Citation Nr: 0810160 Decision Date: 03/27/08 Archive Date: 04/09/08 DOCKET NO. 06-09 583 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Whether new and material evidence has been submitted to reopen a claim for entitlement to service connection for a back disability. 2. Whether new and material evidence has been submitted to reopen a claim for entitlement to service connection for residuals of a laceration to the left thigh. 3. Whether new and material evidence has been submitted to reopen a claim for entitlement to service connection for hypertension with a heart disability. 4. Entitlement to service connection for headaches. 5. Entitlement to service connection for PTSD. 6. Entitlement to an increased (compensable) rating for hemorrhoids. 7. Entitlement to an increased (compensable) rating for epidermophytosis interdigitalis pedis. 8. Entitlement to a total disability rating due to individual employability resulting from service-connected disability (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD M. Riley, Associate Counsel INTRODUCTION The veteran served on active duty from September 1972 to October 1975. This case comes before the Board of Veterans' Appeals (Board) on appeal from a May 2004 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina. Where there is a prior Board decision denying a claim, the Board must initially determine whether new and material evidence has been submitted, regardless of actions by the agency of original jurisdiction. Barnett v. Brown, 83 F.3d 1380, 1384 (Fed. Cir. 1996); Butler v. Brown, 9 Vet. App. 167, 171 (1996). Thus, the Board must make an independent determination as to whether new and material evidence has been presented to reopen the claims of entitlement to service connection for a back disability, residuals of a laceration of the left thigh, and hypertension before reaching the merits of the service connection claims. In September 2007, subsequent to issuance of the statement of the case (SOC), the veteran submitted evidence pertinent to the claims on appeal. This evidence was accompanied by a waiver of RO and VAMC consideration. Thus, the Board will consider the claims on the merits. See 38 C.F.R. § 20.1304 (2007). The issues of entitlement to TDIU, increased ratings for hemorrhoids and epidermophytosis interdigitalis pedis, and service connection for a psychiatric disability to include PTSD, and headaches are remanded to the RO via VA's Appeals Management Center and are addressed in the remand that follows the order section of this decision. FINDINGS OF FACT 1. Service connection for a low back condition was denied in an unappealed June 1976 rating decision. The veteran has made several attempts to reopen his claim for service connection for a low back disorder and was most recently denied in an April 1998 Board decision. 2. The evidence received since the April 1998 Board decision includes evidence that is cumulative or redundant of the evidence previously of record or does not raise a reasonable possibility of substantiating the claim. 3. Service connection for residuals of a laceration to the left thigh was denied in an unappealed June 1976 rating decision. The veteran has made several attempts to reopen his claim for service connection for this condition and was most recently denied in an April 1998 Board decision. 4. The evidence received since the April 1998 Board decision includes evidence that is cumulative or redundant of the evidence previously of record or does not raise a reasonable possibility of substantiating the claim. 5. Service connection for cardiovascular disease, to include essential hypertension, was denied in an October 1995 Board decision. 6. The evidence received since the October 1995 Board decision includes evidence that is cumulative or redundant of the evidence previously of record or does not raise a reasonable possibility of substantiating the claim. 7. A current headache disorder is not related to active duty. CONCLUSIONS OF LAW 1. New and material evidence has not been received to reopen a claim seeking service connection for a low back disability. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156(a) (2007). 2. New and material evidence has not been received to reopen a claim seeking service connection for residuals of a laceration to the left thigh. 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156(a). 3. New and material evidence has not been received to reopen a claim seeking service connection for hypertension with a heart disability. 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156(a). 4. Service connection for headaches is not warranted. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Veterans Claims Assistance Act of 2000 The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2007) redefined VA's duty to assist the veteran in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2007). Under the VCAA, VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must request that the claimant provide any evidence in his possession that pertains to the claim. Pelegrini v. Principi (Pelegrini II), 18 Vet. App. 112, 120-21 (2004), see 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). In letters issued in October 2003 and January 2004, prior to the initial adjudication of the claims, the RO notified the veteran of the evidence needed to substantiate his claims to reopen and claim for entitlement to service connection for PTSD. The letter also satisfied the second and third elements of the duty to notify by informing the veteran that VA would try to obtain medical records, employment records, or records held by other Federal agencies, but that he was nevertheless responsible for providing any necessary releases and enough information about the records to enable VA to request them from the person or agency that had them. With respect to the fourth element of VCAA notice, although the RO did not specifically request that the appellant submit all pertinent evidence in his possession, it did inform him of the evidence that would be pertinent and requested him to submit such evidence or provide VA with the information and authorization necessary for VA to obtain the evidence on the veteran's behalf. These statements served to advise the veteran to submit any evidence in his possession pertinent to the claims on appeal. During the pendency of this appeal, the Court issued a decision which held that, in the context of a claim to reopen, VCAA notice must include an explanation of 1) the evidence and information necessary to establish entitlement to the underlying claim for the benefit sought; and 2) what constitutes new and material evidence to reopen the claim as determined by the evidence of record at the time of the previous final denial. Kent v. Nicholson, 20 Vet. App. 1, (2006). The Court further explained that a notice letter must describe what evidence would be necessary to substantiate the element or elements required to establish the underlying claim that were found insufficient in the previous denial. The October 2003 letter informed the veteran of the appropriate definitions of new and material evidence. In addition, the May 2004 rating decision on appeal informed the veteran that his claims for service connection for residuals of a left thigh laceration, low back disorder, and hypertension were previously denied because the medical evidence of record did not show that these conditions were incurred during active duty service. Therefore, the veteran was provided the notice required by the Kent decision. The United States Court of Appeals for Veterans Claims (Court) has also held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) veteran status; 2) existence of a disability; 3) a connection between the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The veteran has substantiated his status as a veteran and was notified of the second and third elements of the Dingess notice by the October 2003 and January 2004 letters. While he has not received specific information regarding the disability rating and effective date elements of his claims, as the claims are being denied no disability ratings or effective dates will be assigned. Therefore, the veteran is not prejudiced by the delayed notice on these elements. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993) (where the Board addresses a question that has not been addressed by the agency of original jurisdiction, the Board must consider whether the veteran has been prejudiced thereby). The Duty to Assist The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). VA has obtained records of treatment reported by the veteran, including service treatment records, records from various federal agencies, and private medical records. The Board acknowledges that the veteran has not been afforded a VA examination in response to his claim for entitlement to service connection for headaches. Under the VCAA, VA is obliged to provide an examination when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability, the record indicates that the disability or signs and symptoms of disability may be associated with active service; and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C.A. § 5103A(d) (West 2002); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The evidence of a link between current disability and service must be competent. Wells v. Principi, 326 F.3d 1381 (Fed. Cir. 2003). The veteran's reports of a constinuity of symptomatology can satisfy the requirement for evidence that the claimed disability may be related to service. McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). The threshold for finding a link between current disability and service is low. Locklear v. Nicholson, 20 Vet. App. 410 (2006); McLendon v. Nicholson, at 83. The veteran has not reported a continuity of headache symptomatology since service. The record contains no clinical findings of headaches prior to 1991, approximately 16 years after service. There is no competent opinion linking a current headache disorder to service. Because there is no competent evidence that a current disorder may be related to service, an examination is not required. For the reasons set forth above, the Board finds that VA has complied with the VCAA's notification and assistance requirements. The appeal is thus ready to be considered on the merits. III. Service Connection Claims General Legal Criteria Service connection will be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110. Service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. § 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table); see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden/Caluza element is through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Savage 10 Vet. App. 488, 495-97 (1997); see also Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post- service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage, 10 Vet. App. at 495-96; see Hickson, 12 Vet. App. at 253 (lay evidence of in-service incurrence sufficient in some circumstances for purposes of establishing service connection); 38 C.F.R. § 3.303(b). Lay persons are not competent to opine as to medical etiology or render medical opinions. Barr v. Nicholson; see Grover v. West, 12 Vet. App. 109, 112 (1999); Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). Lay testimony is competent, however, to establish the presence of observable symptomatology and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Falzone v. Brown, 8 Vet. App. 398, 405 (1995) (lay person competent to testify to pain and visible flatness of his feet); Espiritu, 2 Vet. App. at 494- 95 (lay person may provide eyewitness account of medical symptoms). "Symptoms, not treatment, are the essence of any evidence of continuity of symptomatology." Savage, 10 Vet. App. at 496 (citing Wilson v. Derwinski, 2 Vet. App. 16, 19 (1991). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno, supra (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2007). Additionally, for veteran's who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, such as psychoses, are presumed to have been incurred in service if such manifested to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307(a), 3.309(a). With chronic diseases shown as such in service, or within the presumptive period after service, so as to permit a finding of service connection, subsequent manifestation of the same chronic disease at any later date, however remote, are service connected unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b) (2007). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (West 2002); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). II. Claims to Reopen Generally, a claim which has been denied in an unappealed rating or Board decision may not thereafter be reopened and allowed. 38 U.S.C.A. §§ 7104(b), 7105(c) (West 2002). 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 evidence is defined as existing evidence not previously submitted to agency decisionmakers. Material evidence means evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence previously of record, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). In determining whether evidence is new and material, the credibility of the evidence is generally presumed. Justus v. Principi, 3 Vet. App. 510, 512-513 (1992). In deciding whether new and material evidence has been submitted the Board looks to the evidence submitted since the last final denial of the claim on any basis. Evans v. Brown, 9 Vet. App. 273, 285 (1996). B. Degenerative Disc Disease Lumbar Spine The veteran was initially denied entitlement to service connection for a low back disability in a June 1976 rating decision based on the RO's determination that neither the veteran's service treatment records nor a March 1976 VA examination report contained medical evidence of a current low back disability. On VA examination in December 1997, the veteran was found to have mechanical low back pain and spondylolysis (meaning a fracture of the pars at L5), which had been stable for 25 years, but which could cause spondylolisthesis. The veteran made several attempts to reopen his claim, and was most recently denied in an April 1998 Board decision. The Board noted that while the record contained evidence that the veteran had a current low back disability, there was no evidence showing that this condition was incurred during active duty service. The evidence was not considered material as it did not raise a reasonable possibility of a change in the prior adverse outcome. The veteran's current claim to reopen was received in September 2002. The medical evidence added to the record since the April 1998 denial includes private medical records and outpatient treatment records from the VAMC. The veteran was provided a lumbar spine MRI in September 2002 that found degenerative disc disease and mild annular bulging. In addition, a diagnosis of lumbar radiculitis was made in July 2003. This evidence is cumulative in that it shows ongoing treatment for the previously identified low back condition. While this evidence pertains to a necessary element for service connection, namely a current disability, that element was previously established. The evidence does not relate to a previously unestablished element needed to substantiate the claim, i.e., evidence that the disability was etiologically related to the veteran's active duty service. Thus, the evidence is not material as it is not sufficient to establish a reasonable possibility of substantiating the claim. While the veteran's statements have been added to the record, they are duplicative of previous arguments and are also insufficient to establish a reasonable possibility of substantiating the claim. While the veteran is competent to describe his symptoms and state when they began, as a lay person he is not competent to render a medical diagnosis or an opinion concerning medical causation. Therefore, his statements regarding the etiology of his low back are neither new, nor material. See Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992); Moray v. Brown, 5 Vet. App. 211, 214 (1993). Accordingly, reopening of the claim is not in order. C. Laceration of the Left Thigh The veteran was initially denied entitlement to service connection for residuals of a left thigh laceration in a June 1976 rating decision based on the RO's determination that the veteran's left thigh laceration occurred prior to his entrance into active duty service. Service treatment records show that