Citation Nr: 0811946 Decision Date: 04/10/08 Archive Date: 04/23/08 DOCKET NO. 00-04 748 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to service connection for headaches, to include as claimed as a chronic disability due to an undiagnosed illness. 2. Entitlement to an increased disability rating for service-connected post-traumatic stress disorder (PTSD), currently rated 30 percent disabling. REPRESENTATION Veteran represented by: Michael J. Mooney, Attorney at Law WITNESSES AT HEARING ON APPEAL Veteran and his spouse ATTORNEY FOR THE BOARD David T. Cherry, Counsel INTRODUCTION The veteran served on active duty from February 1989 to December 1991, to include service in the Southwest Asia Theater of Operations during the Persian Gulf War. This case comes before the Board of Veterans' Appeals (the Board) on appeal from a September 1999 rating decision rendered by the Department of Veterans Affairs (VA) Regional Office in Cleveland, Ohio (the RO). Procedural history Headaches In the September 1999 rating decision, the RO, in pertinent part, denied the veteran's claim of entitlement to service connection for headaches, to include as being due to an undiagnosed illness. The veteran perfected an appeal of that denial. In a September 2002 decision, the Board denied the veteran's claim for service connection for headaches. The veteran subsequently appealed the Board's September 2002 denial of his claims for service connection to the United States Court of Appeals for Veterans Claims (the Court). By means of an Order issued in June 2003, the Court vacated the Board's September 2002 decision and remanded the case to the Board for further development, readjudication and disposition as requested in a Joint Motion for Remand which formed the basis for the Court's Order. In March 2004, the Board remanded the claim for service connection for a headache disorder. In a May 2005 supplemental statement of the case (SSOC), the RO continued the previous denial. In an August 2005 decision, the Board again denied service connection for headaches. In December 2005, the Board denied the veteran's motion for reconsideration of the August 2005 decision. The veteran appealed the August 2005 denial to the Court. In an October 2007 memorandum decision, the Court vacated the Board's decision as to the denial of service connection for headaches and remanded this case to the Board. In January 2008, the Board wrote a letter to the veteran's counsel and informed him that he had the opportunity to submit additional argument and/or evidence in support of the veteran's appeal before the Board proceeded with readjudication. The veteran's counsel responded via a letter dated March 21, 2008. PTSD In the September 1999 rating decision, the RO granted service connection for PTSD and assigned a 30 percent disability rating therefor. The veteran perfected an appeal of the assignment of a 30 percent disability rating. In October 2003 and again in August 2005, the Board remanded this claim to the RO for further development. In a June 2007 supplemental statement of the case (SSOC), the RO continued the previous denial. The issue is again before the Board. Hearing In a November 1999 notice of disagreement (NOD), the veteran requested "an appeal hearing." In a March 2000 VA Form 9, the veteran requested a Travel Board hearing. In April 2000, the veteran and his spouse testified at a hearing held at the RO before a Hearing Officer, a transcript of which has been associated with the veteran's claims file. A review of the transcript and the other documents in the claims file does not reflect that this hearing was in lieu of a Travel Board hearing. However, the veteran's counsel indicated in a July 2005 statement that the veteran did not want a Board hearing. No further development with regard to a hearing is necessary. Remanded issue The issue of an increased rating for service-connected PTSD is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the VA Appeals Management Center (AMC), in Washington, DC. Issues not on appeal Appeal perfected In the August 2005 Board decision, service connection was denied for the following: a skin disorder, to include claimed as due to an undiagnosed illness; a disorder producing lumps on the body, to include claimed as due to undiagnosed illness; hair loss, to include claimed as due to undiagnosed illness; and a disorder producing blood in the urine, to include claimed as due to undiagnosed illness. In December 2005, the Board denied the veteran's motion for reconsideration of the August 2005 decision. In the October 2007 memorandum decision, the Court noted that the veteran did not present any argument with respect to the denials of these claims and that therefore these claims were deemed to have been abandoned. See Bucklinger v. Brown, 5 Vet. App. 435, 436 (1993). Those issues have therefore been resolved. See 38 C.F.R. § 20.1100 (2007). Appeal not initiated In a June 2007 rating decision, service connection was denied for posterior polymorphous dystrophy (claimed as blindness). The veteran has not, to the Board's knowledge, expressed dissatisfaction with that decision. See Archbold v. Brown, 9 Vet. App. 124, 130 (1996) [pursuant to 38 U.S.C.A. § 7105(a), the filing of a notice of disagreement initiates appellate review in the VA administrative adjudication process, and the request for appellate review is completed by the claimant's filing of a substantive appeal after a statement of the case is issued by VA]. Accordingly, that issue will be addressed no further herein. FINDINGS OF FACT 1. The veteran served in the Southwest Asia Theater of Operations during the Persian Gulf War. 2. The competent medical evidence establishes that the veteran has a diagnosed headache disorder. 3. The evidence of record does not demonstrate any in- service headache disorder or any head injury. CONCLUSION OF LAW Service connection for headaches, including due to an undiagnosed illness, is not warranted. 38 U.S.C.A. §§ 1110, 1117, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.317 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSION 1. Entitlement to service connection for headaches, to include as claimed as a chronic disability due to an undiagnosed illness. The veteran is seeking service connection for headaches. As explained below, the remaining issue on appeal, entitlement to an increased rating for PTSD, is being remanded for further development. As noted in the Introduction, this issue was remanded by the Court in an October 2007 memorandum decision. The Court's memorandum decision dealt almost exclusively with the Board's determination in the August 2005 decision that the veteran failed to satisfy the second element under Hickson v. West, 12 Vet. App. 247, 253 (1999). This will be dealt with at some length below. In the interest of clarity, the Board will initially discuss certain preliminary matters. The Board will then address the pertinent law and regulations and their application to the facts and evidence. Stegall concerns In March 2004, the Board remanded the claim for further development. This was accomplished. See Stegall v. West, 11 Vet. App. 268, 271 (1998) [where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance]. In the October 2007 memorandum decision, the Court did not raise any concerns pursuant to Stegall. The Board is confident that if the Court had identified any Stegall deficiencies, such would have surfaced in the October 2007 memorandum decision so that any deficiencies could be corrected. Cf. Chisem v. Gober, 10 Vet. App. 526, 527- 8 (1997) [under the "law of the case" doctrine, appellate courts generally will not review or reconsider issues that have already been decided in a previous appeal of the same case, and therefore, Board is not free to do anything contrary to the Court's prior action with respect to the same claim]. The Veterans Claims Assistance Act of 2000 (VCAA) The Board has given consideration to the provisions of the VCAA. The VCAA includes an enhanced duty on the part of VA to notify a claimant as to the information and evidence necessary to substantiate a claim for VA benefits. The VCAA also redefines the obligations of VA with respect to its statutory duty to assist claimants in the development of their claims. See 38 U.S.C.A. §§ 5103, 5103A (West 2002). The Board has carefully considered the provisions of the VCAA and the implementing regulations in light of the record on appeal, and for reasons expressed immediately below finds that the development of this issue has proceeded in accordance with the provisions of the law and regulations. Notice The RO sent the veteran a letter in September 2004 which was specifically intended to address the requirements of the VCAA. The VCAA letter informed the veteran of the evidence necessary to establish service connection, the evidence to be provided by the veteran, the evidence VA is responsible for obtaining, and the fact that he should submit any evidence in his possession that pertains to this claim. The August 2005 Board decision contained a lengthy discussion of VCAA compliance. See the August 19, 2005 Board decision, pages 6-13. The Board observes that this issue was remanded by the Court in October 2007 with no substantive comments as to either inadequate VCAA compliance or the Board's August 2005 discussion of such compliance. See Chisem, supra. The veteran's attorney has raised no VCAA notice problems. Particularly in light of his duty to assist concerns, see immediately below, it is clear that the veteran through counsel is amply aware of what is required of him and VA in connection with the development of his claim. See DelaCruz v. Principi, 15 Vet. App. 143, 149 (2001) [VCAA notice not required where there is no reasonable possibility that additional development will aid the veteran]. Duty to assist In a December 2006 appellant's brief to the Court and in an April 2007 reply brief of the appellant, the veteran's counsel argued that a January 2005 VA examination was invalid. In the April 2007 reply brief of the appellant, the veteran's counsel requested the Court to "order a C&P exam to be conducted by the VA to determine whether his ongoing problem with headaches, which the VA agrees he has, are medically linked to the service-incurred headaches." See the April 2007 reply brief of the appellant, page 5. As to these assertions, the Court stated "[t]o the extent that the [veteran] argues that the 2005 VA examination was invalid, given the Court's disposition of the [veteran's] claim, the Court will not, at this time, address the other arguments and issues raised by the [veteran]." See the Court decision, page 3 [citing Best v. Principi, 15 Vet. App. 18, 20 (2001)]. In a March 21, 2008 letter to the Board, the veteran's counsel requested a new examination with a medical nexus opinion. Under McLendon v. Nicholson, 20 Vet. App. 79 (2006), VA must provide a VA medical examination in service connection claims when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) evidence establishing that an event, injury, or disease occurred in service; (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service; and (4) insufficient competent medical evidence on file for VA to make a decision on the claim. As is discussed below in detail, the outcome of this claim hinges on element (2), what occurred, or more to the point what did not occur, during service. A medical examination would not shed any light on this crucial element. Referral of this case for an opinion as to etiology would in essence place the examining physician in the role of a fact finder. This is the Board's responsibility. In other words, any medical opinion which provided a nexus between the veteran's claimed disability and his military service would necessarily be based solely on the veteran's uncorroborated assertions regarding what occurred in service. The Court has held on a number of occasions that a medical opinion premised upon an unsubstantiated account of a claimant is of no probative value. See, e.g., Swann v. Brown, 5 Vet. App. 229, 233 (1993) [generally observing that a medical opinion premised upon an unsubstantiated account is of no probative value, and does not serve to verify the occurrences described]; Reonal v. Brown, 5Vet. App. 458, 461 (1993) [the Board is not bound to accept a physician's opinion when it is based exclusively on the recitations of a claimant]. Obtaining a medical nexus opinion under the circumstances presented in this case would be a useless exercise. In short, no additional medical examination and opinion are required per McLendon. Remand for a medical examination and opinion is therefore not necessary. The Board also notes that while the PTSD-increased-rating issue is being remanded for, inter alia, the RO to obtain Social Security Administration (SSA) records, neither the veteran nor the veteran's counsel has indicated that the SSA records provide evidence regarding the critical element discussed below that is missing in the veteran's claim for service connection for headaches - that is, evidence indicating that his current chronic headache disorder was present during service. There is no realistic basis for concluding that the SSA records would reveal any additional information which would be useful to the Board's decision -- that is what occurred during service - since the etiology of disabilities is not a subject of SSA inquiry. Therefore, a remand to obtain records from SSA is not necessary, as neither the veteran nor his counsel has suggested that they are pertinent to his claim for service connection for headaches, and the record does not so indicate. See Brock v. Brown, 10 Vet. App. 155, 161-2 (1997) [VA is not obligated to obtain records which are not pertinent to the issue on appeal]. In short, the Board has carefully considered the provisions of the VCAA in light of the record on appeal, and for the reasons expressed above finds that the development of this claim has been consistent with the provisions of the VCAA. The veteran has been accorded ample opportunity to present evidence and argument in support of his claim. See 38 C.F.R. § 3.103 (2007). He has retained the services of an attorney, who has presented written argument on his behalf. The veteran and his spouse testified at an April 2000 hearing held at the RO before a Hearing Officer. As noted in the Introduction section, he has withdrawn his request for a Board hearing. Accordingly, the Board will proceed to a decision on the merits as to this issue. Relevant law and regulations Service connection - in general Service connection may be established for a disability resulting from a disease or injury incurred in or aggravated by active duty. See 38 U.S.C.A. §§ 1110, 1131 (West 2002). Service connection may be granted for disability shown after service, when all of the evidence, including that pertinent to service, shows that it was incurred or aggravated in service. 38 C.F.R. § 3.303(a)(2007). In order to establish service connection for a claimed disorder, there must be (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 current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). Service connection - undiagnosed illnesses Service connection may also be established for a chronic disability resulting from an undiagnosed illness which became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War or to a degree of 10 percent or more not later than December 31, 2006. See 38 U.S.C.A. § 1117 (West 2002); 38 C.F.R. § 3.317 (2007). Objective indications of a chronic disability include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. Disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. The six-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. A chronic disability resulting from an undiagnosed illness referred to in this section shall be rated using evaluation criteria from the VA's Schedule for Rating Disabilities for a disease or injury in which the functions affected, anatomical localization, or symptomatology are similar. A disability referred to in this section shall be considered service-connected for the purposes of all laws in the United States. 38 C.F.R. § 3.317(a)(2-5) (2007). Signs or symptoms which may be manifestations of an undiagnosed illness include, but are not limited to, fatigue, signs or symptoms involving the skin, headaches, muscle pain, joint pain, neurologic signs or symptoms, neuropsychological signs or symptoms, signs or symptoms involving the respiratory system (upper or lower), sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, or menstrual disorders. 38 C.F.R. § 3.317(b) (2007). When a veteran is found not to be entitled to a regulatory presumption of service connection for a given disability the claim must nevertheless be reviewed to determine whether service connection can be established on a another basis. See Combee v. Brown, 34 F.3d 1039, 1043-1044 (Fed. Cir. 1994). Continuity of symptomatology The mere fact of an in-service injury is not enough; there must be evidence of a chronic disability resulting from that injury. In order to show a chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the veteran's claim. See 38 C.F.R. § 3.303(b) (2007). The chronicity provision of 38 C.F.R. § 3.303(b) applies when evidence, regardless of its date, establishes that a veteran had a chronic condition in service and still has that condition. There must be competent medical evidence unless the evidence relates to a condition as to which lay observation is competent to identify its existence. Standard of review After the evidence has been assembled, it is the Board's responsibility to evaluate the entire record. See 38 U.S.C.A. § 7104(a) (West 2002). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. See 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. § 3.102 (2007). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the United States Court of Appeals for Veterans Claims (the Court) stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Analysis The October 2007 Court memorandum decision In its September 2002 decision, the Board accepted the veteran's reports of in-service headaches (see e.g., his letter dated May 31, 1998 and the April 24, 2000 personal hearing transcript, page 2), and determined that Hickson element (2) had been satisfied with respect to headaches. See the September 2002 Board decision, page 17. In its August 2005 Board decision, the Board noted that the veteran's vascular and neurologic systems were each clinically evaluated as normal at an October 1991 service medical examination and that at this examination the veteran denied having, or ever having had, frequent or severe headaches. The Board determined that in the absence of an in-service disease or injury, Hickson element (2) was not met. In its October 2007 decision, the Court held that "in light of the missing [service medical records], the Board failed to adequately explain its determination that the [veteran] failed to satisfy the second Hickson element." The Court agreed "with the Secretary that the Board failed to adequately address the credibility of the [veteran's] lay evidence of in-service headaches." In essence, the Court requires the Board to provide greater depth of explanation with respect to its reasons and bases with respect to element (2), to include an analysis of the veteran's own statements as to in-service headaches. The Board wishes to make it clear that it is aware of the Court's instructions in Fletcher v. Derwinski, 1 Vet. App. 394, 397 (1991), to the effect that a remand by the Court is not "merely for the purposes of rewriting the opinion so that it will superficially comply with the 'reasons or bases' requirement of 38 U.S.C. § 7104(d)(1). A remand is meant to entail a critical examination of the justification for the decision." The Board's analysis has been undertaken with that obligation in mind. The veteran's recent contentions The veteran's attorney, in his letter to the Board dated March 21, 2008, stated that "Judge Farley's memorandum decision speaks for itself." The Board agrees. Curiously, the attorney then went on to argue that "Restoration of the 2002 decision on the subject of incurrence of service headaches should now occur . . . ." However, in its October 2007 decision the Court specifically and categorically "declined the [veteran's] request that the Court order that the Board adhere to its previous factual finding in its September 2002 decision based on the law-of- the-case doctrine." The Court noted that "the September 2002 decision was vacated by order of the Court." The Court also indicated that "the law-of-the-case doctrine does not apply to matters that 'have not been finally decided by the ... Court.'" [quoting Augustine v. Principi, 343 F.3d 1334 (Fed. Cir. 2003). In short, "Judge Farley's memorandum decision speaks for itself." As the Court pointed out, the Board's 2002 decision has been vacated (in essence at the urging of the veteran's attorney), and it cannot now be "restored". Moreover, the Court specifically directed the Board to analyze all of the evidence and arrive at a conclusion concerning element (2). This will be done below. Missing service medical records Certain of the veteran's service medical records may be missing. Under such circumstances, the Court has held that there is a heightened obligation on the part of VA to explain findings and conclusions and to consider carefully the benefit of the doubt rule. See Cuevas v. Principi, 3 Vet. App. 542, 548 (1992); O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). This was pointed out by the Court in its October 2007 memorandum decision. It is further noted, however, that the case law does not lower the legal standard for proving a claim for service connection, but rather increases the Board's obligation to evaluate and discuss in its decision all of the evidence that may be favorable to the claimant. See Russo v. Brown, 9 Vet. App. 46 (1996). Moreover, there is no presumption, either in favor of the claimant or against VA, arising from missing records. See Cromer v. Nicholson, 19 Vet. App. 215, 217-18 (2005) [the Court declined to apply an "adverse presumption" where records have been lost or destroyed while in Government control which would have required VA to disprove a claimant's allegation of injury or disease in service in these particular cases]. Finally, as will be discussed below there are of record a number of service medical records, including, crucially, report of a physical examination in October 1991, shortly before separation. Discussion The veteran seeks service connection for headaches, both as a symptom of an undiagnosed illness associated with his Persian Gulf service [see 38 C.F.R. § 3.317] or as a disease entity directly related to his military service [see 38 C.F.R. § 3.303]. The Board will address each of these contentions in turn. (i.) Undiagnosed illness It is undisputed that the veteran served in Southwest Asia during the Persian Gulf War. However, the medical evidence clearly demonstrates that the medical problem for which the veteran is seeking service connection, headaches, is the product of a diagnosed disease entity, and not of an undiagnosed illness. The medical evidence does not demonstrate that the veteran's headaches, diagnosed as vascular or tension headaches, are of unknown or unascertainable etiology. The reports of July 1998 and January 2005 VA examinations show a diagnosis of vascular headaches. An August 1999 VA treatment record reflects a diagnosis of tension headaches. Both are know diagnoses. While other medical evidence reflects treatment for complaints of headaches, this evidence does not demonstrate that these headaches are of unknown or unascertainable etiology. Service connection based on the veteran's Gulf War service is therefore not warranted. See 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317(a)(1)(ii). (ii.) Direct service connection The veteran more strongly asserts that he had headaches while on active duty and that service connection should be granted on a direct basis. With respect to Hickson element (1), current disability, there is medical evidence that the veteran currently has a headache disorder. As noted above, vascular headaches and tension headaches have been diagnosed. Hickson element (1) is therefore satisfied. With respect to Hickson element (2), in-service disease or injury, the Board will separately address injury and disease. With respect to in-service injury, the veteran has pointed to no specific in-service injury which he believes is responsible for his current headaches. The medical and other records in the file do not reference any such injury. In an October 15, 1991 report of medical history, the veteran denied any head injuries. Rather, the veteran in essence contends that he had headaches in service and continually thereafter. This contention was the crux of the Court's remand. As was noted by the Court in its October 2007 memorandum decision, and despite assertions to the contrary by the veteran's attorney, the Board is not bound by its previous factual finding in its September 2002 decision that Hickson element (2) had been satisfied by the veteran's lay reporting of headache symptomatology in service. The Board has reviewed the evidence of record. The evidence in favor of in-service headaches consists entirely of the veteran's own statements (although sometimes relayed through others). The evidence against the veteran's claim on this point consists of negative service medical records as well as immediate post service medical records in which in service headaches are not mentioned. In adjudicating a claim, the Board is charged with the duty to assess the credibility and weight given to evidence. See Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998). Indeed, in Jefferson v. Principi, 271 F.3d 1072, 1076 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit, citing its decision in Madden, recognized that that Board had inherent fact-finding ability. In Caluza v. Brown, 7 Vet. App. 498 (1995), aff'd per curium, 78 F.3d 604 (Fed. Cir. 1996), the Court remarked that the credibility of a witness can be impeached by a showing of interest, bias, inconsistent statements, or, to a certain extent, bad character. See also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) [VA cannot ignore a veteran's testimony simply because the veteran is an interested party; personal interest may, however, affect the credibility of the evidence]. Boiled down to its essence, all reference to in-service headaches emanates from the veteran himself. Such references appear in reports of a July 1998 VA examinations a July 1999 VA treatment record, an August 1999 VA treatment record, a May 2004 VA treatment record, and a report of a January 2005 VA examination. However, it is now well established that information from a veteran which is merely transcribed by a medical professional still amounts only to a statement from the veteran. See Moreau v. Brown, 9 Vet. App. 389, 395-396 (1996); Swann v. Brown, 5 Vet. App. 229, 233 (1993) [generally observing that an opinion premised upon an unsubstantiated account is of no probative value, and does not serve to verify the occurrences described]. The Board additionally observes that the veteran's self reports of in-service headaches to health care providers first appear in the record coincident with his July 1998 claim of entitlement to service connection. In Kowalski v. Nicholson, 19 Vet. App. 171, 179 (2005), the Court reaffirmed that in evaluating medical opinion evidence, the Board may reject a medical opinion that is based on facts provided by the veteran that have been found to be inaccurate. The Board may not, however, disregard a medical opinion solely on the rationale that the medical opinion was based on a history given by the veteran. In this case, as is discussed immediately below, the objective medical evidence prior to July 1998 does not indicate that in-service headaches in fact existed. The limited service medical records are entirely silent as to complaints or treatment of headaches, or diagnoses of a headache disorder. The report of the October 1991 service medical examination, which was done after his service in the Southwest Asia Theater of Operations during the Persian Gulf War, shows that the veteran's vascular and neurologic systems were each clinically evaluated as normal. The report of medical history prepared at that time shows that the veteran denied having, or ever having had, frequent or severe headache. Although the Court's decision referred to the fact that certain service medical records may be missing, and the Board has taken cognizance of that, the fact remains that the existing service medical records, including the examination shortly before separation, are pertinently negative as to headaches. There is no presumption that any allegedly missing service medical record would in fact disclose complaints of headache. See Cromer, supra. Also significant is the fact that medical reports for several years after service do not indicate that the veteran experienced in-service headaches but rather that his headaches began after service. Specifically, a December 1992 private treatment record shows that the veteran had had a headache since a blow to his head that month. This was one year after the veteran left military service. A June 1994 VA treatment record reveals that the veteran reported having daily chronic headaches for the past one and half years, i.e., in approximately in December 1992. This record is precisely consistent with the December 1992 private treatment record which shows an initial complaint of headache that month. In a November 2003 statement, the veteran's counsel argues that the June 1994 VA treatment record showing history of daily headaches for only a year and half does not mean that the veteran did not have headaches on a less frequent basis prior to the end of 1992. However, the record "speaks for itself". The veteran simply did not indicate that he had headaches prior to December 1992. Moreover, in December 1992 he in fact indicated that his headaches started that month due to a specific event, a blow to the head. The Board places great weight of probative value on the service medical records and on the immediate post-service medical evidence. Takes together, this evidence supports a conclusion that the veteran did not experience headaches in service and that such headaches began with a blow to the head in December 1992. Such records are more reliable, in the Board's view, than the veteran's later, unsupported assertion of in-service headaches made in connection with his claim for monetary benefits from VA. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) [VA cannot ignore a veteran's testimony simply because the veteran is an interested party; personal interest may, however, affect the credibility of the evidence]. Simply put, in light of the record as a whole, the Board finds that the veteran's assertion of in-service headaches is not credible. The veteran served in Southwest Asia Theater of Operations from September 1990 to March 1991. He has reported that his headaches either began while serving in Southwest Asia or within a month or two after returning from Southwest Asia. Therefore, the veteran is claiming that his headaches began at the latest in the Spring of 1991, several months prior to the October 1991 in-service physical examination. In his October 15, 1991 report of medical history, which he himself signed, the veteran responded "no" to the question concerning frequent or severe headache. It is simply unbelievable that if headaches had existed the veteran would not have mentioned them. The Board in particular observes that the veteran specifically reported other seemingly minor problems, such as a history of eye trouble and cramps in his legs, in the same report of medical history. The only logical explanation for this omission is that the veteran was not in fact troubled by headaches during service. Moreover, the veteran's "no" response, and the pertinently negative examination results, are reinforced by his report in December 1992 that his headaches began that month. There thus is no objective evidence of a headache disorder or a head injury in service. Although the Board has taken the veteran's assertions into consideration, for reasons stated above evidence against the claim preponderates. Hickson element (2) has not been met, and the veteran's claim fails on that basis. Turning for the sake of completeness to Hickson element (3), medical nexus, there is of record no medical opinion which specifically serves to link the veteran's current headaches disorder to his military service. A May 2004 VA treatment record reflects an assessment of constant headaches since 1991. However, this is not a nexus opinion as such but rather appears to be reflective of veteran's statement to the examiner concerning his history of in-service headaches, which the Board has determined is incredible. See Godfrey v. Brown, 8 Vet. App. 113, 121 (1995) [the Board is not required to accept doctors' opinions that are based upon the claimant's recitation of medical history]; and Elkins v. Brown, 5 Vet. App. 474, 478 [rejecting medical opinion as "immaterial" where there was no indication that the physician reviewed the claimant's service medical records or any other relevant document that would have enabled him to form an opinion on service connection on an independent basis]. The Board may not disregard a medical opinion solely on the rationale that the medical opinion was based on a history given by the veteran. See Kowalski v. Nicholson, 19 Vet. App. 171 (2005). In this case, the Board's rejection of the medical assessment linking the veteran's current headache disorder to his military service is based on a review of the entire record. In particular, there are no service medical records corroborating his allegation of in-service headaches, nor does the early post-service medical evidence corroborate his assertion. The veteran evidently revised his history in connection with his 1998 claim for monetary benefits from the government. To the extent that the veteran himself believes that his current headaches are due to his military service, it is now well established that lay persons without medical training, such as the veteran, are not competent to comment on medical matters such as diagnosis, date of onset or cause of a disability. See Espiritu, supra; see also 38 C.F.R. § 3.159 (a)(1). The statements offered by the veteran are not competent medical evidence and do not serve to establish medical nexus. Implicit in the veteran's presentation is the contention that his headaches began in service and continued thereafter. A claim can still be substantiated if continuity of symptomatology is demonstrated after service. See Savage v. Gober, 10 Vet. App. 488 (1997); 38 C.F.R. § 3.303(b). However, as has been discussed in some detail in connection with element (2), there was no headache disorder diagnosed in service and no documented complaints of headaches in service. Supporting medical evidence is required. See Voerth v. West, 13 Vet. App. 117, 120-1 (1999) [there must be medical evidence on file demonstrating a relationship between the veteran's current disability and the claimed continuous symptomatology, unless such a relationship is one as to which a lay person's observation is competent]. Such evidence is lacking in this case. The May 2004 assessment of headaches staring in 1991 is based on the veteran's own statement to that doctor concerning his alleged in-service headaches, which history the Board has rejected. Continuity of symptomatology after service is therefore not demonstrated. In short, there is not of record competent medical nexus evidence linking the veteran's current headaches to service. Hickson element (3) therefore has also not been satisfied, and the claim also fails on that basis. Conclusion In summary, in the absence of the required Hickson second and third elements, the Board concludes that a preponderance of the evidence is against the veteran's claim of entitlement to service connection for headaches. The benefit sought on appeal is accordingly denied. ORDER Entitlement to service connection for headaches is denied. REMAND 2. Entitlement to an increased disability rating for service-connected PTSD, currently rated 30 percent disabling. For reasons expressed immediately below, the Board believes that this issue must be remanded for further procedural and evidentiary development. Reasons for remand VCAA notice While the RO provided notice as to as to Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006) in March 2006, in light of the subsequent Court decision in Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), more detailed notice must be provided. The Court in Vazquez-Flores held that a notice letter must inform 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 and the effect that worsening has on the claimant's employment and daily life. The March 2006 VCAA letter did not satisfy that requirement. Also, the veteran is rated under a Diagnostic Code that contains criteria necessary for a 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). In this case, the Diagnostic Code in question pertains to specific psychiatric symptomatology. The notice letters did not provide at least general notice of that requirement. VA examination The veteran last underwent a VA psychiatric examination in January 2005, which was three years ago. Recent VA medical records reflect diagnoses of cognitive disorder not otherwise specified and depressive disorder not otherwise specified. It is unclear which of the veteran's psychiatric symptomatology is attributable to the service-connected PTSD and which psychiatric symptomatology is attributable to other, non-service-connected psychiatric disorders. Under the circumstances here presented, the Board believes that another medical examination is necessary. VA treatment records A printout of a computer screen regarding records at the Indianapolis VA medical center (MC) shows that the veteran received psychiatric treatment at that facility during the period from June 1998 to June 1999. These records must be obtained. The veteran has been receiving treatment at the Dayton VAMC. The last request from that facility was completed in June 2007. Additional records from that facility should be obtained. SSA records A January 2005 VA treatment record shows that the veteran reported that he was receiving Social Security disability benefits because of his PTSD. Records from SSA must be obtained. Accordingly, this case is remanded to the Veterans Benefits Administration (VBA) for the following actions: 1. VCAA notice pursuant to Vazquez- Flores v. Peake, 22 Vet. App. 37 (2008) should be furnished to the veteran, with a copy to his counsel. The VCAA notice should inform the veteran that that, to substantiate a claim, the veteran must provide, or ask the Secretary to obtain, medical or lay evidence demonstrating a worsening or increase in severity and the effect that worsening has on the veteran's employment and daily life. The VCAA notice should inform the veteran that he is rated under a Diagnostic Code that contains criteria necessary for a 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). 2. VBA should attempt to obtain records pertaining to the veteran from the Indianapolis VAMC from June 1998 to June 1999 and from the Dayton VAMC from June 2007 to the present. Any treatment records so obtained should be associated with the veteran's claims file. 3. VBA should contact the Social Security Administration in order to obtain any records pertaining to the veteran. Any such records so obtained should be associated with the veteran's VA claims folder. 4. VBA should schedule the veteran for a VA psychiatric examination to evaluate the current severity of his PTSD. To the extent practicable, the examiner should identify all symptomatology associated with the veteran's PTSD, and any symptomatology associated with other disorders. If psychological evaluation or other diagnostic testing is deemed to be necessary by the examiner, such should be scheduled. A report of the examination should be prepared and associated with the veteran's VA claims folder. 5. After the development requested above has been completed to the extent possible, and after undertaking any additional development it deems necessary, VBA should then review the record and readjudicate the veteran's claim. If the decision remains unfavorable to the veteran, a supplemental statement of the case (SSOC) should be prepared. The veteran and his counsel should be provided with the SSOC and an appropriate period of time should be allowed for response. The veteran has the right to submit additional evidence and argument on the matter the Board has remanded. See 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 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). ______________________________________________ Barry F. Bohan Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs