Citation NR: 9600927 Decision Date: 01/22/96 Archive Date: 02/07/96 DOCKET NO. 94-01 933 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Des Moines, Iowa THE ISSUES 1. Entitlement to service connection for the residuals of neck and head injuries. 2. Entitlement to service connection for post traumatic stress disorder. 3. Entitlement to service connection for a heart condition, including hypertension. WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD Martin F. Dunne, Counsel INTRODUCTION The veteran served on active duty in the Air Force from October 1965 until August 1972 and from January 1973 until January 1977. He served in Vietnam from November 1966 until December 1967. This matter comes before the Board of Veterans’ Appeals (Board) from a February 1991 rating decision of the Department of Veterans Affairs (VA) Des Moines, Iowa, Regional Office (RO) that denied the veteran’s claim. REMAND On the issue of entitlement to service connection for the residuals of neck and head injuries, the veteran’s service medical records show that, while in Vietnam, he sustained injuries in two separate incidents which occurred on the same day in July 1967. He sustained head injuries, lacerations and abrasions, in a diving accident and, later in the day, he sustained injuries to his chest and back when a 2 1/2 ton truck in which he was a passenger went off the road, hit a telephone pole, and he was thrown from the vehicle. In December 1973, he was seen for complaints relating to his left shoulder, hand and fingers. X-rays taken of his left shoulder in January 1974 revealed possible cervical outlet syndrome. Post-service, he was seen at St. Anthony’s Hospital in April 1980 for virtually identical complaints relating to his neck, left shoulder, arm, and wrist. A lesion of the cervical spine was suspected. On VA examination conducted in January 1991, the veteran described his in-service injuries and reported that, subsequent to those injuries, he had had chronic neck pain with radiculopathy down the left shoulder area. The diagnoses included chronic pain syndrome in the lower cervical spine, a history of an in-service head injury, and possible mild degenerative disc disease of the cervical spine. As for the issue of entitlement to service connection for post traumatic stress disorder (PTSD), the veteran, at his personal hearing held at the RO in December 1992, described incidents that occurred while he was in Vietnam. Included was the last name of an airman (George) who was severely injured while performing maintenance on a fighter jet when the ejection seat accidentally released. He also described an incident that occurred on a runway where a plane loaded with napalm, and located not far from where he was performing maintenance on another plane, exploded killing the pilot and co-pilot. In the veteran’s claims file there is a private physician’s August 1989 diagnosis of PTSD and letters from a clinical social worker at a private mental health clinic relating that the veteran had been treated for PTSD since January 1989. In January 1991, the veteran underwent a VA psychiatric examination for PTSD and the examiner diagnosed dysthymia, primary type, late onset. A diagnosis of PTSD was not made. In June 1991, the veteran underwent another psychiatric examination by yet another private psychiatrist. Again, the diagnosis was PTSD. Significantly, each of the above-mentioned examinations was based upon interviews with the veteran and on a history as related by him. The Board, however, is not bound to accept medical opinions which are based on history supplied by the veteran where that history is unsupported by the medical evidence. Black v. Brown, 5 Vet.App. 177 (1993); Swann v. Brown, 5 Vet.App. 229 (1993); Reonal v. Brown, 5 Vet.App. 458 (1993); Guimond v. Brown, 6 Vet.App. 69 (1993). Moreover, the Board is not required to accept a physician’s diagnosis “[j]ust because a physician or other health care professional accepted the appellant’s description of his [wartime] experiences as credible and diagnosed the appellant as suffering from PTSD.” West v. Brown, 7 Vet.App. 70, 77 (1994) quoting Wilson v. Derwinski, 2 Vet.App. 614, 618 (1992). Indeed, service connection for PTSD requires medical evidence establishing a clear diagnosis of the disorder, credible supporting evidence that the claimed in-service stressor(s) actually occurred, and a link, established by medical evidence, between current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304(f). The Board further observes that the stressor information which the veteran has supplied to the RO has not been referred to the United States Army and Joint Services Environmental Support Group (ESG) in an attempt to verify the claimed stressors. In this respect, the Board acknowledges that the information provided by the veteran probably is not as complete as the ESG will need to verify the existence of the veteran's claimed stressors. Nevertheless, the provisions of the VA ADJUDICATION PROCEDURE MANUAL M21-1 (MANUAL M21-1) pertaining to the adjudication of PTSD provide that "where records available to the rating board do not provide objective or supportive evidence of the alleged in-service traumatic stressor, it is necessary to develop this evidence." MANUAL M21-1, Part VI, 7.46(f)(2) (emphasis added). Accordingly, as the development outlined in MANUAL M21-1 includes providing the information submitted by the veteran to the ESG, such development is mandatory. The veteran’s non-VA psychiatric examinations found that the veteran has PTSD; however, examinations based on a questionable history are inadequate for rating purposes. West, 7 Vet.App. at 77-8. Thus, it is necessary that the veteran be provided an examination where the examiner has the accurate history of the veteran's military service. In reviewing the evidence of record, the Board notes that, in connection with the claim for entitlement to service connection for a heart condition, there is the inextricably intertwined claim of entitlement to service connection for hypertension. The latter issue has not been adjudicated by the RO and must be addressed before an appellate decision is made on the former issue. See, Harris v. Derwinski, 1 Vet.App. 180 (1991). In support of his claim, the veteran maintains that several elevated blood pressure readings are recorded in his service medical records and that hypertension was diagnosed in June 1977, i.e., within a year of his separation from active duty service, while he was in St. Benedict’s Hospital being treated for left renal calculi. He further contends that the in-service diagnoses of probable viral pericarditis and atrial fibrillation were, in fact, initial symptoms of atherosclerotic cardiovascular disease that ultimately resulted in the myocardial infarctions of December 1988 and December 1989. Therefore, pursuant to the VA's duty to assist the veteran in the development of facts pertinent to his claim under 38 U.S.C.A. § 5107(a); 38 C.F.R. § 3.103(a), this case is REMANDED to the RO for the following development: 1. The RO should obtain and associate with the veteran’s claims file copies of all non-VA post-service health treatment records pertaining to neck and head complaints and heart condition, including hypertension, and, in the case of PTSD, or any psychiatric symptomatology in general, his treatment records since January 1989. 2. The RO is to request from the veteran a statement containing as much detail as possible regarding any and all stressful events to which he was exposed in service. He should be asked to provide specific details of the claimed stressful events to the best of his ability. The veteran's statement should include dates, places, detailed descriptions of the events, the number of times these events occurred, the locations, the identities of any individual he may have witnessed being killed or seriously wounded and any other identifying information concerning other individuals involved in the events. 3. After obtaining the foregoing requested information from the veteran, the RO should forward it, together with copies of the veteran's service personnel records and copies of his multiple records of service (DD Form 214), to the United States Army and Joint Services Environmental Support Group, 7798 Cissna Road, Springfield, Virginia 22150, in an attempt to verify the claimed stressors. Any information obtained is to be associated with his claims file. 4. Following receipt of the ESG's report and completion of any additional development warranted or suggested by that office, see e.g. Zarycki v. Brown, 6 Vet.App. 91, 99 (1993), the RO should prepare a report detailing the nature of any combat action, or in-service stressful event, verified by the ESG. If no combat stressor has been verified, the RO should so state in its report. This report is then to be added to the claims folder. 5. Once the above-mentioned development has been accomplished, then, and only then, is the RO to arrange for the veteran to undergo orthopedic, neurologic, cardiology, and psychiatric examinations at a VA medical facility. These examinations must be conducted in accordance with the VA's Physician's Guide for Disability Evaluation Examinations. All appropriate tests are to be conducted and X-rays taken. The veteran's claims file, together with a copy of this remand, must be provided to and reviewed by all examiners prior to their respective studies. The examiners are to report detailed findings, both positive and negative, and provide complete rationale for all opinions expressed. All examination reports are to be incorporated with the veteran's claims file. The psychiatric examination is to be conducted by a board of two VA psychiatrists who are familiar with PTSD and, preferably, who have not previously seen or treated the veteran. In conducting the veteran's psychiatric examination, the board of two psychiatrists are to note and distinguish the symptomatology of any and all psychiatric disorders found, including PTSD if existing. The examiners must express an opinion whether any psychiatric disability is linked to any specific incident or incidents in service. If symptoms of differing psychiatric disorders cannot be distinguished, the examiners should so state and explain why. In determining whether or not the veteran has PTSD due to an in-service stressor, the board of two psychiatrists are hereby notified that only the verified history, detailed in the reports provided by the ESG and/or the RO, may be relied upon. If the examiners believe that PTSD is the appropriate diagnosis, they must specifically identify which stressor(s) detailed in the ESG's and/or the RO's report is (are) responsible for that conclusion. Any and all opinions expressed must be accompanied by complete rationale and the medical evaluation report is to be incorporated in the veteran’s claims file. Following completion of the foregoing, the RO must review the claims file to ensure that all of the above-mentioned development has been completed in full. In particular, the RO should review the VA psychiatric examination report to verify that any diagnosis of PTSD was based on the verified history provided by the ESG and/or RO. If the examiners relied upon a stressor history which was not verified, that examination report must be returned as inadequate for rating purposes. The Board emphasizes that the Court has held that a diagnosis of PTSD, related to service, based on an examination which relied upon an unverified history is inadequate. West, 7 Vet.App. at 77. The orthopedic and neurologic examiners are to determine the nature, severity and extent of any head or cervical spine disorder found. The examiners are requested to offer opinions as to whether it is as likely as not that there is an etiological relationship, or nexus, between any currently noted head or cervical spine condition and an incident that occurred or injury sustained while he was in service. If the examiners are unable to provide opinions, that fact should be noted in the examination report, together with detailed rationale explaining why the opinions cannot be provided. Complete written rationale must be offered with all opinions expressed and the examination report must be associated with the veteran’s claims file. The cardiology examiner is to express an opinion as to whether it is as likely as not that there is an etiological relationship, or nexus, between the veteran’s current heart condition, including hypertension, and elevated blood pressure readings noted in service, hypertension noted within a year of separation from service, and questionable pericarditis and atrial fibrillation noted in service. Complete written rationale must be offered with all opinions expressed and the examination report must be associated with the veteran’s claims file. If the examiner is unable to provide opinions, that fact should be noted in the examination report together with a detailed rationale explaining why the opinions cannot be provided. 6. Following completion of the foregoing, the RO must review the claims file and ensure that all of the above mentioned development has been completed in full. If any development is incomplete, including if the examination reports do not include the requested opinions, or if the opinions do not include supporting rationale, appropriate corrective action is to be implemented. 7. Lastly, the RO is to review and reevaluate the veteran’s claim of entitlement to service connection for the residuals of neck and head injuries, PTSD, and heart condition, including hypertension. If any or all of the decision remains unfavorable to the veteran, he and his representative are to be provided with a supplemental statement of the case and afforded a reasonable period of time in which to respond. Thereafter, in accordance with current appellate procedures, the claims file, to include the additional requested evidence, is to be returned to the Board for further appellate consideration. The Board expresses no opinion, either legal or factual, as to the final outcome warranted in this case. The veteran need take no action until he is contacted by the RO. WARREN W. RICE, JR. Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. Under 38 U.S.C.A. § 7252 (West 1991), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Veterans Appeals. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (1994). - 2 -