on examination for entrance into service, he was noted to have a healed scar of the left thigh. The Medical Evaluation Board found him to be unfit for service due to an old laceration injury of the left thigh with scarring involving the skin, muscle and nerves. The March 1976 VA examination report indicates that the veteran complained of acne in the scar during service. On examination the scar was described as asymptomatic and no disability was found. The examiner concluded that there were no residuals of the laceration aside from a well-healed scar. The veteran made several attempts to reopen his claim, and was most recently denied in an April 1998 Board decision. At that time, the Board noted that the medical evidence of record, including records of outpatient treatment at the VAMC, did not include evidence of structural, vascular, or muscular damage to the left thigh. These additional medical records were not considered material as they were cumulative of evidence previously of record and did not establish that the veteran's residuals of a left thigh laceration were permanently aggravated during active duty service. The veteran's current claim to reopen was received in September 2002. The medical evidence added to the record since the April 1998 Board decision includes additional clinical records from the VAMC and private treatment records. While the veteran complained of left leg pain to his private doctor in September 2001 and February 2003, no diagnosis with respect to the leg or thigh was rendered. VAMC treatment records show no treatment for residuals from the veteran's left thigh laceration. This evidence is clearly not new and material as it does not establish that the veteran's pre- existing condition was permanently aggravated as a result of his active duty service. Similarly, the veteran's statements are duplicative of previous arguments and are also insufficient to establish a reasonable possibility of substantiating the claim. As noted above, the veteran is competent to describe his symptoms and state when they began, but as a lay person he is not competent to render a medical diagnosis or an opinion concerning medical causation. Therefore, his statements regarding the aggravation during service of his residuals of a left thigh laceration are neither new, nor material. See Espiritu, 2 Vet. App. 492, 494 (1992); Moray, 5 Vet. App. 211, 214 (1993). Accordingly, reopening of the claim is not in order. D. Hypertension with Heart Disability The veteran was denied entitlement to service connection for cardiovascular disease, to include essential hypertension, in an October 1995 Board decision. The Board determined that the evidence of record, including service treatment records, outpatient VA treatment records, a March 1976 VA examination, and the transcript of a December 1991 hearing, did not establish that the veteran had cardiovascular disease or hypertension during service or within a year after his separation from active duty and there was no other evidence of a nexus between the current disability and service. The veteran's current claim to reopen was received in September 2002. The medical evidence added to the record since the October 1995 Board decision includes additional clinical records from the VAMC and private treatment records. While the veteran has continued to receive treatment for hypertension, there remains no competent evidence of a nexus between his current disability and his active duty service, or evidence that hypertension manifested in service or within a year of discharge. Therefore, the evidence is clearly not new and material as it does not establish that the veteran's disability is etiologically related to active duty service. As noted above, the veteran is competent to describe his symptoms and state when they began, but as a lay person he is not competent to render a medical diagnosis or an opinion concerning medical causation. Therefore, his statements regarding the cause of his disability are neither new, nor material. See Espiritu, 2 Vet. App. 492, 494 (1992); Moray, 5 Vet. App. 211, 214 (1993). Accordingly, reopening of the claim is not in order. ORDER New and material evidence has not been submitted to reopen a claim for entitlement to service connection for a back disability. New and material evidence has not been submitted to reopen a claim for entitlement to service connection for residuals of a laceration to the left thigh. New and material evidence has not been submitted to reopen a claim for entitlement to service connection for hypertension with a heart disability. REMAND Under the VCAA, VA is obliged to provide an examination when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability, the record indicates that the disability or signs and symptoms of disability may be associated with active service; and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C.A. § 5103A(d) (West 2002); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The evidence of a link between current disability and service must be competent. Wells v. Principi, 326 F.3d 1381 (Fed. Cir. 2003). The veteran's reports of a constinuity of symptomatology can satisfy the requirement for evidence that the claimed disability may be related to service. McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). The threshold for finding a link between current disability and service is low. Locklear v. Nicholson, 20 Vet. App. 410 (2006); McLendon v. Nicholson, at 83. The veteran was seen with complaints of headaches during service. He reported persistent headaches on his first post- service examination in March 1976. He has been seen with occasional complaints of headaches since 1991, and complains of current headaches. This history suggests that the current headaches may be related to service. An examination is needed to obtain a medical opinion as to whether the veteran has current headaches related to service. The veteran has alleged that he has PTSD as the result of incidents during boot camp including physical abuse, such as kicking and hitting, by the drill instructors, participating in live fire exercises, and observing injuries incurred by other recruits. In addition, he stated in his January 2004 stressor statement that after boot camp, he was harassed because of his race. The veteran has a valid diagnosis of PTSD as it shows he was diagnosed with PTSD while receiving treatment at the VAMC in March 2003. In June 2004 the veteran's VA psychiatrist noted that the veteran had also provided him with this list of stressors and that his history and symptoms were consistent with PTSD. A claim for service connection for PTSD based on personal assault in service will not be denied without first advising the claimant that evidence from sources other than service records or evidence of changes in behavior may constitute credible supporting evidence of the claimed stressors and allowing him the opportunity to submit evidence or advise VA of the sources of such evidence. 38 C.F.R. § 3.304(f)(3) (2007). It does not appear that the veteran has been provided such notice. VA may submit any evidence it receives to an appropriate medical or mental health professional for an opinion as to whether the personal assault occurred. Id. Such an opinion is needed in this case. In an increased-compensation claim, section 5103(a) requires, at a minimum, that VA notify the claimant that, to substantiate a claim, the claimant must provide, or ask the Secretary to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life. Further, if the diagnostic code under which the claimant is rated contains criteria necessary for entitlement to a higher disability rating that would not be satisfied by the claimant demonstrating a noticeable worsening or increase in severity of the disability and the effect of that worsening has on the claimant's employment and daily life (such as a specific measurement or test result), the Secretary must provide at least general notice of that requirement to the claimant. Vazquez-Flores v. Peake, No. 05-0355, No. 05-0355 (U.S. Vet. App. Jan. 30, 2008); cf. Overton v. Nicholson, 20 Vet. App. 427, 441 (2006) (in an increased rating claim the veteran had notice of the evidence needed to substantiate the claim where he was told that to substantiate the claim he needed evidence showing that the disability had increased in severity). In addition, the issue of entitlement to a TDIU is inextricably intertwined with the veteran's claim for service connection in that the originating agency must rate the veteran's service-connected headaches before the Board decides the TDIU issue. In light of these circumstances, this case is REMANDED for the following actions: 1. The veteran should be provided the notice required under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b), as required by Vazquez-Flores, to include notice concerning the disability evaluation and effective-date elements of his claims, notice that he should submit all pertinent evidence in his possession, and evidence of the impact of his disabilities on employment and daily life. 2. The veteran should be advised that evidence from sources other than service records or evidence of changes in behavior may constitute credible supporting evidence of the claimed stressors, and allowing him the opportunity to submit, or advise VA of the sources of such evidence 3. Afford the veteran a VA examination to determine whether he has a current headache disorder related to service. The examiner should review the claims folder, and note such review in the examination report or in an addendum. The examiner should then provide opinions as to whether the veteran has a current headache disorder. If a headache disorder is identified, the examiner should provide an opinion as to whether it is, at least as likely as not (50 percent probability or more) related to headaches noted in service or is otherwise related to a disease or injury in service. The examiner should provide a rationale for the opinion. 4. Afford the veteran a VA psychiatric examination to ascertain whether he has PTSD related to in-service stressors. The examiner should review the claims folder, and note such review in the examination report or in an addendum. The examiner should provide opinions as to whether the veteran meets the criteria for a diagnosis of PTSD, and if so, specify the stressors supporting the diagnosis. If the supporting stressor consists of an in-service personal assault, the examiner should provide an opinion as to whether there is evidence of behavior changes indicating that the stressor occurred. 5. If the benefits sought on appeal are not fully granted issue a supplemental statement of the case before returning the case to the Board, if otherwise in order. By this remand, the Board intimates no opinion as to any final outcome is warranted. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2007). ______________________________________________ Mark D. Hindin Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs