Citation Nr: 0814740 Decision Date: 05/05/08 Archive Date: 05/12/08 DOCKET NO. 05-32 536 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to an increased disability rating in excess of 50 percent for post-traumatic stress disorder (PTSD). 2. Entitlement to an increased disability rating in excess of 10 percent for residuals of colostomy with psychophysiological reaction. 3. Entitlement to an increased (compensable) disability rating for bilateral hearing loss. 4. Entitlement to service connection for sexual dysfunction. 5. Whether new and material evidence has been submitted to reopen a claim of entitlement to service connection for hypertension. 6. Whether new and material evidence has been submitted to reopen a claim of entitlement to service connection for arthritis. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESSES AT HEARINGS ON APPEAL Veteran and spouse ATTORNEY FOR THE BOARD Christopher McEntee, Associate Counsel INTRODUCTION The veteran served on active duty from September 1968 to September 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2002 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. In December 2007, the veteran testified during at a video conference hearing before the undersigned Acting Veterans Law Judge. A transcript of that hearing is of record. As indicated below, the Board has reopened the veteran's claims seeking entitlement to service connection for hypertension and for arthritis. These reopened claims, as well as the veteran claims seeking service connection for sexual dysfunction, and increased disability ratings for residuals of colostomy and bilateral hearing loss, are addressed in the Remand portion of the decision below and are remanded to the RO via the Appeals Management Center in Washington, DC. FINDINGS OF FACT 1. The veteran's PTSD has been manifested by depressed and anxious mood, intrusive thoughts, difficulty sleeping, flashbacks, hypervigilance, increased startle response, and memory impairment. The evidence also shows that the veteran has been alert, fully oriented, with fair eye contact, normal speech, fair concentration and attention, goal-directed thought process, and no homicidal or suicidal ideations. 2. In January 1972, the RO issued a decision which denied service connection for hypertension and for arthritis. Although provided notice of this decision the following month, the veteran did not perfect an appeal thereof. 3. In May 1994, the RO issued a decision which denied service connection for hypertension and for arthritis, secondary to inservice Agent Orange exposure. Although provided notice of this decision that same month, the veteran did not perfect an appeal thereof. 4. Evidence received since the RO's May 1994 decision includes evidence which is new and bears directly and substantially on the matters under consideration herein, and is so significant that it must be considered in order to fairly decide the veteran's claims seeking service connection for hypertension and for arthritis. CONCLUSIONS OF LAW 1. The criteria for a disability evaluation in excess of 50 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2007). 2. Evidence submitted to reopen the claim of entitlement to service connection for hypertension is new and material, and therefore, the claim is reopened. 38 U.S.C.A. §§ 5108, 7105 (West 2002); 38 C.F.R. § 3.156 (as in effect prior to August 29, 2001). 3. Evidence submitted to reopen the claim of entitlement to service connection for arthritis is new and material, and therefore, the claim is reopened. 38 U.S.C.A. §§ 5108, 7105 (West 2002); 38 C.F.R. § 3.156 (as in effect prior to August 29, 2001). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA has certain notice and assistance requirements. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2006); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2007). Upon receipt of a substantially complete application for benefits, VA must notify the claimant what information or evidence is needed in order to substantiate the claim and it must assist the claimant by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5103(a), 5103A; 38 C.F.R. § 3.159(b); see Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). VA satisfied VCAA notification requirements here in letters from VA dated in June 2001, November 2003, March 2006, and April 2007. 38 U.S.C.A. § 5103 and 38 C.F.R. § 3.159. VA informed the veteran of the evidence needed to substantiate his claims, and of the elements of his claims. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); Kent v. Nicholson, 20 Vet. App 1 (2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (noting that a VCAA defect may be cured by the issuance of a fully compliant notification letter followed by a re-adjudication of the claim). VA requested from the veteran relevant evidence, or information regarding evidence which VA should obtain (the Board also finds that the veteran was otherwise fully notified of the need to give to VA any evidence pertaining to his claims). Pelegrini v. Principi, 18 Vet. App. 112 (2004) (veteran should be notified that he should submit any pertinent evidence in his possession). VA advised the veteran of the respective duties of the VA and of the veteran in obtaining evidence needed to substantiate his claims. And VA submitted its initial notification letter to the veteran prior to the rating decision on appeal. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006) (VCAA notice must be provided to a claimant before the initial unfavorable RO decision). Also prior to the RO's final re-adjudication of issue concerning the veteran's PTSD, a letter from the RO in March 2006 notified the veteran that he must submit, or request that VA obtain, evidence of the worsening of his disability to include the effects on employment and daily life. Moreover, during the course of this appeal, the veteran was informed of the specific requirements to obtain a higher rating for his PTSD, and given notice of the different types evidence available to demonstrate the above. Vazquez- Flores v. Peake, 22 Vet. App. 37 (2008); Prickett, 20 Vet. App. at 376. In addition, the Board finds that any presumed prejudice incurred by the veteran as a result of incomplete notice has been rebutted by the record, and that proceeding with a final decision is appropriate here. See Sanders v. Nicholson, 487 F.3d 881 (2007); see also Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328. As the veteran and his representative demonstrated in the December 2007 video conference hearing before the Board, the veteran understands the disability criteria for PTSD under Diagnostic Code 9411 of 38 C.F.R. § 4.130. As such, the Board finds that the veteran has demonstrated "actual knowledge" of these criteria. The incomplete notice here is harmless error therefore. See Vazquez-Flores, supra. The Board finds that VA satisfied VCAA notification requirements in this matter. In addition, the duty to assist the veteran has also been satisfied in this case. The RO has obtained the veteran's service medical records, VA medical treatment records, and his identified private treatment records. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In addition, the veteran was provided with VA examinations that addressed his claims in this matter. Finally, there is no indication in the record that additional evidence relevant to the issues being decided herein is available and not part of the record. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield and Dingess/Hartman, both supra. I. Increased Rating for PTSD The veteran sustained injuries to his groin and abdomen areas during combat operations in Vietnam. In a March 1978 rating decision, the RO granted service connection for residuals of colostomy with pychophysiological gastrointestinal reaction. The RO rated this condition as 10 percent disabling from September 1971, and as 30 percent disabling from September 1977. In a December 1985 rating decision, the RO noted the veteran's PTSD diagnosis in rating the veteran for the psychological aspect of the residuals of his colostomy. The RO granted a 50 percent disability evaluation for this condition from December 1982. In June 2001, the veteran filed his current increased rating claim for this disorder. In a July 2002 rating decision, the RO denied the veteran's claim for increase. The veteran appealed this decision to the Board. In support of his appeal, he argued that his PTSD should be separately service connected from his physical disorder involving his colostomy. During the pendency of the appeal, in an August 2005 Supplemental Statement of the Case, the RO agreed that separate service connection findings were appropriate for the PTSD and for the residuals of colostomy. The RO assigned a 50 percent disability evaluation for PTSD, and a 10 percent evaluation for residuals of the colostomy. Nonetheless, the veteran's claim continues on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993) (an appellant is presumed to seek the maximum available benefit even where an increase is granted during the appeal period). Following a thorough review of the record, the Board finds remand appropriate here with regard to the veteran's claim for increase for residuals of a colostomy. As will be detailed in the remand portion of this decision, additional notification under the VCAA is necessary with regard to that issue. The Board also finds, however, that the record is sufficiently developed to decide the veteran's claim for increase for PTSD. As will be detailed below, the Board finds a rating in excess of 50 percent unwarranted here at any time during the period of appeal. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4 (2007). The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2007). In considering the severity of a disability, it is essential to trace the medical history of the veteran. See 38 C.F.R. §§ 4.1, 4.2, 4.41 (2007). Consideration of the whole- recorded history is necessary so that a rating may accurately reflect the elements of disability present. See 38 C.F.R. § 4.2 (2007); Peyton v. Derwinski, 1 Vet. App. 282 (1991). The evidence may establish that varying and distinct levels of disability impairment severity during an appeal warrant staged ratings (different disability ratings during various time periods). See Hart, supra; see also Fenderson v. West, 12 Vet. App. 119, 126-27 (1999). The current regulations establish a general rating formula for mental disorders. 38 C.F.R. § 4.130. Ratings are assigned according to the manifestation of particular symptoms. However, the use of the term 'such as' in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Accordingly, the evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV). Id. Pursuant to Diagnostic Code (DC) 9411, PTSD is rated 50 percent disabling when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent evaluation is warranted under DC 9411 where there is objective evidence demonstrating occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to suicidal ideation; obsessional rituals which interfere with routine activities, speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, or effectively; impaired impulse control, such as unprovoked irritability with periods of violence; spatial disorientation, neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances, including work or a work-like setting; and the inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2007). In evaluating the evidence, the Board has noted the various Global Assessment of Functioning (GAF) scores that clinicians have assigned. The GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See DSM-IV; Carpenter v. Brown, 8 Vet. App. 240 (1995). For example, a GAF score of 61-70 reflects some mild symptoms, such as depressed mood and mild insomnia, or some difficulty in social, occupational, or school functioning, such as occasional truancy, or theft within the household, but generally functioning pretty well, and has some meaningful interpersonal relationships. A GAF score of 51-60 indicates moderate symptoms (e.g., flat affect, circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational or school functioning (e.g., having few friends or having conflicts with peers or co-workers). A GAF score of 41-50 is assigned where there are, 'Serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). DSM-IV at 46-47. In this matter, the Board finds a rating in excess of 50 percent unwarranted during the entire appeal period. Although the medical evidence shows adverse symptoms from the veteran's PTSD, these symptoms have not resulted in deficiencies in most areas of his life. The record contains VA and QTC Medical Services examination reports, dated in March 2002, December 2004, August 2005, and September 2006, and a private examination report dated in January 2005. The record also contains VA treatment records addressing the veteran's PTSD treatment, lay statements from relatives of the veteran and from a former supervisor, and transcripts of the veteran's testimony at the Board and RO hearings. The March 2002 examiner noted the veteran's complaints of decreased mood, insomnia, irritability, low energy, hopelessness, flashbacks, nightmares, hyperautonomic arousal, low sex drive, family struggles, and need to avoid triggers. The examiner noted that the veteran "is paying a very heavy price for the service he gave to this country." Nevertheless, the examiner also found the veteran to have good insight and judgment, with normal psychomotor activity, full and reactive affect, good eye contact, a fair mood, and speech of normal rate, rhythm, cadence, and modulation. The veteran's thought process was logical, organized, and goal directed, and his thought content was devoid of any attenduation to internal stimuli and devoid of any suicidal or homicidal ideations, plan or intent. The examiner noted the veteran's long-standing marriage. He noted that the veteran had been employed by the US Postal Service since 1984, and the examiner assigned the veteran a GAF between 50 to 55, noting that "when symptoms are less fulminant he functions at a level of 65." The December 2004 examiner noted the veteran's statement that he had no friends. The examiner noted the veteran's reported discomfort around crowds, his compromised relationships with siblings, and his lack of hobbies other than watching television and lying on the couch. The examiner noted the veteran's problems with concentration, and noted the veteran's history of anxiety and depression. He noted the veteran's reports of suicidal thoughts, of flashbacks, of having several nightmares per month, of intrusive thoughts, irritability, and anger. The examiner noted the veteran's hypervigilance, and startle response. During the examination the examiner noted that the veteran spoke loudly, and seemed tense, uptight, angry, and irritable, with decreased memory and concentration. The examiner also noted the veteran's shifting eye contact. But again, a rating in excess of 50 percent is not warranted during this period of the appeal because the criteria for a 70 percent rating is not met. The examiner noted that the veteran was alert, oriented times three, cooperative, with adequate grooming and hygiene. He noted that the veteran's thought process was goal directed, and that he did not endorse any suicidal or homicidal ideations, or auditory or visual hallucinations. His judgment and insight was fair, and he noted the veteran's report that he is not a violent person, but that instead he is passive. The examiner noted the veteran's 34-year marriage, and his long-term employment with the post office. The report also noted the veteran's statement that he would leave this employment due to his concentration difficulties and physical pain associated with other service-connected disorders. The examiner assigned the veteran a GAF score between 60 and 51, and in his summary, the December 2004 examiner stated that the veteran's PTSD symptoms cause moderate impairment occupationally and socially. The January 2005 private examiner described the veteran as ashen, and that he spoke rapidly. The veteran reported suspicion of other people and weekly intrusive thoughts. The examiner also noted symptoms of isolation, restricted affect, sleep difficulty, difficulties with concentration and understanding, hypervigilance, and depression. But the January 2005 private examiner also described the veteran as clean, neat, with styled hair, cooperative, understanding during the interview, clear, alert, oriented time three, and with good eye contact. The examiner described the veteran's conversation as understandable, with organized associations. The veteran's memory was adequate, and he exhibited satisfactory judgment and insight. There were no hallucinations and mood changes, and the veteran denied hopelessness. The reported concluded with a GAF score of 50. The August 2005 examiner noted that the veteran had retired from the US Postal Service in November 2004. The examiner noted the veteran's report of sadness, depression, intrusive thoughts 2-3 times weekly, sleep disturbances, hypervigilance, and exaggerated startle response. The examiner also noted the veteran's report of having no friends, of isolating, and of expressing himself verbally with anger. The examiner said the veteran's affect was mildly dysphoric and restricted in range. But he also noted the veteran's report of having good relationships with his spouse and two adult children, that he had not had suicidal ideation since the previous winter season. He described the veteran as alert, NAD, casually dressed, with fairly good grooming, good eye contact, fluent and spontaneous speech that was at a normal rate. He said the veteran was logical and oriented times three, without evidence of memory impairment. The examiner noted that he advised the veteran on treatment options for his PTSD. The examiner noted that the veteran did not undergo PTSD treatment for the previous 20 years, and the veteran was motivated for treatment. The examiner assigned the veteran a GAF score of 40. The September 2006 examiner noted the veteran's statement that his PTSD was getting worse. The examiner noted the veteran's 36-year marriage, but noted his report of increased tension in the relationship since the veteran's retirement. The examiner also noted the veteran's reported discomfort around his two grandchildren because of their energy. He reported a lack of hobbies and friends, and a discomfort in crowds with other people. The veteran also reported having nightmares, sleep disturbances, intrusive thoughts, anger, hypervigilance with an exaggerated startle response, depression, anxiety, and shakiness. The examiner noted the veteran's loud voice during the interview, his tense affect, and his irritable mood. He noted the veteran's passive suicidal ideations with any plan or intent. The examiner noted that the veteran exhibited shifty eye contact, and distractibility, and memory and concentration impairment during the interview. But, as with the other VA examiners, this examiner noted symptomatology that indicates that the veteran's PTSD does not meet the necessary criteria that would warrant an increased evaluation to 70 percent here. This examiner described the veteran as alert, oriented, cooperative, coherent, goal directed, with fair judgment and insight, with adequate personal hygiene and grooming, and without any hallucinations or delusions. And the examiner noted that the veteran did not experience flashbacks anymore. Ultimately, this examiner assigned the veteran with a GAF score of 45. In the summary of the report, the September 2006 VA examiner noted that the veteran's PTSD had worsened since his retirement. The examiner noted the veteran's reported conflict with his spouse and his reported decreased concentration as a result of intrusive thoughts and physical pain. The record contains VA treatment records dated from August 2005 to December 2007. These records reflect the essentially the same symptomatology noted in the four VA examination reports - depression, sleep disturbances, and restricted affect, but also note a logical and oriented mindset, fluent speech, appropriate dress and manner, and the absence of suicidal or homicidal ideation. The Board notes that the veteran's thoughts of suicide are noted in some of the records dated throughout 2007. But in general, these treatment records show that the veteran has not had any consistent suicidal ideation. The GAF scores noted in these records range from 40 to 45, which indicates serious impairment. Although GAF scores are important in evaluating mental disorders, the Board must consider all the pertinent evidence of record and set forth a decision based on the totality of the evidence in accordance with all applicable legal criteria. See Carpenter, 8 Vet. App. at 242. Accordingly, an examiner's classification of the level of psychiatric impairment, by word or by a GAF score, is to be considered but is not determinative of the percentage VA disability rating to be assigned; the percentage evaluation is to be based on all the evidence that bears on occupational and social impairment. Id.; see also 38 C.F.R. § 4.126 (2007); VAOPGCPREC 10-95, 60 Fed. Reg. 43186 (1995). With consideration of the entire record, the Board finds that the objective medical evidence of record does not support an evaluation in excess of 50 percent at any time during the appeal period. The VA examination reports, and treatment reports, demonstrate that PTSD severely impairs the veteran. But the evidence does not show that level of impairment required for a 70 percent rating - there is no showing of suicidal or homicidal ideation; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately, or effectively; impaired impulse control; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances; or the inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. In reaching this decision, the Board notes the conflict in the veteran's marriage since he retired. But the Board also notes that the veteran has remained within his marriage, and plays a role in the lives of his children and grandchildren. Moreover, the record consistently shows that, though the veteran's mood is depressed, he is nevertheless well oriented and logical. In short, the evidence would not support a conclusion that the veteran's PTSD has caused occupational and social impairment with deficiencies in most areas of his life. Id. Based on all the evidence of record, to include all classifications by the examiners of the level of psychiatric impairment, the preponderance of the evidence of record does not show occupational and social impairment that meets the criteria for a rating in excess of 50 percent for the disability at issue at any time during the appeal period. See Hart, supra. Finally, in reaching this decision the Board considered the doctrine of reasonable doubt. However, as the preponderance of the evidence is against the veteran's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). II. Claims to Reopen In a January 1972 rating decision, the RO denied the veteran's claims for service connection for hypertension and for arthritis. In a May 1994 rating decision, the RO again denied the veteran's claims for service connection for hypertension and arthritis. The veteran did not appeal either of these decisions. As such, these decisions became final. See 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. § 20.200 (2007). In June 2001, the veteran filed to reopen his claims for service connection for hypertension and for arthritis. In the July 2002 rating decision currently on appeal, the RO denied these claims. The veteran timely appealed this decision to the Board. See 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. § 20.200 (2007). During the pendency of the appeal, the veteran and his representative argued: that the veteran's hypertension relates directly to his service; that the veteran's hypertension relates to his service-connected PTSD; that the veteran's hypertension relates to medication prescribed for other service-connected disorders; and that the veteran's arthritis relates to in-service injuries from the explosion that ejected him from a tank and caused his several service- connected disorders. See 38 C.F.R. §§ 3.303, 3.310. Service connection for VA compensation purposes will be granted for a disability resulting from disease or personal injury incurred in the line of duty or for aggravation of a preexisting injury in the active military, naval or air service. See 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303(a) (2007). Service connection may be established on a secondary basis for a disability that is proximately due to, the result of, or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310(a) (2007). Establishing service-connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310(a) (2006). See also Allen v. Brown, 7 Vet. App. 439 (1995) (en banc) reconciling Leopoldo v. Brown, 4 Vet. App. 216 (1993) and Tobin v. Derwinski, 2 Vet. App. 34 (1991). However, where a claim has been finally decided, VA, before addressing that claim anew, must first determine whether new and material evidence has been submitted to reopen that claim. 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156. If new and material evidence is presented or secured with respect to a final decision, the Secretary shall reopen and review the former disposition of that claim. See 38 U.S.C.A. § 5108. As such, to address the merits of the veteran's underlying service connection claims here, the Board must first decide whether VA has obtained new and material evidence since the final May 1994 rating decision which denied the veteran's service connection claims for hypertension and arthritis. The requirement of submitting new and material evidence to reopen a claim is a material legal issue that the Board is required to address on appeal regardless of the RO's determination. Barnett v. Brown, 83 F.3d 1380, 1383-84 (Fed. Cir. 1996). When a claim to reopen is presented, a two-step analysis is performed. The first step is to determine whether the evidence presented or secured since the last final disallowance of the claim is "new and material." See Elkins v. West, 12 Vet. App. 209, 218-19 (1999) (en banc); see also 38 U.S.C.A. § 5108; Hodge v. West, 155 F.3d 1356, 1359-60 (Fed. Cir. 1998). Under the version of 38 C.F.R. § 3.156(a) applicable to this case, new and material evidence is defined as evidence not previously submitted which bears directly and substantially upon the specific matter under consideration, which is neither cumulative nor redundant, and which by itself or in conjunction with evidence previously assembled is so significant that it must be considered in order to fairly decide the merits of the claim. 38 C.F.R. § 3.156(a) (as in effect prior to August 29, 2001); Hodge v. West, 155 F.3d 1356 (Fed. Cir. 1998). The Board acknowledges that there has been a regulatory change in the definition of new and material evidence that is applicable to all claims filed on or after August 29, 2001. As the veteran's claim in this case was filed prior to August 29, 2001, the earlier version of the definition of new and material evidence remains applicable in this case. Again, VA denied the veteran's service connection claims in a final May 1994 rating decision. To determine whether new and material evidence has been submitted since then, the Board must compare the evidence of record at the time of that decision with the evidence of record received since that decision. i. Evidence of Record Considered in the May 1994 Rating Decision The relevant evidence in May 1994 consisted of the veteran's statements claiming in-service and current arthritis and hypertension disorders; service medical records that do not indicate hypertension or arthritic problems; an October 1968 service medical record which states "126/98 x 2"; a September 1969 intensive care-recovery ward medical record indicating elevated blood pressure readings; a September 1971 separation report of medical examination that found no hypertensive or arthritic disorders; a November 1971 VA examination report that found no hypertension or arthritis; a private September 1976 hospital summary report that does not note arthritis or hypertension; November 1977, November 1980, December 1981, and March 1983 VA examination reports which do not note hypertension or arthritis; a March 1981 statement from the veteran complaining of "aching" in his pelvic area, legs and middle back, and of hypertension; a transcript of an RO hearing held in November 1981; a September 1982 private surgery report that does not mention hypertension; a March 1983 statement in which the veteran complains of osteoarthritis in his legs and ankles; a VA discharge summary report, reflecting inpatient VA treatment for PTSD from July to October 1985, noting hypertensive blood pressure readings; an August 1989 VA discharge summary report noting the veteran's complaints of pain but not noting hypertension; and an October 1992 private hospital summary report noting the veteran's complaints of chronic pain, but not rendering hypertension or arthritis diagnoses. In sum, the evidence in May 1994 indicated that - despite the veteran's complaints of orthopedic pain, and despite indications in the record that he had had high blood pressure readings - the veteran had not been diagnosed with hypertension or with arthritis. As such, VA denied the veteran's claims. Again, this decision became final. It is therefore not subject to revision upon the same factual basis. See 38 U.S.C.A. § 7105; 38 C.F.R. § 20.200. ii. Evidence of Record Received Since the May 1994 Rating Decision The evidence that must be considered in determining whether there is a basis for reopening the veteran's claims for service connection is evidence that has been added to the record since the final May 1994 rating decision. Since that decision, the RO has received additional statements from the veteran; VA treatment records reflecting complaints of chronic pain; private treatment records dated in December 1994 noting diagnoses of hip and knee arthritis; private treatment records dated from October 1997 noting diagnoses of hypertension; a January 1998 private examination report which indicates that the veteran's hypertension relates to his PTSD; a private treatment record dated in February 1999 noting arthritis of the neck; the transcript of a January 2004 personal hearing before the RO; a letter from the RO, dated in September 1971, which states that the veteran had service-connected arthritis and hypertension but that compensation was not due because these disorders were less than 10 percent disabling; VA treatment records showing diagnoses of hypertension and of degenerative joint disease at C-3, 4; lay statements from the veteran's former supervisor, his son, and his spouse; an August 2003 note from the veteran's private physician, noting the veteran's neck arthritis, and stating that the veteran's in-service injuries could relate to that arthritis; a medical journal article stating that stress may relate to hypertension; a June 2004 VA radiology report noting arthritis in the veteran's hips; an August 2004 letter from the veteran's private physician relating the veteran's arthritis and hypertension to service; and the transcript of the December 2007 video hearing before the Board. This is certainly new evidence in the claims file. Moreover, the Board finds some of this evidence to be material as well. The evidence showing current diagnoses of arthritis and hypertension is material as these diagnoses were not before VA in the January 1972 and May 1994 rating decisions. The letters from the veteran's private physicians suggesting a link between the veteran's service and his arthritis and hypertension is material. And the veteran's testimony in his December 2007 hearing is material as well - in that hearing, the veteran argues that his hypertension is related to PTSD; and in the hearing, he argues persuasively that the traumatic injuries he experienced during service caused his current degenerative arthritic disorders. See Roebuck v. Nicholson, 20 Vet. App. 207 (2006) (claim alleging separate theories of causation constitutes one claim for adjudication purposes). Indeed, this new and material evidence bears directly and substantially upon the specific issues of service connection here. Hence, the Board finds that the new and material evidence is so significant that it must be considered in order to fairly decide the merits of the veteran's service connection claims. See 38 C.F.R. § 3.156(a) (as in effect prior to August 29, 2001). Accordingly, the veteran's claims to reopen the claims for service connection for arthritis and hypertension are granted. Having reopened the veteran's claims, the next question is whether the Board is permitted to conduct a de novo review at this time. See Bernard v. Brown, 4 Vet. App. 384 (1994) (in assessing claims to reopen, the Board must determine whether the veteran has been given adequate notice of the need to submit evidence or argument on that question, and an opportunity to address the question at a hearing, and, if not, whether the veteran is prejudiced thereby). In this matter, the Board finds a remand appropriate. Additional medical evaluation is necessary into the issues of whether the veteran incurred arthritis or hypertension during service, whether hypertension relates to the veteran's service-connected PTSD, and whether hypertension relates to prescribed medication for other service-connected disorders. See 38 C.F.R. § 3.310. ORDER An increased evaluation for PTSD is denied. New and material evidence having been submitted, the claim for service connection for hypertension is reopened. New and material evidence having been submitted, the claim for service connection for arthritis is reopened. REMAND As indicated earlier, the Board finds remand appropriate here for the following issues: increased rating for bilateral hearing loss, increased rating for residuals of colostomy with psychophysiological reaction, service connection for sexual dysfunction, service connection for hypertension, and service connection for arthritis. Additional medical evaluation is appropriate for each claim. Moreover, the Board finds additional VCAA notice necessary with regard to the veteran's increased rating claim for residuals of colostomy with psychophysiological reaction. See Vazquez-Flores, supra. Accordingly, the case is REMANDED for the following action: 1. The RO should provide the veteran with a new VCAA letter addressing the veteran's increased rating claim for residuals of colostomy with psychophysiological reaction. See Vazquez-Flores, supra. 2. The veteran should be scheduled for VA examinations with appropriate specialists in order to determine the nature and severity of the veteran's service-connected hearing loss and service-connected residuals of colostomy with psychophysiological reaction. 3. The veteran should also be scheduled for VA examinations with appropriate specialists in order to determine the nature, severity and etiology of any current sexual dysfunction, hypertension, and arthritis. 4. The examiners evaluating the veteran's claims to service connection for sexual dysfunction, hypertension, and arthritis should advance opinions on the likelihood (likely, at least as likely as not, not likely) that any such disorder relates to service. 5. The examiner evaluating the veteran's claim to service connection for hypertension should also advance an opinion on the likelihood that the veteran's hypertension relates to his service-connected PTSD, or to medication prescribed for any service-connected disorder. And the examiner evaluating the veteran's claim to service connection for sexual dysfunction should likewise advance an opinion on the likelihood that such a disorder relates to medicine prescribed for a service-connected disorder. 6. The claims file must be made available to and reviewed by the examiners in conjunction with the examinations, and the examination reports should reflect that such reviews were made. All pertinent symptomatology and findings should be reported in detail. Any indicated diagnostic tests and studies should be accomplished. The veteran's complaints should be recorded in full. Each examiner should provide a complete rationale for any conclusions reached. 7. The RO should then readjudicate the issues on appeal. If a determination remains unfavorable to the veteran, the RO should issue a Supplemental Statement of the Case that contains notice of all relevant actions taken, including a summary of the evidence and applicable law and regulations considered pertinent to the issues. An appropriate period of time should be allowed for response by the veteran and his representative. Thereafter, the case should be returned to the Board for further appellate consideration, if in order. The veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims 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). ______________________________________________ WILLIAM YATES Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs