Citation NR: 9631259 Decision Date: 11/05/96 Archive Date: 11/14/96 DOCKET NO. 91-20 884 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUES 1. Entitlement to service connection for heart disability. 2. Entitlement to service connection for sterility due to gonorrhea and/or balanitis. 3. Entitlement to service connection for pulmonary disability due to asbestos exposure. 4. Entitlement to service connection for asthma due to mustard gas exposure. 5. Whether new and material evidence has been submitted to reopen the claim of entitlement to service connection for arthritis of the right hip and spine. 6. Whether new and material evidence has been submitted to reopen the claim of entitlement to service connection for residuals of a head injury. 7. Whether new and material evidence has been submitted to reopen the claim of entitlement to service connection for conversion reaction with psychogenic cephalgia. 8. Whether new and material evidence has been submitted to reopen the claim of entitlement to service connection for post-traumatic stress disorder, and if so, whether the claim may be granted. 9. Entitlement to an increased (compensable) rating for residuals of a tonsillectomy. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD Nancy S. Kettelle, Counsel INTRODUCTION The veteran had active service from August 1947 to July 1950 and from December 1950 to December 1953. This matter came to the Board of Veterans’ Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Los Angeles, California. The Board remanded the case for additional development in December 1991 and May 1995. The case has now been returned for further appellate consideration. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends he has heart disability due to war stress and that he should be granted service connection for sterility due to gonorrhea and/or balanitis for which he believes he received inadequate treatment in service. He also contends that he has current pulmonary disability due to asbestos exposure in service. The veteran in effect contends that there is new and material evidence to reopen claims for service connection for arthritis of the right hip and spine, residuals of a head injury, conversion reaction with psychogenic cephalgia, and post-traumatic stress disorder (PTSD). He contends that he has arthritis of the right hip and spine as a result of a back injury in service as evidenced by treatment for back complaints in service. He argues that service connection should be granted for residuals of a head injury because statements from a friend and his brother confirm that he had a head injury in service. He makes no explicit contentions regarding specific residuals of the head injury or the claim for service connection for conversion reaction with psychogenic cephalgia, but points out that he has provided lay statements attesting to his changed behavior after service compared with his behavior before service. With respect to service connection for PTSD, the veteran contends that he was in combat in Korea while with the 65th Combat Engineers and that he was awarded the Bronze Star Medal. Citing West v. Brown, 7 Vet.App. 70 (1994), he argues that this award is reasonable supportive evidence of stressors in service. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991 & Supp. 1995), has reviewed and considered all of the evidence and material of record in the veteran's claims files. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the claims for service connection for heart disability and sterility due to gonorrhea and/or balanitis are not well grounded. It is also the decision of the Board that the preponderance of the evidence is against the claim for service connection for pulmonary disability due to asbestos exposure. The Board has also decided that new and material evidence has not been submitted to reopen claims for service connection for arthritis of the right hip and spine, service connection for conversion reaction with psychogenic cephalgia and service connection for residuals of a head injury. It is the decision of the Board that new and material evidence has been submitted to reopen the claim for service connection for PTSD but that the preponderance of the evidence is against the grant of service connection for PTSD. FINDINGS OF FACT 1. The claim for service connection for heart disability is not plausible. 2. The claim for service connection for sterility due to gonorrhea and/or balanitis is not plausible. 3. The evidence does not demonstrate a causal relationship between the veteran’s pulmonary disability, first shown many years after service, and any asbestos to which he may have been exposed during service. 4. In a March 1986 decision, the Board denied service connection for arthritis of multiple joints, including arthritis of the spine and the right hip. 5. The evidence received since the March 1986 decision is either cumulative or duplicative of evidence previously of record or is not sufficiently relevant and probative, when reviewed in the context of all the evidence, to establish a reasonable possibility of changing the outcome of the prior denial of the claim. 6. In a March 1966 decision, the Board denied service connection for psychogenic cephalgia, claimed as a residual of head trauma; service connection for psychiatric disability, including PTSD, was denied in a March 1986 Board decision. 7. The evidence received since the March 1986 decision denying service connection for psychiatric disability other than PTSD is either cumulative or duplicative of evidence previously of record or is not sufficiently relevant and probative, when reviewed in the context of all the evidence, to establish a reasonable possibility of changing the outcome of the prior denial of the claim. 8. The evidence received since the March 1986 decision denying service connection for PTSD includes evidence which is not cumulative or duplicative of evidence previously of record and is sufficiently relevant and probative, when viewed in the context of all the evidence, to establish a reasonable possibility of changing the outcome of the prior denial of the claim. 9. The veteran does not have PTSD related to service. 10. In the March 1986 decision, the Board denied service connection for residuals of a head injury. 11. The evidence received since the March 1986 decision denying service connection for residuals of a head injury is either cumulative or duplicative of evidence previously of record or is not sufficiently relevant and probative, when reviewed in the context of all the evidence, to establish a reasonable possibility of changing the outcome of the prior denial of the claim. CONCLUSIONS OF LAW 1. The claim for service connection for heart disability is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 2. The claim for service connection for sterility due to gonorrhea and/or balanitis is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 3. Pulmonary disability due to asbestos exposure was not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131 (West 1991); 38 C.F.R. § 3.303 (1995). 4. Evidence received since the March 1986 Board decision denying service connection for arthritis of multiple joints including the spine and right hip is not new and material, and the claim for service connection for arthritis of the spine and right hip is not reopened. 38 U.S.C.A. § 5108 (West 1991); 38 C.F.R. § 3.156(a) (1995). 5. Evidence received since the March 1986 Board decision denying service connection for psychiatric disability other than PTSD is not new and material, and the claim for service connection for conversion reaction with psychogenic cephalgia is not reopened. 38 U.S.C.A. § 5108 (West 1991); 38 C.F.R. § 3.156(a) (1995). 6. Evidence received since the March 1986 Board decision denying service connection for PTSD is new and material, and the claim is reopened. 38 U.S.C.A. § 5108 (West 1991); 38 C.F.R. § 3.156(a) (1995). 7. PTSD was not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131 (West 1991); 38 C.F.R. § 3.303, 3.304(f) (1995). 8. Evidence received since the March 1986 Board decision denying service connection for residuals of a head injury is not new and material, and the claim is not reopened. 38 U.S.C.A. § 5108 (West 1991); 38 C.F.R. § 3.156(a) (1995). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service connection may be granted for disability resulting from disease or injury incurred or aggravated during service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. In addition, service connection for arteriosclerosis may be established on a presumptive basis if it is manifest to a degree of 10 percent of more within one year after separation from service. 38 U.S.C.A. §§ 1101(3), 1112(a) (West 1991); 38 C.F.R. §§ 3.307, 3.309(a) (1995). Service connection may also be granted for any disease diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). However, as a preliminary matter the Board must determine whether the veteran has presented evidence of well-grounded claims, that is, claims that are plausible and meritorious on their own or capable of substantiation. If not, his claims must fail, and VA is not obligated to assist the veteran in the development of his claims. 38 U.S.C.A. § 5107(a); Murphy v. Derwinski, 1 Vet.App. 78 (1990); Grottveit v. Brown, 5 Vet.App. 91 (1993); Tirpak v. Derwinski, 2 Vet.App. 609 (1992). The United States Court of Veterans Appeals (Court) has stated repeatedly that 38 U.S.C.A. § 5107(a) unequivocally places an initial burden on a claimant to produce evidence that his claim is well grounded. See Grivois v. Brown, 6 Vet.App. 136(1994); Grottveit v. Brown, 5 Vet.App. 91, 92 (1993); Tirpak v. Derwinski, 2 Vet.App. 609, 610-11 (1992). The Court has stated that the quality and quantity of evidence required to meet this statutory burden depends upon the issue presented by the claim. Grottveit at 92. Where the determinative issue involves medical causation or a medical diagnosis, competent medical evidence to the effect that the claim is plausible or possible is required. Id. Further, in order for a claim to be considered plausible, and therefore well grounded, there must be evidence of both a current disability and evidence of a relationship between that disability and an injury or disease incurred in service or some other manifestation of the disability during service. Rabideau v. Derwinski, 2 Vet.App. 141, 143 (1992); Brammer v. Derwinski, 3 Vet.App. 223, 225 (1992); Cuevas v. Principi, 3 Vet.App. 542, 543 (1992). The veteran’s service medical records for his first period of service include no complaint, finding or treatment related to heart disability or pulmonary disability. The records do show that the veteran was hospitalized in April 1949 for treatment of a penile ulcer, from May to June 1949 for balanitis and in March 1950 for “new” urethritis, acute, due to gonococcus. At his discharge examination in July 1950, laboratory tests were negative, and the physician stated there was no venereal disease. No abnormalities related to the veteran’s claimed disabilities were noted at his December 1950 enlistment examination for his second period of service. In late December 1950 and in April 1951 he was diagnosed as having “new” urethritis, acute, due to gonococcus and was treated without loss of time from duty. In August 1951 he was hospitalized and diagnosed as having urethritis, acute, due to gonococcus, new, and was treated with penicillin. At a February 1952 rotation examination and at his December 1953 discharge examination, chest X-rays were negative, laboratory studies were negative, and no complaint or finding related to any of the claimed disabilities was noted. The first post-service medical evidence is the report of a September 1964 VA examination. On examination, the veteran’s heart was well within normal limits in size and rhythm. There were no murmurs or thrills detected, and there was no dependent edema. The veteran gave a history of one episode during which he had some pain in his left arm and up into his left shoulder which came on while exercising. Rest relieved the discomfort, and the physician stated that electrocardiograms taken at the time were entirely normal. The physician noted that this had been a solitary attack and had not been repeated. He also stated that on physical examination there was no indication of arteriosclerotic heart disease, coronary insufficiency or angina. With respect to the respiratory system, the physician stated there was good mobility and no cough. The chest was negative to percussion and auscultation. At a March 1977 VA examination, the physician reported that heart sounds were good, there was normal sinus cardiac rhythm, and there was no audible murmur. The veteran’s lungs were clear on auscultation, and there were no rales or rhonchi. The veteran refused a chest X-ray. At a July 1984 VA examination, heart sounds were good. There were no murmurs, rhythm was regular, there was no gallop, nor were there premature ventricular contractions. Lungs were clear to auscultation and percussion, and there were no rales. Chest X-ray showed moderate elevation of the left diaphragm, and lungs appeared to be clear. The record includes a November 1984 letter from Robert Lugliani, M.D., a consultant in pulmonary disease, who reported that the veteran complained of increasing shortness of breath, dyspnea on exertion, increasing cough, wheezing and sputum production and increasing and progressive respiratory distress. The veteran reported that the symptoms had been present for the previous ten years and were becoming progressively worse with time. The veteran related that from 1952 to 1953, almost to 1954, he was in the army and was building an air force base in Goose Bay Labrador where he used asbestos materials and insulation . The veteran said he could recall cutting and sawing asbestos wall coverings. The veteran also reported that for approximately 13 months, in 1956 and 1957, he worked for Burton Manufacturing Company as a laborer manufacturing asbestos. The veteran stated that during that time he was exposed to copious quantities of smoke, dust and fumes including asbestos dust and fiber. The veteran told the physician that in neither situation was he ever offered face masks or respirators. Dr. Lugliani reported that chest X-ray revealed increased bronchovesicular markings with some hyperinflation, and he said that increased bibasilar interstitial changes were noted. He also stated that there was some questionable pleural thickening along the right mid-thoracic chest cage. Dr. Lugliani stated that a pulmonary function screen showed evidence of significant obstructive airway disease. On physical examination, the lungs revealed bilateral scattered rhonchi, and a few crepitant bibasilar rales were present in both right and left lower lung bases. The impression was moderately severe to severe obstructive airway disease and probable asbestos related lung disease. Dr. Lugliani stated that the veteran most probably had asbestos related lung disease based on his heavy exposure to asbestos during the early 50’s. He went on to say that there was a high probability that the veteran might have asbestos related lung disease and that he therefore merited further assessment to include additional pulmonary function studies and additional chest X-rays to be interpreted by a “B” reader. In May 1985, Charles L. Taylor, M.D., a radiologist, reported that chest X-rays revealed elevation of the left hemidiaphragm. He stated that the parenchymal lung fields were free of infiltrate, and he noted some ectasia of the thoracic aorta. His impression was slight elevation of the left hemidiaphragm, and he stated that differentials included partial atelectasis of the left lower lobe, partial paralysis of the phrenic nerve on the left, subdiaphragmatic mass or eventration or hernia of the left hemidiaphragm. A September 1985 VA X-ray report indicates that a chest X-ray at that time showed a scar at the left costophrenic angle. In a November 1985 letter, Brian P. Dolan, M.D., M.P.H., reported that he examined the veteran in September 1985 for evaluation of his pulmonary systems. The veteran gave a history of asbestos exposure in service in 1953 in construction, handling supplies and occasionally repairing steam pipes on board ship. He gave a history of asbestos exposure as a brake repairman doing two to three brake jobs per day in 1954. In 1957 he worked as a carpenter’s helper and was exposed to asbestos while working beside insulators who installed asbestos and fiberglass insulation. In 1958, while sweeping out newly constructed buildings, he was exposed to large amounts of asbestos-containing dust. For 8 to 9 months in 1975, he was exposed to asbestos, wood and plaster dust while his home was being remodeled. In his letter, Dr. Dolan noted that pulmonary function tests showed evidence of mixed restrictive and obstructive lung disease. He stated that chest X-rays were suggestive of asbestotic lung disease with bilateral interstitial opacities, but that characteristic pleural plaques and pleural and diaphragmatic calcifications were not present so that a definite diagnosis of asbestotic lung disease could not be made. Dr. Dolan stated that he felt that the veteran’s asbestos exposure significantly contributed to his present pulmonary disability. In a July 1987 initial internal medicine evaluation and report, Cranford L. Scott, M.D., stated that he had examined the veteran in April 1987 and that the veteran gave a history of asbestos exposure in service when he participated in the building of air force base facilities, when he loaded building supplies and materials and when he assisted occasionally with the repair of steam pipes that were insulated with asbestos wrappings. He also reported that following service he worked for the BMW Brake shop as a brake repairman, usually performing two to three brake repair jobs per day with exposure to asbestos from the repair process. The veteran said that he then worked for the Burton Manufacturing Company as a molder for approximately two years. He then worked for the Woods Construction Company as a construction laborer and said he was exposed to asbestos during his one year of employment there. He stated that at that job he worked beside insulators who used asbestos and fiberglass insulation materials. The veteran reported that he did not wear any type of respiratory protective devices during military service or while working for any of the employers. He also reported that in 1958 he went to work for the American Maintenance and Building Company, doing custodial work primarily, and said that in that work he had to remove a large amount of residual plastering and insulation materials from newly constructed buildings. He reported that there was a lot of dust emanating from these particulate matters. Dr. Scott referred to chest X-rays performed at Dr. Dolan’s office and the accompanying report of a radiologist who had stated there were small, irregular opacities in the right mid and lower lung zones, type S, perfusion 0/1, and that there was a horizontal discoid opacity at the left base which was either a fibrous scar or a temporary focus of segmental atelectasis. After review of the X-rays, pulmonary function studies and clinical examination, Dr. Scott’s final diagnoses included history of asbestos exposure with evidence of slight to moderate pulmonary restrictive disorder due to pulmonary asbestosis. Dr. Scott explained that although the veteran did not have the presence of persistent crepitant crackles on lung exam, findings of pleural plaques and/or thickening on chest X-ray or the presence of clubbing of the fingers, he did have four other diagnostic criteria sufficient to establish a diagnosis of pulmonary asbestosis, namely, history of exposure, dyspnea that had become increasingly worse in the previous 7 to 8 years, abnormal chest X-ray and abnormal pulmonary function studies consistent with restrictive ventilatory disorder. Dr. Scott concluded that there were four definite places of employment where the veteran was exposed to asbestos. He stated that it was difficult to offer any percentages as to which of his former employers was more or less culpable, but stated that he noted that the veteran’s last employer was the American Building and Maintenance Company where the veteran worked for a year and reported daily exposure to asbestos- containing materials as he performed custodial duties. Clinical records from Quincy Medical Center show that in February 1989, the veteran was seen for follow-up of a severe cold/upper respiratory infection and chronic obstructive pulmonary disease. Diffuse wheezes were noted on examination, and the diagnoses included chronic obstructive pulmonary disease, acute exacerbation. A chest X-ray at Quincy Medical Center at that time showed scattered interstitial markings which the radiologist stated were probably chronic and fibrotic. The radiologist noted eventration of the left hemidiaphragm. The impression was no acute or active process. The interpretation at pulmonary function tests in February and April 1989 was severe chest restriction. A report from Hawthorne Radiology Associates shows that in March 1989 a digital chest radiograph demonstrated mild emphysematous change, and a CT scan of the chest showed mild emphysematous changes without focal lung nodule infiltrate or mass. The radiologist saw no extrapleural lesions. The impression was mild senescent changes and no focal pulmonary lesions. An echocardiogram in March 1989 was within normal limits. In an August 1989 letter, V.M. Anakwenze, M.D., of Quincy Care Medical Group stated that the veteran had given a history of asbestosis and had presented several months earlier with severe wheezing. Dr. Anakwenze stated that the veteran required medication on a chronic basis. Clinical records from Quincy Care Medical Center dated from May 1989 to March 1991 show that the veteran was seen for medication refills on a monthly basis and that his complaints included coughing, wheezing, heart palpitations and impotence. Diagnoses during that period included chronic obstructive pulmonary disease, asthma, congestive heart failure, premature atrial contractions and impotence. Clinical records from Charles Okonkwo, M.D., dated from September 1984 to December 1993 show that the veteran was seen with complaints including chest pain, heart palpitations, wheezing, coughing and dyspnea on exertion. Diagnoses during that period included arteriosclerotic heart disease, premature atrial contractions and chronic obstructive pulmonary disease. In February and August 1989 X-ray reports furnished by Dr. Okonkwo, Charles L. Taylor, M.D.,(whose May 1985 report was mentioned earlier) reported that examination revealed elevation of the left hemidiaphragm and that differential considerations included partial paralysis of the phrenic nerve, diaphragmatic eventration and partial atelectasis of the left lower lobe. In his February 1989 report, Dr. Taylor stated that the parenchymal lung fields were clear, and in August 1989, he stated that the lung fields were clear and there was no active parenchymal infiltrate. Clinical assessments by Dr. Okonkwo in March and July 1989 included chronic obstructive pulmonary disease and questionable asbestosis. In an August 1989 letter, Dr. Okonkwo stated that the veteran was under his care for respiratory problems which had worsened in the previous six months. At a July 1995 VA examination, the physician noted that the veteran’s history included exposure to asbestos in the 50s. The veteran’s complaints included dyspnea, wheezing and paroxysmal nocturnal dyspnea. The assessment after examination was dyspnea likely related to asthma, questionable restrictive pattern secondary to elevated diaphragm versus possible exposure. The physician stated there was no evidence on chest X-ray. The veteran was to return for additional tests. In a VA consultation report, dated in August 1995, the consulting physician noted that the consultation was requested for evaluation of asbestos exposure and that the veteran complained of dyspnea for years and gave a history of asbestos exposure in the 50s. It was also noted that the veteran had a history of asthma with wheezing and nocturnal dyspnea. The physician noted that chest X-rays showed elevated hemidiaphragm (old), pulmonary function tests showed restrictive lung disease, severe, and CT chest scan showed no parenchymal abnormality. After examination, the impression included asthma. The impression also included restrictive disease of unknown etiology, most likely secondary to elevated hemidiaphragm. The physician stated there was no evidence of asbestos on CT, although this could not be ruled out. In an examination report completed in August 1995 at a VA pulmonary clinic, the physician stated that pulmonary function studies indicated severe restrictive disease without evidence of airway hyper-reactivity. The physician also stated that CT of the chest confirmed elevation of the left hemidiaphragm and no parenchymal disease. The diagnosis was asthma by history and restrictive lung disease of unknown etiology . The physician stated that this could represent asbestosis but it was unlikely in view of CT findings; he said the restrictive lung disease was most likely secondary to elevation of the hemidiaphragm. A VA outpatient record shows that the veteran was seen in a chest clinic in November 1995. The impression after examination was asthma, restrictive lung defect likely secondary to diaphragmatic condition and history of asbestos. Heart disability With respect to the veteran’s claim for service connection for heart disability, there is no medical evidence of heart disability earlier than the 1980s, and there are no clinical records or medical opinions relating any current heart disability to service. The Board is left with only the veteran’s assertion that he has heart disability due to war stress. However, the veteran is not qualified, as a lay person to furnish medical opinions or diagnoses. See Espiritu v. Derwinski, 2 Vet.App. 492, 494-95 (1992). With a claim such as this, where the determinative issue involves medical diagnosis and etiology, competent medical evidence is required to fulfill the well-grounded claim requirement of 38 U.S.C.A. § 5107(a). Heuer v. Brown, 7 Vet.App. 379, 384 (1995). Because the veteran cannot meet his initial burden by relying on his own opinion as to medical matters and he has submitted no cognizable evidence to support his claim, the claim for service connection for heart disability is not well grounded and must be denied. Sterility due to gonorrhea and/or balanitis The veteran contends that he suffers from sterility as a result of gonorrhea and/or balanitis in service asserting that he received improper treatment for those conditions. However, he has failed to submit medical evidence of sterility or medical evidence relating any current sterility to his in-service urethritis due to gonococcus and/or balanitis, or to the in-service treatment for those conditions. Consequently, the claim is not well grounded. See Espiritu, at 494-495; Grottveit at 91, 93. In support of the veteran’s claim, his representative cited the Merck Manual, 15th edition, page 234, stating that it indicates that sterility can be a complication of gonorrhea. As this reference does not establish any connection between the veteran’s particular condition and his service, it does not serve to make the claim well grounded. See Edenfield v. Brown, 8 Vet. App. 384 (1995) (en banc). As detailed above, the Board has denied service connection for heart disability and sterility due to gonorrhea and/or balanitis on the basis that those claims are not well grounded. Although the Board has considered and denied the claims on grounds different from that of the RO which denied them on the merits, the veteran has not been prejudiced by the Board’s decision. This is because in assuming that the claims were well grounded, the RO accorded the veteran greater consideration than the claims in fact warranted under the circumstances. Bernard v. Brown, 4 Vet.App. 384, 392-94 (1993). To remand these issues for consideration of whether the claims are well grounded would be pointless and, in light of the law cited above, would not result in a determination favorable to the veteran. VA O.G.C. Prec. Op. 16-92, 57 Fed.Reg. 49,747 (1992). Pulmonary disability due to asbestos exposure Regarding the claim for service connection for pulmonary disability due to asbestos exposure, the Board finds that this claim is well grounded within the meaning of 38 U.S.C.A. § 5107(a). That is, the claim is at least plausible. Further, the Board is satisfied that relevant facts sufficient to reach an equitable decision have been developed to the extent possible and that no further assistance to the veteran with respect to this claim is required to comply with 38 U.S.C.A. § 5107(a). In this regard, the RO has made repeated, though unsuccessful, attempts to obtain the veteran’s service personnel records for confirmation of the veteran’s claimed duty assignments. Neither the service department nor the veteran has been able to furnish such records. In addition, the veteran has been afforded a special VA pulmonary examination as requested by the Board. In McGinty v. Brown, 4 Vet.App. 428, 432 (1993), the Court observed that there has been no specific statutory guidance with regard to claims for service connection for asbestosis and other asbestos-related diseases, nor has the Secretary of VA promulgated any regulations. The Court noted, however, that in 1988 VA issued a circular on asbestos-related disease which provided some guidelines for considering compensation claims based on exposure to asbestos. The Board notes that the circular, Department of Veterans Benefits, Veterans Administration, DVB Circular 21-88-8 (May 11, 1988), was rescinded by the Director of the VA Compensation and Pension Service in September 1992 and, at that time, its contents were added as paragraph 7.68 of Part VI of the VA Adjudication Procedure Manual, M21-1 (hereinafter Manual M21- 1). According to Manual M21-1, Part VI, paragraph 7.68, the most common disease related to asbestos exposure is interstitial pulmonary fibrosis (asbestosis), and clinical diagnosis of asbestosis requires a history of exposure and radiographic evidence of parenchymal lung disease. In addition, it is stated that asbestos fibers may also produce pleural effusions and fibrosis, pleural plaques, mesotheliomas of pleura and peritoneum, lung cancer, and cancers of the gastrointestinal tract. In paragraph 7.68 it is also noted that cancers of the larynx and pharynx as well as the urogenital system (except the prostate) are also associated with asbestos exposure. There is no medical evidence suggesting that the veteran’s pulmonary disability was present in service or until many years thereafter, and neither the veteran nor his representative has contended otherwise. Review of the evidence outlined above shows that Dr. Lugliani in 1984 did conclude that the veteran most probably had asbestos related lung disease based on his heavy exposure to asbestos during the early 1950s. Dr. Lugliani’s report which included a history of asbestos exposure in 1952 and 1953 in service and later exposure in 1956 and 1957, supports a finding of the presence of pulmonary disease due to asbestos exposure in service. However, later reports, that is those from Dr. Dolan and Dr. Scott indicate that the veteran subsequently reported that he had additional asbestos exposure in 1954 while working as a brake repairman, while working beside installers of asbestos and fiberglass in 1957 and while sweeping out newly constructed buildings in 1958. In addition, Dr. Dolan noted that the veteran reported asbestos exposure for 8 or 9 months in 1975 while his home was being remodeled. Neither Dr. Dolan nor Dr. Scott specifically attributed the veteran’s restrictive pulmonary disability to asbestos exposure in service, and Dr. Scott remarked that it was difficult to offer any percentages as to which of the veteran’s former employers was more or less culpable. However, in that regard, Dr. Scott pointed out that the veteran reported daily exposure to asbestos-containing materials at his custodial job during 1958. Although a February 1989 chest X-ray report included from Quincy Medical Center stated that there were scattered interstitial markings, said by the radiologist to be probably chronic and fibrotic, and chronological records from Dr. Okonkwo show assessments including questionable asbestosis in March and July 1989, in February and August 1989 reports of chest X-rays another radiologist, Dr. Taylor, stated that lung fields were clear and there were no parenchymal infiltrates. Further, a March 1989 CT scan of the chest (with contrast) from Hawthorne Radiology Associates showed mild emphysematous changes without a focal lung nodule, infiltrate or mass. In view of the conflicting medical evidence from the private physicians, the Board requested VA examination of the veteran to include an opinion as to whether it is at least as likely as not that the veteran’s asbestos exposure in service played a material causal role in the development of any currently present pulmonary disability. As outlined above, the VA examiners diagnosed the veteran as having restrictive pulmonary disease, but found only elevated hemidiaphragm on chest X-ray. This was confirmed on CT which also showed no parenchymal disease. Although on one report it was stated that asbestos could not be ruled out and on another it was indicated that the restrictive lung disease could represent asbestosis, in each instance the physician stated that the restrictive lung disease was most likely secondary to elevation of the hemidiaphragm. This evidence is consistent with the results of the earlier 1989 CT scan and does is against a finding that the veteran’s current pulmonary disability is due to asbestos exposure at all, let alone that asbestos exposure in service played a material causal role in its development. The veteran’s complete claims file with all prior medical reports having been before the VA examiners, the Board gives greater weight to this current evidence than to the reports of Dr. Lugliani, Dr. Dolan and Dr. Scott, who apparently did not have the results of CT scans available to them. Under the circumstances, the Board finds that the preponderance of the evidence against the claim as it does not demonstrate that the veteran has current pulmonary disability attributable to asbestos exposure in service. Arthritis of the right hip and spine The veteran is claiming entitlement to service connection for arthritis of the right hip and spine. In a March 1986 decision, the Board denied service connection for arthritis of multiple joints, and in that decision considered arthritis of the cervical and lumbar spine and arthritis of the right hip. The denial was based on the finding that arthritis was not demonstrated in service and was first clinically established many years after service. Evidence of record in March 1986 included the veteran’s service medical records which included no finding or diagnosis of arthritis of right hip or spine. The service medical records do show that the veteran complained of low back pain in early July 1953. He was given heat treatments daily to the small part of the back with the last treatment in mid-July 1953. The report of the veteran’s December 1953 separation examination shows no complaint concerning the right hip or spine. The examiner evaluated the veteran’s lower extremities, spine and other musculoskeletal elements as normal. Also of record was the report of the September 1964 VA examination at which the examiner reported that the veteran’s musculoskeletal system was normal. The physician stated there were no subjective symptoms or objective findings. There was no limitation of motion of any joint. The record included a June 1971 X-ray report from Century Medical Group. Films of the lumbosacral spine revealed normal articular facets, normal transverse processes and very slight narrowing of the L4-5 intervertebral disc space. Cervical spine films showed extensive degenerative changes and spurring anteriorly at C4, 5 and 6, with slight loss of vertebral body height of C5 suggesting old traumatic residual. Also of record was an October 1971 letter from Stuart H. Baumgard, M.D, in which he stated that he had first seen the veteran in June 1971 following an automobile accident earlier that month. It was noted that the veteran stated that since the accident he had been suffering with continuous severe neck pain and continuous low back pain less severe than his neck pain. Dr. Baumgard stated that past history was non- revealing for previous trauma or previous neck or back pain. He stated that X-rays of the cervical spine showed severe degenerative arthritis and degenerative disc disease of the lower cervical vertebrae and that X-rays of the lumbosacral spine showed moderately severe degenerative disc disease of the 4th lumbar disk. The diagnosis reported by Dr. Baumgard was sprained ligaments intermuscular capsule of the cervical spine, aggravating pre-existing degenerative disc disease and degenerative arthrosis and sprained ligaments intermuscular capsule of the lumbosacral spine, aggravating pre-existing degenerative disc disease. In the record was a January 1972 letter from Dr. Baumgard to an insurance company. Dr. Baumgard listed the veteran’s date of injury as June 1971. Dr. Baumgard stated that as of January 1972 the veteran’s neck discomfort had markedly improved but low back discomfort had markedly intensified. After examination, the diagnoses included sprain, ligamentous capsule of the cervical spine, aggravating pre-existing degenerative disc disease and degenerative arthrosis, resolving. The diagnoses also included sprain, ligamentous capsule of the lumbosacral spine, aggravating pre-existing degenerative disc disease, probable herniated lower lumbar disc. Also in the record was a July 1973 letter from Ernest E. Ramey, M.D., who stated he examined the veteran and reviewed the veteran’s accompanying file. Dr. Ramey noted that the veteran’s history included having sustained a back injury in 1969 when he slipped on some stairs and was off work two months. The veteran reported that he had no difficulty until an April 1971 automobile accident. Dr. Ramey noted that the available records showed that a diagnosis of contusion of the left shoulder, hip and knee was made at that time. Dr. Ramey stated that additional reports showed a separate injury in June 1971 when the veteran’s car was struck in the rear by another car causing injuries of his back and neck. Dr. Ramey stated that July 1973 X-rays of the lumbosacral spine revealed a minimal decrease in the interspace between the L5 and S1, posteriorly. He said the remainder of the joint spaces appeared to be intact and the remainder of the bony architecture was within normal limits. After examination, the clinical diagnosis was lumbosacral strain, chronic. Dr. Ramey commented that with respect to the veteran’s lumbosacral spine he could find no evidence of a degenerated or herniated intervertebral disc. In an April 1975 letter, Dr. Ramey stated that the veteran was seen for re-evaluation and complaints included low back pain. On examination, there was limitation of motion of the lumbosacral spine with minimal muscle spasm and positive straight leg raising on the left side. Dr. Ramey stated there was excellent range of motion of both hips without crepitation noted. X-rays of the lumbosacral spine revealed a decrease in the interspace posteriorly between L5 and S1. The clinical diagnosis was chronic lumbosacral strain with left sciatica. In a July 1975 billing statement from Washington-Main Family Medical Group it was reported that the diagnosis for the veteran included generalized arthritis, cervical neck sprain and lumbar syndrome. In a July 1975 letter, Hugo V. Caesar, M.D., stated that the veteran had been under his care and was considered to have chronic sprain symptoms of the lumbar spine without any evidence of neurologic abnormality. Dr. Caesar stated that in July the veteran complained that his back was still achy. After examination, the impression included chronic low back syndrome. The record also included a portion of an August 1975 letter from Century Medical Group in which it was stated that the veteran gave a history of an April 1971 automobile accident and said that subsequently he had had pain in the left knee and back. At a March 1977 VA examination, the veteran complained of backache. On examination, there was pain on motion of the lumbar spine. The examiner reported that the cervical spine was within normal limits. Hip flexion was 100 degrees, abduction 40 degrees and adduction 20 degrees. March 1977 VA X-rays of the lumbosacral spine showed no gross narrowing of the intervertebral disc spaces. The pedicles, transverse processes, spinous process were intact. There was no spondylolisthesis, and the sacroiliac joints appeared normal. The impression was negative exam. In a June 1983 letter, Ernesto B. Banaag, M.D., (who, according to the letterhead was in practice with Morris Halfon, M.D.) reported that he had seen the veteran in March 1983 for examination and treatment of injuries the veteran stated were a direct result of a fall on March 1, 1983. The veteran stated he slipped and fell and was immediately aware of pain in his left groin and hip areas as well as his low back. Dr. Banaag stated that X-rays of the cervical spine showed proliferative osteophytes of the 4th through 6th vertebral bodies and that the lumbosacral spine showed no radiographic abnormality. He stated that X-rays of the pelvis revealed mild degenerative changes of the right and left hips. After examination, the clinical diagnoses included acute cervical spine sprain superimposed upon osteoarthritis and acute dorsolumbar spine sprain with musculoligamentous stretch injury. Of record was the report of a July 1984 VA examination where the veteran complaints included neck, lumbosacral spine and hip pain which he said were due to arthritis. After examination, clinical diagnoses included degenerative joint disease of the cervical spine and lumbosacral spine. July 1984 VA X-rays of the cervical spine showed advanced enthesopathy characterized by ligamentous ossification and para-articular osteophytes which the radiologist said were compatible with Forestier’s disease. X-rays of the lumbosacral spine showed the bodies, intervertebral spaces and small spinal joints in addition to the sacroiliac joints were all within normal limits. X-rays of both hips showed no significant bony, articular or soft tissue changes. In a sworn statement dated in October 1984, a fellow serviceman, [redacted] stated that he saw the veteran in Los Angeles, California, after service in 1954 and the veteran mentioned spinal pains. Mr. [redacted] sated that he advised the veteran to go to the VA hospital and that the veteran did so; Mr. [redacted] also stated that the next year he took the veteran to the hospital. He said that when he saw the veteran a few years later he had trouble walking due to arthritis. Also of record was a November 1984 statement from Morris Halfon, M.D., who reported that the veteran had been treated since March 1983 for arthritis of the cervical area and lumbosacrum and that he had degenerative changes in the knees and right hip. At an August 1985 hearing at the RO, the veteran testified that his low back pain began when he was in boot training and had to carry back packs. He testified that in addition when he was in Korea he had to sleep on the ground with only a sleeping bag when the temperature was 30 degrees below zero. He stated that this created more problems with his back and that he did have treatments on his back in service. He testified that at that time he was told that he had some form of arthritis of his back. The veteran’s representative stated that the veteran had reported that he had sought VA treatment in 1954 for his back and head. In view of the prior Board decision denying service connection for arthritis of the spine and right hip, the Board must determine whether new and material evidence has been added to the record since March 1986 decision to reopen the claim under 38 U.S.C.A. § 5108. New evidence is evidence that is not merely cumulative of other evidence in the record, and material evidence is that which is sufficiently relevant and probative of the issue at hand to establish a reasonable possibility that the outcome would be different when the new evidence is considered in light of all the evidence. See Blackburn v. Brown, 8 Vet.App. 97, 102 (1995); Colvin v. Derwinski, 1 Vet.App. 171 (1991). In determining whether new and material evidence has been presented to warrant reopening under 38 U.S.C.A. § 5108, consideration must be given to all of the evidence submitted since the last final disallowance of the claim. Evans v. Brown, No. 93-1120 (U.S. Vet. App. Aug. 1, 1996). The evidence to be analyzed here is that received since the March 1986 Board decision, as this is the most recent final decision concerning service connection for arthritis of the spine and right hip. The issue at hand to which any new evidence must be directed in order for the disallowed claim to be reopened is the specified basis for the last final disallowance of the claim. Evans slip op. at 18. As was noted earlier, in the March 1986 decision, the Board denial was based on the finding that arthritis was not demonstrated in service and was first clinically established many years after service, thus defining the issue at hand. Evidence added to the record subsequent to the March 1986 Board decision includes a December 1985 VA examination report. The veteran gave a history of arthritis in his back while he was in the army and said he had treatment at that time. He stated that his back had hurt ever since then. He also said that his back and neck hurt so much that he had to use a heating pad every night. On examination, there was limitation of motion with pain, and straight leg raising produced lumbosacral pain. The pertinent diagnosis was “Hx ‘arthritis’ knees, back, 1950, no Xrays available.” In an April 1986 rating decision, the RO confirmed and continued the denial of service connection for arthritis and found that the additional evidence was not new and material. In the same rating decision, the RO confirmed and continued a prior denial of the veteran’s claim of entitlement to a permanent and total rating for pension purposes. In an April 1986 letter, the RO informed the veteran of its decision continuing the denial of his pension claim, but did not inform him concerning its decision that there was no new and material evidence to reopen the claim of entitlement to service connection for arthritis. Also added to the record were clinical records from Dr. Okonkwo dated from January 1983 to December 1993. Complaints during that period included back and neck pain and the assessments included degenerative joint disease and degenerative disc disease. In a January 1988 X-ray report from A. Reece, M.D., concerning the lumbar spine, the impression was osteoarthritis of the facet joints at the L5- S1 level and the sacroiliac joints, bilaterally. Other evidence added to the record includes clinical records from Quincy Care Medical Center, dated from February 1989 to March 1991. Recorded in those records are complaints of back pain. The reported diagnoses include arthritis. Among the evidence added to the record are multiple copies of the veteran’s service medical records, copies of VA examination reports and X-ray reports, and copies of letters from private physicians of record in March 1986. In an August 1994 statement, Dr. Halfon reported that the veteran gave a history of having had an injury of the low back in service in Korea. Dr. Halfon reported that the veteran stated he fell on ice in Korea, was treated at a clinic and had had back trouble since the injury. Dr. Halfon stated that X-rays of the lumbar spine showed hypertrophic lipping with minor degenerative changes in posterior joints, particularly L5-S1. He reported that the veteran had severe changes in the neck area with spurring at C3, C 6 and C7 and ossicles at C2 in addition to hypertrophic spurring in C4-C6 segments. He stated the diagnoses were chronic arthritis of the lumbosacral spine (degenerative) and discogenic disease of the cervical spine. In addition, Dr. Halfon noted that the veteran also had a large olecranon spur removed from his right elbow which may have occurred with the fall. Added to the record in December 1995 were VA medical certificates dated in August and September 1982. The veteran complained of pain in the left side of his neck which had been worse for the past 2 to 3 months. He stated that he had had recurrences since 1951 when he was hit in the head with a rifle in combat. The diagnosis after clinical examination and X-rays was cervical and lumbar discogenic disease. In January 1996, the RO requested VA treatment records for the veteran dated from January 1954 to March 1995. In response, the RO received records related to hospitalization for psychiatric treatment in March 1995, an August 1982 X-ray report, a September 1982 consultation sheet, a September 1985 X-ray report and photocopies of some of the veteran’s service medical records. In the August 1982 X-ray report it was stated that the impression from X-rays of the lumbosacral spine was minimal degenerative changes and the impression from X-rays of the cervical spine was large anterior osteophytes and narrowed disc spaces from C4 through C7. On the September 1992 consultation sheet it was noted that the veteran complained of pains on the left side of his neck which had been worse over the previous 2 to 3 months. The provisional diagnosis was cervical discogenic disease. The sheet shows that the veteran did not report for a consultation with the rehabilitative medicine service scheduled for November 1982. The September 1985 X-ray report shows that X-rays of the lumbar spine revealed mild degenerative spondylosis of the lumbar spine at L4-L5 where the disc space was narrowed. The Board notes that arthritis is a chronic disease subject to service connection on a presumptive basis if it becomes manifest to a degree of 10 percent or more within one year of separation from service. See 38 U.S.C.A. § 1101(3), 1112; 38 C.F.R. §§ 3.307, 3.309(a). Alternatively, service connection may be established by showing continuity of symptomatology after discharge, see 38 C.F.R. § 3.303(b), unless there is medical evidence that there was an in-service condition that was “chronic” although not diagnosed as such in service, see Id., or there is evidence that connects the current condition to an in-service condition or event, see 38 C.F.R. § 3.303(d). The evidence that has been submitted since the March 1986 Board decision includes many documents that are duplicates of those previously of record and are thus obviously not new. Other evidence outlined above is relevant and was not previously of record. It includes medical evidence related to post-service treatment and diagnosis of the veteran’s arthritis of spine, but not the right hip. However, none of the evidence suggests that arthritis of spine was present within the first post-service year. Although the August 1982 VA medical certificate recorded the veteran’s history of having been hit in the head with a rifle butt in service with recurring neck pain, and the clinical diagnosis in August 1982 included discogenic disease of the cervical spine and X-rays at that time showed large osteophyte formation and narrowing of cervical disc spaces, neither the clinical physician nor the radiologist made any statement as to the cause or age of the cervical spine disability. As this evidence does not support a finding of a causal relationship between the in-service head injury and post-service disability, it is not probative of the issue at hand and is not material to reopen the claim. As noted above, Dr. Halfon in his August 1994 statement related that the veteran gave a history of a low back injury in service and that he currently had arthritis of the cervical and lumbosacral spine. Dr. Halfon said that the veteran “also had a large olecranon spur removed from his right elbow which may have occurred with the fall.” To the extent that that it may be inferred from the passage about the elbow that Dr. Halfon was implying that there is a causal connection between the claimed fall in service in the early 1950’s and the current arthritis of the spine, he was apparently basing his opinion strictly on history provided by the veteran, as there is no indication that Dr. Halfon considered the veteran’s intercurrent history of back injuries in 1969, 1971 and 1983. The Court has stated that opinions which are predicated on history related by the veteran can be no better than the facts alleged by him. Swann v. Brown, 5 Vet.App. 229, 233 (1993). Thus, the Board finds this opinion to have very limited probative value and concludes that when viewed in conjunction with all other evidence of record it would not raise a reasonable possibility of a different outcome on the merits, and thus is not material. In the absence of the submission of new and material evidence, the claim for service connection for arthritis of the right hip and spine is not reopened. Conversion reaction with psychogenic cephalgia, residuals of a head injury and PTSD In a March 1966 decision, the Board denied service connection for psychogenic cephalgia and explained that it was described by the veteran as residuals of a head injury in service. In its March 1986 decision, the Board denied service connection for residuals of a head injury based on the finding the evidence did not show the in-service origin or worsening of chronic residuals of a head injury. In the same decision the Board denied service connection for an acquired psychiatric disorder, including PTSD, finding that an acquired psychiatric was not present in service and the veteran had not been shown to have PTSD. The veteran is attempting to reopen the claims for service connection for conversion reaction with psychogenic cephalgia, residuals of a head injury and PTSD. With respect to each of the claims, the initial question is whether new and material evidence has been presented since the last final disallowance of the claim which, in each instance, was the March 1986 Board decision. Evidence of record at the time of the March 1986 Board decision included the veteran’s service medical records. The veteran’s service medical records for his first period of service include no history, complaint or finding relating to residuals of a head injury. Service medical records for the second period of service show that in November 1952 the veteran complained of recurrent headaches from a skull injury in Korea and reported that he had not received an X-ray at the time of the injury. A consultation sheet with a consultation request dated in January 1953 shows that the veteran gave a history of onset of headaches, dizziness and attacks of blurred visions three months following a blow on the head in the spring of 1951. It was stated that X-ray examination revealed an old fracture line involving the skull, more distinct on right side. It was noted that the X-ray request indicated that the veteran complained of pain on the left. In the consultation request it was stated that neurological examination, spinal tap and physical examinations were essentially negative. It was also stated that the possibility of post-traumatic organic brain disease was to be ruled out, and the provisional diagnosis was post- traumatic organic brain disease. A Clinical Record Cover Sheet shows that the veteran was seen as an outpatient at Walter Reed Army Hospital in February 1953, and the consultation sheet mentioned earlier shows that on that date an electroencephalogram was normal, awake and drowsy. Service medical records also show that the veteran was seen at an army hospital in New Orleans in April 1953 and stated that he had an old fracture on the right side of his head but that now the left side hurt, and he further stated that he had a “knot” on the left side which caused pain on the left side of his face. Additional history reported at that time was that the veteran sustained a fracture one year earlier when he was hit by a rifle butt in Korea on the left side, but the fracture was on the right side of the skull. Examination was negative, and X-rays were requested. In an April 1953 report of skull X-rays, the radiologist stated that no bone injury was recognized. The report of the veteran’s December 1953 separation examination includes no complaint, finding or diagnosis related to a head injury or psychiatric disability. In connection with his initial claim in 1964 for service connection for residuals of a head injury the veteran asserted that he had migraine headaches and possible brain damage as a result of his head injury in service. He stated that the injury occurred on April 1, 1951, and that he was treated at a first aid station of the 77th Combat Engineers, 25th Division. He referred to physicians from whom he received treatment and friends and family members who had knowledge of his injury. The record shows that VA attempted to obtain records and statements from individuals identified by the veteran. A VA Form 3101, Request for Information, shows that in August 1964 the RO requested information from the army. The RO reported that the veteran alleged a skull fracture with treatment in April 1951 at an aid station of the 77th Combat Engineers, 25th Division. The RO noted that there was reference to skull injuries in subsequent service medical records in the file and requested a search of company records at the time of the injury with a line of duty determination if available. The service department responded in October 1964 with USARCEN Form 598 stating that the veteran’s organization designation from 1 March 1951 to 13 April 1951 was Co. A 73rd Engineers Battalion. He was taken sick on 2 March 1951 (diagnosis not shown). The immediate disposition was hospitalization, with hospitalization at the 279th general hospital from 8 March 1951 to 11 April 1951 when he was returned to duty. The veteran’s specific location from 2 March to 8 March 1951 was not stated. It was stated the sick reports, excused from duty reports, morning reports, patient rosters and other unit type personnel records had been used in preparing the report. Service medical records show that on March 8, 1951, the veteran was admitted to the 279th general hospital in Osaka, Japan. The record shows that the veteran’s organization was Co A, 73rd Combat Engineers Battalion and that the initial admission was 1st MASH, APO, date unknown, and that the veteran was transferred to the 279th general hospital from the 157th MASH. It was stated that a transfer card was requested but not received. The diagnoses listed were tonsillitis, chronic, streptococcal, follicular, bilateral, suppurative and impaction of tooth #17. The tooth was extracted and a tonsillectomy was performed. The record indicates the veteran was released from the hospital on April 10, 1951, and was returned to duty. At the September 1964 VA examination, the veteran gave a history of having been struck on the head by a rifle butt or a blunt instrument which knocked him unconscious. He reported that this occurred in service and stated that he was on point of a patrol and when he regained consciousness he was alone with one buddy who killed the Chinese soldier who attacked him. He said a company aid man placed a bandage on the scalp wound, but he was not hospitalized for this. He stated that a few days later he sought treatment for headaches from his battalion surgeon, but it was not until approximately two years later that he sought additional treatment for his alleged skull fracture. At the September 1964 VA examination, the veteran complained of “migraine” headaches. On examination of the skull and scalp, there was an elevation of the periosteum at the bregma in the mid line, at the junction of the occiput and the parietal bone. Laterally, approximately 2 inches from the mid line and about 3 inches above the left ear, there was another slight irregularity felt in the periosteum covering the skull. These were the points that the veteran stated were involved when he was hit on the head by some object while in Korea. No scars were detectable. It was noted that the veteran’s headaches were not localized to the site of the injury and that they were made worse by emotional disturbances. The physician stated that the headaches could be due to functional disturbance of the cranial circulation, but also noted that the veteran was serving a prison term of 5 years to life for assault with a deadly weapon during an armed robbery and that it might be possible that the veteran was attempting to rationalize his act by establishing his headaches on a post-traumatic basis. The physician stated it was his opinion that any anxiety that the veteran might have was situational and that his headaches were associated with a guilt complex in which the veteran was trying to rationalize and blame it onto the alleged trauma to his head while he was in service. He stated that he did not believe that the veteran’s headaches were of a post-traumatic etiology. The diagnoses included head injury alleged periosteal thickening of the left parietal area and cephalgia, psychogenic, conversion reaction with vasomotor disturbances, migrainoid in character without anorexia, nausea and vomiting. A March 1972 consultation report from Midway Hospital in conjunction with knee surgery shows that at a physical examination the head was normocephalic. In his July 1975 letter primarily concerning orthopedic complaints and findings, Dr. Caesar reported that he examined the veteran and that examination revealed that the head was normocephalic with no external signs of trauma. At the September 1977 VA examination, the veteran made no complaints concerning his head, and his head and neck were evaluated as normal. In his June 1983 letter, Dr. Banaag stated that he had seen the veteran in March 1983 for examination and treatment of injuries the veteran said were the direct result of a fall in early March 1983. The veteran reported that he had fallen backward and that among other injuries his head struck the bricks of a flower bed and headaches developed. On examination, the head was normocephalic and nontender and diagnoses included history of blunt trauma to the head. In a statement received in April 1984, the veteran reported that he received a serious concussion when he was with the 933rd anti-aircraft battalion in Japan and that he received a combat injury when he was in the 65th Combat Engineers Battalion, 25th Division. He stated that his company was ambushed while sweeping for mines ahead of the front line and he suffered a blow to his head. He said he was a medic at the time and did not complain about his injury. He stated that he was also with the 77th Combat Engineers, 25th Division. At a July 1984 VA psychiatric examination, the veteran complained of headaches which he blamed on being struck on the head with a rifle butt while on patrol duty during the Korean conflict. The physician noted that the veteran claimed that he suffered a skull fracture in Korea but that his history suggested only that he may have suffered a concussion. The veteran stated that he lost quite a few of his buddies and some of them were blown up. He also said that at one time he went to drink in a stream and there were some dead bodies in it. The veteran reported his post- service work and prison history. After examination, the impression was cephalgia, probably tension headaches and borderline personality, with a history of 7½ years in prison for burglary. It was noted on the examination report that psychological testing was not completed because the veteran claimed he could not see well enough to finish the tests. In his October 1984 sworn statement, the veteran’s fellow serviceman, [redacted], stated that he had known the veteran since the Korean war and that he and the veteran would visit each other’s outfit in Korea. Mr. [redacted] stated that he had knowledge of the veteran’s injuries in service and at one time saw the veteran with a bandage around his head. Mr. [redacted] said the veteran was injured while on a mine-sweeping detail and had a serious concussion but that the veteran said it was nothing to stop him from carrying on. Mr. [redacted] stated that the veteran was rotated back to the United States in 1951 and that he next saw him after service in 1954. Mr. [redacted] said that at that time the veteran mentioned he had head and spinal pain and sometimes would black out. He said he took the veteran to the VA hospital in Los Angeles and the doctor said the veteran had an old fracture of the skull. He also stated that the veteran then seemed to start feeling very depressed and a few years later had problems remembering people, places and names. In an October 1984 statement the veteran reported that his combat was while he was in the 65th Combat Engineers, 25th division, and that was where his head injury occurred. At the August 1985 hearing at the RO, the veteran testified that his head injury was sustained in Korea during combat. He testified that he was in the combat engineers and while ahead of the front lines on a mine-sweeping mission in Korea he was struck on the head with a pick-handle or some type of hard instrument. He testified that his buddy shot the Chinese soldier who attacked him. He testified that his head was wrapped in bandages and he just carried on having been told it would be put on the record. He testified that he was a medic and carried on trying to help others who were injured. He testified that after he returned to the states it was discovered that he had a hairline fracture of the skull due to his head injury. The veteran also testified that prior to service he had no head injury or any accident involving his head. The veteran’s representative commented that the veteran had reported that he had sought VA treatment for his head problems in 1954. In its March 1986 decision, the Board denied service connection for residuals of a head injury on the basis that evidence added to the record subsequent to the March 1966 decision did not show that residuals of a head injury originated or became worse in service. The Board also denied service connection for an acquired psychiatric disorder, including PTSD, finding that a claim for psychogenic cephalgia had previously been denied and that an acquired psychiatric disorder was not present in service or thereafter and the veteran did not have PTSD. Evidence added to the record after March 1986 includes the clinical records from Dr. Okonkwo dated from January 1993 to December 1993 and the clinical records from Quincy Care Medical Center dated from February 1989 to March 1991. None of those include any complaint, finding or report of treatment identified as related to residuals of a head injury, conversion reaction with psychogenic cephalgia or PTSD. In a March 1994 sworn statement, the veteran’s brother reported that he and the veteran were in the army in Korea at the same time. He stated that he was with the 3rd Infantry Division, 7th Regiment, Company A and the veteran was in the 65th Combat Engineers, Company A, 25th Division. The veteran’s brother stated that he and the veteran both saw extremely heavy combat duty during a spring offensive in Korea in 1951. He stated that he visited the veteran when he was injured in 1951 and after 1951 did not see him again until 1978. The veteran’s brother stated that his brother had never been the same and would never be the same from his head injury. He also stated that MASH lost a lot of servicemen’s records and records were not shipped with them. In a July 1994 rating decision, the RO regarded the statement from the veteran’s brother as new and material to reopen the claim for service connection for residuals of a head injury but denied the claim on the merits on the basis that there was no medical evidence of chronic functional impairment resulting from the head injury. The veteran appealed. In letters received in September 1994, Mrs. [redacted], a friend of the veteran, reported that she had grown up with him. She stated that when he returned from service there was something wrong with him, he could not hold a job, and he behaved differently than he had before service. A letter from Mr. [redacted] was also received in September 1994. He reported that he had grown up with the veteran and that they had gone through training together in the army. He said he saw the veteran again when they were both home in 1950 and that he saw the veteran several times when they were both in Korea whenever they were both in the same area of fighting. He said that while there he was told that the veteran was in the rear with a head injury but that he was never told by anyone in the veteran’s company how the injury was received. Mr. [redacted] stated that he next saw the veteran in 1952 and at that time there was a difference in the veteran, he was not himself and it seemed he had begun to forget things and talked to himself. Mr. [redacted] said the veteran does not think and act as he did before he went to Korea, that something happened while the veteran was in Korea and he sometimes seems to forget where he is and where he is going and cannot hold a job. The report of a September 1994 psychiatric evaluation from Ara D. Kadoyan, M.D., shows that the veteran stated that since 1984 he had been having nightmares of the Korean war including seeing dead bodies covered with flies and seeing his friend being blown up. He reported that he felt depressed all the time, was unable to stay asleep and had been withdrawn and reclusive, not socializing with people. The veteran also complained of being paranoid and thinking people were following and watching him. The physician noted hallucinations and delusional thoughts. After examination, the impression was PTSD. In an October 1994 rating decision, the RO determined that new and material had not been presented to reopen a claim for service connection for conversion reaction with psychogenic cephalgia or a claim for service connection for PTSD. The veteran appealed. In October 1994, the RO received clinical records and prescription forms from Kenneth K. Nazari, M.D., showing that in September 1994 the veteran was seen with complaints of chronic headaches since the 1960s and concurrent staggering of gait and shaking of his hands. After examination, the impression was cephalgia and tremor. In October 1994, the veteran stated he was still having headaches and flashbacks of the Korean war. The assessment was cephalgia and insomnia. Medication was prescribed. VA hospital records and a discharge summary added to the record show that the veteran was hospitalized in March 1995 reporting flashbacks of dead bodies with flies on them and flashbacks of combat in Korea. He said that he saw many of his colleagues being killed in the war and had been having nightmares and depression since that time. He complained of sleep difficulty and memory problems. The veteran reported that two weeks prior to admission he had seen three shooting victims near his house and said his symptoms had exacerbated since that time. On mental status examination, the veteran indicated vague auditory hallucinations and some thought of paranoid ideation. His mood was depressed and affect was constricted and irritable. Attention span, concentration and memory were poor. The veteran refused an MRI of the head. It was noted that the report of a September 1994 CT scan of the head read as a negative investigation. The discharge diagnoses included depression, rule out dementia and pseudodementia, PTSD and rule out organic mood disorder. In an October 1995 letter, a VA physician stated that the veteran was currently receiving psychiatric care for psychological damage received during the Korean war in 1951- 52 and had been diagnosed with PTSD. The August 1982 VA medical certificate was received in December 1995 and shows that the veteran was seen with complaints of neck pain on the left side which had been worse over the past 2 to 3 months. He stated that he had had recurrences since 1951 when he was hit in the head with a rifle in combat. After examination and X-rays, the diagnosis was cervical and lumbar discogenic disease. VA mental hygiene clinic records dated from April to September 1995 show treatment for PTSD. In a March 1996 rating decision, the RO determined that new and material evidence had been presented to reopen the claim for service connection for PTSD and denied the claim on the merits. The RO found that there was no confirmed diagnosis of PTSD meeting all required diagnostic criteria and that the evidence was inadequate to establish that a stressful experience sufficient to cause PTSD actually occurred. The veteran continued his appeal. Received in April 1996 was a March 1996 VA PTSD consultation clinic progress note in which the physician stated the veteran was in the Korean conflict and experienced severe catastrophic stressors of combat. The physician stated that the veteran described watching his very close friend be killed and then having to assume his position as a medic, faced with multiple situations in which he was not trained to help. The veteran reported that he continued to experience severe nightmares and intrusive memories, avoidance of reminders of combat, hyper-aroused states of irritability and an increased startle response. The physician stated that the veteran had been unable to work since 1971 because of the enumerated symptoms. In an April 1996 letter, a VA psychiatrist stated that the veteran had been treated for PTSD at a VA mental hygiene clinic since March 1995 and by him personally since July 1995. The psychiatrist stated that he had established that the veteran served in Korea and received four “Bronze Stars (confirmed by certified DD-214).” The psychiatrist stated that the veteran reported a continuous history of combat- related nightmares, flashbacks and intrusive memories since his separation from service. The contents of these episodes reportedly included incidents where he saw friends killed in combat and conditions under which he was in extreme danger of physical harm. The psychiatrist stated that the veteran currently exhibited evidence of emotional and social avoidance, avoidance of recalling combat events as well as avoidance of stimuli that recalled his war experiences including movies and television programs containing any violent content. In addition, he stated that the veteran exhibited symptoms of hyperarousal including insomnia, irritability, hypervigilance and an exaggerated startle response, none of which was present prior to military service. The psychiatrist stated that the Axis I diagnosis was PTSD. The RO continued its denial of the claim for service connection for PTSD and issued a Supplemental Statement of the Case in which it considered the April 1996 letter from the VA psychiatrist. The RO concluded that the available evidence did not establish that the claimed in-service stressor sufficient to cause PTSD actually occurred. In conjunction with this, the RO outlined the conditions for award of the Bronze Service Star stating that within the Korean Theater between June 27, 1950, and July 27, 1953, one Bronze Service Star was awarded for each campaign under any of the following conditions: (1) Assigned or attached to and present for duty with a unit during the period in which it participated in combat. (2) Under order in the combat zone, in addition meets any of the following requirements: (a) awarded a combat decoration; (b) furnished a certificate by a commanding general of a corps, higher unit, or independent force that he actually participated in combat; (c) served at a normal post of duty; or (d) aboard a vessel other than in a passenger status and furnished a certificate by the home port commander of the vessel that he served in a combat zone. (3) Was an evader or escapee in the combat zone or recovered from a prisoner of war status in the combat zone during the time limitations of the campaign. In response to the Supplemental Statement of the Case, the veteran argued that in his combat experience with the 65th Combat Engineers he served on the front lines. He noted that the Supplemental Statement of the Case gave a good description of Bronze Service Stars, but then asserted that he was awarded the Bronze Star Medal. Citing West v. Brown, 7 Vet. App. 70 (1994), he argued that the Bronze Star is reasonable supportive evidence of stressors in service. Evidence added to the record since March 1986 includes no medical treatment record, examination report or medical opinion indicating that the veteran currently has conversion reaction with psychogenic cephalgia. The medical evidence is new but is neither relevant to or probative of the issue of service connection for conversion reaction with psychogenic cephalgia. To the extent that statements received in 1994 from the veteran’s brother and his friends, including another serviceman, are presented to support the claim to reopen, they state only that the veteran’s behavior was changed after service. The implicit assertions as to diagnosis and etiology, that is, that the veteran has conversion reaction with psychogenic cephalgia that was incurred in service, do not establish medically that the veteran has the disability or that it was incurred in service. Thus, this evidence, though new, is not probative of the issue of service connection for conversion reaction with psychogenic cephalgia because neither the veteran’s brother nor friends, as lay persons, are competent to offer medical opinions, and their assertions as to medical matters cannot serve as the predicate to reopen the claim under 38 U.S.C.A. § 5108. See Espiritu v. Derwinski, 2 Vet.App. 492, 494-95 (1992); see also Moray v. Brown, 5 Vet.App. 211, 214 (1993). With respect to the claim for service connection for residuals of a head injury, the only medical evidence added to the record that mentions the head injury is the August 1982 medical certificate received in December 1995. The veteran complained of neck pain which he said had recurred since 1951 when he was hit in the head with a rifle in combat. The diagnosis after examination and X-rays was cervical and lumbar discogenic disease. This evidence, although it mentions the veteran’s in-service head injury and his assertion of recurrences of neck pain since the injury, contains only a recitation of what the veteran had told the VA medical personnel, and as it is unenhanced by any additional medical comment by the examiner, is not competent medical evidence of an etiological relationship between the in-service head injury and a present condition. The evidence is thus not material and cannot serve to reopen the claim. See Butler v. Brown, 9 Vet.App. 167, 170 (1996); see also Leshore v. Brown, 8 Vet.App. 406, 409 (1995). The 1994 statements from the veteran’s brother and friends were previously not of record, but only the statements from the brother and Mr. [redacted] mention the head injury and are thus relevant to the attempt to reopen the claim for service connection for residuals of a head injury. The brother recalled that the veteran had been injured in 1951 and asserted that he had never been the same and would never be the same from his head injury. Mr. [redacted] recalled that he had been told that the veteran had received a head injury and observed that in the years following the injury there was a difference in the veteran in that he was not himself, forgot things and talked to himself. Although these statements were not previously of record, they are cumulative of Mr. [redacted]’s October 1984 statement as to the veteran’s changed behavior after service. Further, to the extent that they relate current disability to the in-service head injury, neither of these added statements is probative of the issue at hand as the veteran’s brother and Mr. [redacted], as laymen, are not competent to opine regarding medical matters. Moray at 214; see Espiritu at 494-95. Thus, these statements cannot be material because they are not probative of a causal link between the veteran’s service and a present condition. Butler at 170. The veteran, therefore, has not met the threshold requirement to reopen his claim for service connection for residuals of a head injury. Relative to the attempt to reopen the claim for service connection for PTSD, evidence added to the record, as outlined above, includes medical reports, progress notes and letters from physicians who have reported a diagnosis of PTSD with stressors related to combat in Korea, with witnessing friends being blown up or otherwise killed and drinking from a stream containing dead bodies as specific stressors. Presuming this evidence, and the veteran’s brother’s statement that the veteran saw extremely heavy combat duty during a spring offensive in Korea in 1951, is credible for the purpose of determining whether the claim should be reopened per the Court’s direction in Justus v. Principi, 3 Vet.App. 510, 513 (1992), the Board finds this evidence, which is new, to be relevant and probative of the presence of PTSD related to a stressor claimed to have occurred in service. When viewed in the context of all the evidence of record, it raises a reasonable possibility of changing the outcome of the prior denial of the claim. Having determined that new and material evidence has been added to the record, the veteran’s claim for service connection for PTSD is reopened. 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156(a). Having determined that the veteran’s claim for service connection for PTSD has been reopened, the merits of his claim must be evaluated in light of all the evidence, both new and old. Manio v. Derwinski, 1 Vet.App. 140, 146 (1991). With respect to PTSD, 38 C.F.R. § 3.303(f) specifically applies to the adjudication of claims for service connection and provides in pertinent part that service connection for PTSD requires medical evidence establishing a clear diagnosis of the condition, credible supporting evidence that the claimed in-service stressor actually occurred, and a link, established by medical evidence, between current symptomatology and the claimed in-service stressor. If the claimed stressor is related to combat, service department evidence that the veteran engaged in combat or that the veteran was awarded the Purple Heart, Combat Infantryman Badge, or similar combat citation will be accepted, in the absence of evidence to the contrary, as conclusive evidence of the claimed in-service stressor. In addition, Manual M21- 1 lists Bronze Star Medal with “V” Device as among the individual decorations considered evidence of participation in a stressful episode. Manual M21-1, Part VI, 7.46(c) (Oct. 11, 1995). However, corroborating evidence of a stressor is not restricted to service records, but may be obtained from other sources. Id. In its March 1996 Supplemental Statement of the Case in which it considered the March 1995 VA hospital records and discharge summary showing that Axis I diagnoses for the veteran included PTSD based on his recollections of having seen colleagues being killed in the war and having flashbacks of dead bodies with flies on them, the RO explained that the evidence was inadequate to establish that the claimed stressful events actually occurred. In a March 1996 report a VA physician stated that the veteran described a very close friend being killed and then having to assume his position as a medic. Notwithstanding the notice from the RO in the Supplemental Statement of the Case, the veteran has provided no specific information as to his friend’s name or the date or location (other than Korea) of the claimed stressful event. The veteran has instead argued that his brother’s statement shows that they fought side by side on the front lines and that his brother received the Medal of Honor and he received the Bronze Star Medal. Citing West v. Brown, 7 Vet.App. 70 (1994), he argues that this award is reasonable supportive evidence of stressors in service. The record shows that the RO made repeated attempts to obtain the veteran’s service personnel records. During this process, it was learned, in a report form DARP-VSE-B dated in September 1993, that the veteran’s individual military records had been sent to the Army Board of Corrections of Military Records. In a report dated in May 1994 it was indicated that the veteran’s records had been returned to the National Personnel Records Center (NPRC). In June 1994, NPRC furnished copies of the veteran’s DD Form 214, copies of service medical records, copies of post-service medical records and examination reports as well as copies of RO rating actions, letters and other materials already in the claims files. The material received does not include a DA Form 20 or other military personnel records for the veteran. Also received in June 1994 from NPRC was a copy of DD Form 149, Application for Correction of Military Record, dated in April 1991 and signed by the veteran showing that he asserted that he should have been separated from service on disability retirement because of injuries including his skull injury. He stated that his army file should include a recommendation for a Purple Heart but that he supposed that his MASH record for his Purple Heart was lost. There is no indication that the veteran’s application resulted in correction of his military records, nor does the veteran contend otherwise. In the absence of detailed military personnel records, the Board turns to the veteran’s DD Form 214 which shows that he received the Korean Service Medal, 4 Bronze Service Stars, one Overseas bar and the National Defense Service Medal. The veteran at one point argued that the Bronze Service Stars were evidence of combat, but later agreed with the description in which the RO outlined the conditions for award of the Bronze Service Star showing that it was not in itself evidence of combat. The veteran subsequently asserted that he was awarded the Bronze Star Medal and that this is evidence of stressors in service. Available evidence does not show that the veteran was awarded the Bronze Star Medal, and the veteran has submitted no evidence whatever to corroborate this claim. The only remaining evidence pertaining to the veteran’s contention that he experienced the claimed stressful events in combat are the October 1984 statement from Mr. [redacted], the veteran’s own August 1985 hearing testimony, the March 1994 statement from his brother and the September 1994 statement from Mr. [redacted] who also served in Korea. Mr. [redacted] said he and the veteran would visit each other’s outfit and that he at one time saw the veteran with a bandage on his head. He said the veteran was injured on a mine- sweeping detail, but Mr. [redacted] did not say that the injury was the result of enemy action or that he witnessed the injury. At the hearing in August 1985, the veteran testified that his head injury was sustained in combat while ahead of the front lines on a mine-sweeping mission; however, at that time the veteran did not describe the combat events he now describes as stressors, that is, seeing friends blown up and in particular seeing a very close friend being killed. Mr. [redacted] stated that he saw the veteran in Korea whenever they were in the same area of fighting and that he was told that the veteran received a head injury but did not know how the injury was received. Although Mr. [redacted] and Mr. [redacted] confirm that the veteran was in Korea and that he received a head injury, neither asserts that that veteran received his injury as a result of enemy action or that he was otherwise in combat. In his March 1994 statement the veteran’s brother reported that the veteran received a head injury in Korea and that he and the veteran both saw extremely heavy combat duty during a spring offensive in Korea in 1951. Although this statement confirms that the veteran received a head injury in service, it does not serve to demonstrate that the veteran was in combat as claimed because the veteran and his brother were not in the same unit and his brother does not state that he was in combat with the veteran, indicating that the brother does not have first-hand knowledge that the veteran was in fact in combat. In the absence of such corroborating evidence or service records confirming combat, the Board finds that the evidence does not demonstrate that the veteran served in combat or that there is credible supporting evidence of the actual occurrence of the specific stressful events claimed by the veteran, that is, seeing his friends being blown up or otherwise killed. In the absence of establishment of the claimed stressful events, an essential element required for service connection for PTSD under 38 C.F.R. § 3.304(f), the claim for service connection for PTSD must be denied. ORDER Service connection for heart disability is denied. Service connection for sterility due to gonorrhea and/or balanitis is denied. Service connection for pulmonary disability due to asbestos exposure in service is denied. New and material evidence not having been submitted, reopening of the claim for service connection for arthritis of the right hip and spine is denied. New and material evidence not having been submitted, reopening of the claim for service connection for conversion reaction with psychogenic cephalgia is denied. New and material evidence not having been submitted, reopening of the claim for service connection for residuals of a head injury is denied. The claim for service connection for PTSD is reopened and denied. REMAND Among the veteran’s claims is entitlement to service connection for asthma due to exposure to Mustard Gas in service. Medical evidence outlined earlier shows that the veteran has been diagnosed as having asthma. In December 1991, the veteran reported that he was exposed to mustard gas in the army in 1947 and also stated that he had additional exposure at Aberdeen Proving Ground in Maryland while training newly inducted soldiers. In a sworn statement dated in November 1993, the veteran’s niece stated that many years earlier the veteran had told her that he was in a test for mustard gas at some base in Alabama and later in Korea. She said she did not remember the dates. With respect to claims involving exposure to mustard gas and Lewisite, VA, in August 1994 issued the regulation currently in effect that provides, with limited exceptions, that full body exposure to nitrogen or sulfur mustard agent in service and subsequent development of certain diseases, including asthma, is sufficient to establish service connection. See 38 C.F.R. § 3.316. The regulation does not preclude a claimant from establishing that exposure to mustard gas actually caused the disability for which he is claiming service connection and that service connection is therefore warranted on a direct basis. Subsequent to the changes in the regulation, the Veterans Benefits Administration (VBA) of VA issued guidelines for development of claims relating to exposure to mustard gas or Lewisite (VBA Circular 21-9594 dated February 23, 1995, and Change 1 dated May 19, 1995). That document indicates that appropriate development in Army claims includes calling the VA central office to determine whether the claimant’s name is on a list of participants in mustard gas testing/training. The record indicates that this was done, and it was determined that the veteran’s name was not on the list. However, Appendix B of the circular also indicates that appropriate development for claims related to testing between 1950 and 1955 includes request of a record search by Commander, U.S. Army Chemical and Biological Defense Agency. There is no indication that this has been done, and the case must be returned for this development. The veteran is claiming entitlement to an increased rating for residuals of a tonsillectomy. Reports of 1995 VA examinations show that the veteran complained of throat pain and hoarseness which he said had been present since his tonsils were removed in service. The examination reports do not show that the veteran was examined for tonsillectomy residuals, and this should be done. The disability should be the be rated with consideration of that portion of the VA Schedule for Rating Disabilities (Rating Schedule) related to the respiratory system as it was in effect prior to October 7, 1996, as well as with consideration of revisions that became effective on that date. Accordingly, the case is REMANDED to the RO for the following actions: 1. The RO should contact the veteran and request that he provide additional information, if possible, as to the dates and locations of his claimed exposure to mustard gas in service. In addition, the RO should request that the veteran identify the names, addresses and approximate dates of treatment of all VA and non-VA health care providers from which he has recently received treatment or evaluation for tonsillectomy residuals. With any necessary authorization from the veteran, the RO should attempt to obtain and associate with the claims file copies of medical records identified by the veteran that have not been secured previously. 2. Then, the RO should review the claim for service connection for asthma due to mustard gas exposure following the guidelines for development of claims relating to mustard gas in VBA Circular 21-95-4 (dated February 23, 1995, Change 1 dated May 19, 1995, and any additional changes). All actions required by the guidelines are to be undertaken including requesting a record search by Commander, U.S. Army Chemical and Biological Defense Agency, Attn: AMSCB-CIH, Aberdeen Proving Ground, MD 21010-5423. All actions should documented fully in the veteran’s claims file. 3. The RO should arrange for VA examination of the veteran by a board certified ear, nose and throat specialist, if available, to determine the nature and extent of residuals of the veteran’s tonsillectomy, to include, but not be limited to, a determination as to whether, and if so, to what extent, the veteran has hoarseness with inflammation or thickening of the cords or inflammation or infiltration of mucous membrane. All indicated studies should be performed, and the claims files should be made available to the physician prior to the examination. 4. Then, the RO should review the claims files and ensure that all requested development has been conducted and completed in full. If any development is incomplete, appropriate corrective action is to be taken. 5. Thereafter, the RO should readjudicate the claim of entitlement to service connection for asthma due to exposure to mustard gas in service. The RO should also readjudicate the claim of entitlement to an increased rating for tonsillectomy residuals with consideration of the provisions of the Rating Schedule before and after the revisions that became effective October 7, 1996. If the benefits sought on appeal are not granted to the veteran’s satisfaction, the RO should issue a Supplemental Statement of the Case, and the veteran and his representative should be provided an opportunity to respond. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. By this REMAND, the Board intimates no opinion as to any final outcome warranted. No action is required of the veteran until he is otherwise notified by the RO. SHANE A. DURKIN Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, 741 (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. NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991 & Supp. 1995), a decision of the Board of Veterans’ Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans’ Judicial Review Act, Pub. L. No. 100-687, § 402, 102 Stat. 4105, 4122 (1988). The date that appears on the face of this decision constitutes the date of mailing and the copy of this decision that you have received is your notice of the action taken on your appeal by the Board of Veterans’ Appeals. Appellate rights do not attach to those issues addressed in the remand portion of the Board’s decision, because a 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) (1995). - 2 -