getting close to anyone because they'll leave you anyway by bird or angel, . . . . In other words, the veteran's duties involved no more than the ordinary stressful environment experienced by all those who serve in a combat zone. See Hayes v. Brown, 5 Vet. App. 60 (1993). We find, therefore, little credible supporting evidence that the veteran experienced a stressor event in service. We turn now to the PTSD diagnosis by Rosalyn Harris-Offutt, BS, CRNA, LPC, ADS, the evaluation by Thomas Holm, PhD, and the examination by the VA psychiatrist. It is clear from Dr. Holm's report that his evaluation was extensive. He administered psychological tests and, in his interview, delved into the veteran's childhood, his education, his military service, his employment, and his family. He said the veteran demonstrated some features of PTSD, but he did not note a stressor event that met the DSM criteria, and he did not find a persistent avoidance of stimuli associated with traumatic events or a numbing of general responsiveness. He felt that a diagnosis of PTSD was not warranted. On the other hand, Rosalyn Harris-Offutt did diagnose PTSD, and we presume that a PTSD diagnosis by a mental health professional was made in accord with the DSM unless evidence shows to the contrary. Cohen at 140. Here, we find that the presumption is rebutted by evidence that Rosalyn Harris-Offutt failed to give any consideration whatever to the DSM criterion for a stressor event. That is, she failed to identify even one single stressor event upon which she relied for her diagnosis. Thus, her diagnostic conclusion is not supported by clinical findings. Black, supra. Moreover, it is not entirely clear that the diagnosis, as opposed to the treatment, of mental disorders is within the scope of her expertise as a Licensed Professional Counselor. LeShore, Layno, supra. It seems unlikely that her training as a Certified Registered Nurse would provide her with the requisite expertise, and we are unable to find an explanation, at least one that seems to apply, for the abbreviation "ADS." Accordingly, we find the opinion of Dr. Holm credible, and worthy of considerable weight, while that of Ms. Harris-Offutt is neither. In sum, there is no credible supporting evidence that the veteran experienced a stressor event in service, and no credible medical evidence that he has PTSD. In the absence of such evidence, service connection for PTSD is not warranted. 38 C.F.R. § 3.304(f). Turning now to the issues of service connection for malaria and for a skin disorder, a May 1965 RO decision denied service connection for a skin disorder and a November 1982 RO decision denied service connection for malaria. The veteran was notified of those decisions and advised of his right to appeal them. 38 U.S.C.A. § 5104; 38 C.F.R. § 3.103(f). He did not appeal the decisions within one year of notification thereof, and they became final. 38 U.S.C.A. § 7105(c); 38 C.F.R. § 20.302, 20.1103. Final VA decisions are not subject to revision on the same factual basis. 38 U.S.C.A. § 7105(c); 38 C.F.R. § 3.104(a). In order to reopen the claims, the veteran must present new and material evidence with respect thereto. 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156(a). "New and material evidence" is evidence not previously reviewed by VA adjudicators, that is neither cumulative nor redundant, that bears directly and substantially upon the specific matter under consideration, and that, 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. Hodge v. West, 155 F.3d 1356 (Fed. Cir. 1998); 38 C.F.R. § 3.156(a). Subsequent to the Hodge decision, the Court announced a three-step process for reviewing applications to reopen claims previously and finally denied. First, VA adjudicators were to determine whether new and material evidence, as defined by 38 C.F.R. § 3.156(a), had been received; second, if new and material evidence had been received, adjudicators were to determine whether, based upon all the evidence and presuming its credibility, the claim was well grounded; and third, if the claim was well grounded and the duty to assist had been fulfilled, adjudicators were to evaluate the merits of the claim. Elkins v. West, 12 Vet. App. 209 (1999) (en banc); Winters v. West, 12 Vet. App. 203 (1999) (en banc), vacated on other grounds sub nom. Winters v. Gober, 219 F.3d 1375 (Fed. Cir. 2000). As indicated above, VCAA eliminated the second step of the Elkins review, the well-grounded requirement, so the application to reopen the claims depends only on whether, since the May 1965 or November 1982 RO decisions, new and material evidence has been received upon which to do so. The veteran's claim for service connection for a skin disorder was denied in 1965 because his service medical records did not reflect a skin disorder and because medical evidence did not relate light-sensitive dermatitis or possible dermatitis externa, the skin disorder diagnosed in May 1965, to his military service. Cuevas, Rabideau, supra. We digress briefly to note that, while the veteran's June 1996 letter primarily asserted that he had a skin disorder caused by Agent Orange, a claim addressed below, he also contended there, and on several occasions since, that he had been treated for a skin disorder in service and currently has the same skin disorder. Those contentions go to the basis of the 1965 denial of service connection, and we view them as an effort to reopen that claim. See Livesay v. Principi, 15 Vet. App. 165, 170-1 (2001) (remanded for Board to assess communications from appellant and to provide a statement of reasons and bases for not construing those communications as attempts to reopen a claim previously denied). We cannot conclude our digression without noting that this issue of service connection for a skin disorder was not addressed by the RO since 1965, and we must consider whether the veteran would be prejudiced by our doing so now. Bernard v. Brown, 4 Vet. App. 384, 392-4 (1993) (held, "when . . . the Board addresses in its decision a question that had not been addressed by the RO, it must consider whether the claimant has been given adequate notice of the need to submit evidence or argument on that question and an opportunity to submit such evidence and argument and to address that question at a hearing, and, if not, whether the claimant has been prejudiced thereby."); VAOPGCPREC 16-92 (Jul. 24, 1992). Thus, we must determine whether the veteran had adequate notice of the need to submit new and material evidence to reopen the claim for service connection for a skin disorder, and opportunity to argue the claim and, if he did not, whether he would be prejudiced if we address that issue. First, although neither the August 1998 SOC nor the December 2001 SSOC addressed the requirement for new and material evidence to reopen the claim for service connection for a skin disorder, the August 1998 SOC did explain the law regarding finality of VA decisions and the need for new and material evidence to reopen a claim after a final VA decision. The explanation was provided in connection with the veteran's claim for service connection for malaria, but the explanation would have been the same for the skin- disorder claim. Further, as the Court has said: It is axiomatic that claimants do not submit claims merely for the reopening of their previously and finally denied claims. Rather, they submit claims for VA benefits, which, in cases of previously and finally denied claims, implicate both the question of whether there is new and material evidence to reopen the claim and the question of whether, upon such reopening, the claimant is entitled to the requested benefits. Bernard, at 392. It would be folly to assume that the veteran would have submitted different evidence than that received had he known of the requirement for new and material evidence, and we commit no such folly. Rather, we find that he submitted, or the RO obtained, all the evidence pertinent to his claim of which he was aware. Accordingly, he will suffer no prejudice if we review that evidence for that which is new and material. See Jackson v. Gober, No. 99-366 (Vet. App. Jul. 25, 2000) (mem.), aff'd sub nom., Jackson v. Principi, 265 F.3d 1366, 1369-70 (Fed. Cir. 2001) (the Board must review all questions necessary to the decision in a matter regardless of the scope of review by the RO). Here, the veteran had no notice that the Board would address the issue of whether new and material evidence had been submitted to reopen the claim for service connection for a skin disorder. However, he submitted, or the RO obtained, all of the medical evidence pertaining to a skin disorder without regard to etiology, and the veteran has repeatedly argued, including at hearing, that he had a skin disorder in service. In this case, there is such a significant overlap between the issue of new and material evidence to reopen a claim for service connection for a skin disorder and the issue actually addressed by the RO, that of service connection for a skin disorder caused by Agent Orange exposure, that we are confident that no prejudice will accrue to the veteran by our addressing the claim denied in 1965. The 1965 claim was denied, in part, because the veteran's service medical records did not reflect complaints, diagnoses, or treatment of a skin disorder. Indeed, his skin was normal by clinical evaluation at his February 1965 separation examination. Further, he gave no history, at that examination, of a skin disorder during service. We see that history or, rather, the lack thereof, as significant in view of the fact that he did give a history of several other disorders indicating that he completed the form in a careful and thoughtful manner. In his June 1996 claim letter, the veteran contended that he was treated for a skin disorder in February 1965, but his service medical records for February 1965 show only his separation examination. At his June 1998 hearing, he testified that he was treated for a skin disorder in February 1964, but his service medical records for February 1964 show only vaccinations against plague and cholera. In sum, the 1965 claim was denied, in part, because there was no medical evidence that the veteran had a skin disorder in service, and the veteran recognized the lack of such evidence in his May 1982 letter. None of the evidence received since 1965 bears directly or substantially on that issue. That is, there is still no medical evidence in this record that the veteran had a skin disorder in service. The 1965 claim was also denied because there was no medical evidence linking a skin disorder diagnosed then as light- sensitive dermatitis, or possible dermatitis externa, to service. None of the evidence received since 1965 bears directly or substantially on that issue. That is, there is still no medical evidence in this record linking a current skin disorder to the veteran's military service. In sum, none of the evidence received since 1965 addresses the two evidentiary shortcomings in that old claim, i.e., lack of medical evidence of a skin disorder in service and lack of medical evidence relating any current skin disorder to service. Elkins, supra. That is, the veteran's service medical records, all of which are included in the file, still do not show that he was treated for a skin disorder in service notwithstanding his contentions to the contrary. Further, there is still no medical evidence in this record that relates any current skin disorder to his military service. Thus, in the absence of new evidence that bears directly and substantially upon those two issues, the claim for service connection for a skin disorder cannot be reopened. 38 U.S.C.A. § 5108; Elkins, supra; 38 C.F.R. §§ 3.104(a), 3.156(a), 20.1103 (2001). Service connection for malaria was denied in 1982 because the veteran's service medical records did not reflect it. In his May 1982 letter, he described "spells" manifested by headaches, dizziness, and musculoskeletal pain. In an August 1982 letter, he said he developed fever, shortness of breath, swollen joints, and pain in joints, muscles, head, and chest in 1968, that a relative gave him some malaria medication he had, and that the symptoms subsided. In a July 1997 letter, [redacted] said the veteran had "malaria syndrome," and he gave him some pills for it in 1967. In a May 1998 letter, the veteran's son-in-law said he had seen the veteran having "attacks of what I consider malaria." However, it has not been made to appear that either the veteran, Mr. [redacted], or the veteran's son-in-law, has any medical training or expertise that would qualify either of them to diagnose malaria. See Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992) (a layman is usually not competent to testify regarding matters requiring medical knowledge). At his June 1998 hearing, the veteran testified that, in May 1964, doctors told him he had malaria, but he was not treated for it then. However, a layman's statement of what a physician told him does not constitute medical evidence of diagnosis or etiology. Robinette v. Brown, 8 Vet. App. 69, 75-7 (1995). The veteran then testified that he had recurrences in August 1964 and January 1965, that he was treated for it on both those two occasions, and that the treatment in January 1965 included two injections per day. However, his service medical records show nothing in May or August 1964. They do show penicillin therapy for gonorrhea in June 1964, an infection he reported on the medical history he prepared for his February 1965 separation examination, and for inguinal adenopathy of unknown etiology in January 1965. In sum, the veteran's service medical records do not show that he had malaria in service, and none of the evidence received since the service-connection claim was denied in 1982 shows otherwise. In fact, there is no medical evidence in this record that he has, or ever has had, malaria. In the absence of such evidence, reopening of the 1982 claim for service connection for malaria is not warranted. Before turning to the claim of service connection for a skin disorder caused by Agent Orange exposure, we note that the RO denied such a claim in its 1982 decision. Generally, when a claim has been previously and finally denied, new and material evidence must be received to reopen it. 38 U.S.C.A. §§ 5108, 7105(c) (West 1991 & Supp.); 38 C.F.R. §§ 3.104(a), 3.156(a), 20.1103 (2001). That would entail the analytical process set forth above with regard to the claims for service connection for malaria and for a skin disorder. However, where a law creates a new basis for a benefit previously and finally denied, a claim made under the provisions of the new law is a new claim separate and distinct from the one previously and finally denied, and de Novo review of the evidence is required even though new and material evidence has not been received. Spencer v. Brown, 4 Vet. App. 283 (1993), aff'd 17 F.3d 368 (Fed. Cir. 1994). As will be seen below, Spencer is controlling here and, accordingly, the RO conducted, as will we, a de novo review of the evidence for the veteran's claim. In 1984, Congress passed the Veterans' Dioxin and Radiation Exposure Compensation Standards Act, Pub. L. 98-542, 98 Stat. 2725 (Oct. 24, 1984). The act has been codified at 38 U.S.C.A. § 1116 and amended several times since. It provides that, when a veteran who served in Vietnam between January 9, 1962, and May 7, 1975, develops one of several disorders to a degree of 10 percent or more and, in the case of some of the disorders, within a requisite period of time after exposure, that disorder is presumed to have been incurred in service. In addition, Congress delegated to the Secretary of Veterans Affairs the authority to add disorders to those listed in the act when sound medical and scientific evidence shows a positive association between such additional disorders and exposure to herbicides. 38 U.S.C.A. §§ 1116(a)(3), (a)(1)(B), (b)(1). The statute has been implemented by 38 C.F.R. §§ 3.307(a)(6) and 3.309(e). The disorders presumed to be caused by Agent Orange exposure are: chloracne or other acneform disease consistent with chloracne, Hodgkin's disease, multiple myeloma, non-Hodgkin's lymphoma, acute and subacute peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancers of the lung, bronchus, larynx, or trachea), and soft-tissue sarcomas other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma. Chloracne and porphyria cutanea tarda must become manifest to a degree of 10 percent or more within one year, and respiratory cancers within 30 years, after the last date of exposure. Acute and subacute peripheral neuropathy mean transient peripheral neuropathy that appears within weeks or months of exposure to an herbicide agent and resolves within two years of the date of onset. With regard to disorders added by the Secretary, service in Vietnam during the period prescribed created only a rebuttable presumption of exposure to herbicides, and affirmative evidence that the veteran was not exposed to herbicides while stationed in Vietnam would rebut the presumption. 38 U.S.C.A. § 1116(a)(3); 38 C.F.R. § 3.307(a)(6)(iii). Further, active service in Vietnam did not establish a presumption of exposure to herbicide unless the veteran developed a listed disorder. McCartt v. West, 12 Vet. App. 164, 168 (1999); 38 C.F.R. § 3.307(a)(6)(iii). McCartt was effectively overruled by the Veterans Education and Benefits Expansion Act of 2001, Pub. L. 107-103, 115 Stat. 976 (Dec. 27, 2001), which amended section 1116 to add diabetes mellitus type II, to remove the 30-year limitation on respiratory cancers, and to establish a presumption that Vietnam veterans were exposed to herbicide agents. In this case, the veteran has not been diagnosed with any of the disorders presumed to have been caused by Agent Orange exposure, and service connection on a presumtive basis is not warranted. However, since regulations on presumptive service connection do not operate to exclude the traditional approach to service connection claims, service connection may be established by medical evidence that he has a disorder caused by Agent Orange exposure. 38 U.S.C.A. § 1110; Combee v. Brown, 34 F.3d 1039, 1043-5 (Fed. Cir. 1994); Ramey v. Brown, 9 Vet. App. 40, 44 (1996), aff'd sub nom. Ramey v. Gober, 120 F.3d 1239 (Fed. Cir. 1997), cert. denied, 118 S. Ct. 1171 (1998); 38 C.F.R. § 3.303(d). However, there is no medical evidence in this record that the veteran has a disorder caused by Agent Orange exposure. ORDER New and material evidence has not been submitted to reopen a claim for service connection for a skin disorder, and the application to reopen the claim is denied. New and material evidence has not been submitted to reopen a claim for service connection for malaria, and the application to reopen the claim is denied. Service connection for a skin disorder due to Agent Orange exposure is denied. Service connection for PTSD is denied. LAWRENCE M. SULLIVAN Member, Board of Veterans' Appeals IMPORTANT NOTICE: We have attached a VA Form 4597 that tells you what steps to take if you disagree with our decision. We are in the process of updating the form to reflect changes in the law effective December 27, 2001. See the Veterans Education and Benefits Expansion Act of 2001, Pub. L. No. 107-103, 115 Stat. 976 (2001). Meanwhile, please note these important corrections to the advice in the form: ? These changes apply to the section entitled "Appeal to the United States Court of Appeals for Veterans Claims." (1) A "Notice of Disagreement filed on or after November 18, 1988" is no longer required to appeal to the Court. (2) You are no longer required to file a copy of your Notice of Appeal with VA's General Counsel. ? In the section entitled "Representation before VA," filing a "Notice of Disagreement with respect to the claim on or after November 18, 1988" is no longer a condition for an attorney-at-law or a VA accredited agent to charge you a fee for representing you.