Citation Nr: 0007332 Decision Date: 03/17/00 Archive Date: 03/23/00 DOCKET NO. 97-12 469 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUES 1. Entitlement to service connection for hearing loss. 2. Entitlement to service connection for tinnitus. 3. Entitlement to service connection for PTSD. 4. Entitlement to service connection for sinusitis, secondary to nasal fracture. 5. Entitlement to service connection for rhinitis secondary to nasal fracture. 6. Entitlement to service connection for headaches secondary to nasal fracture. 7. Entitlement to service connection for depression and anxiety secondary to nasal fracture. REPRESENTATION Appellant represented by: John Stevens Berry, Attorney ATTORNEY FOR THE BOARD G. R. Gleeson, Associate Counsel INTRODUCTION The veteran served on active military duty from May 1966 to April 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office in Lincoln, Nebraska (RO), dated in April 1996, March 1997, and September 1997. The claims for service connection for hearing loss and tinnitus were previously remanded by the Board in a June 1998 opinion. In that remand opinion, the Board asked that the veteran be scheduled for an audiology examination to determine the etiology of the veteran's hearing loss and tinnitus. The RO scheduled the veteran for an examination on two occasions, and both times the veteran failed to report. The claims are now properly before the Board for further appellate review. In correspondence dated in February 1998, the veteran's representative had requested a personal hearing. In a letter dated in January 2000, the Board contacted the veteran's representative, inquiring whether a hearing was still desired. The veteran's representative replied in a letter dated in February 2000, stating that their office had attempted to reach the veteran and had been unsuccessful, and asking that the Board proceed with appellate review. FINDINGS OF FACT 1. There is no probative medical evidence that the veteran's hearing loss is due to military service. 2. There is no probative medical evidence that the veteran's tinnitus is due to military service. 3. The veteran did not serve in a combat capacity, and he has no diagnosis of PTSD based on verified stressors. 4. There is no competent medical evidence of a nexus between the veteran's sinusitis and his period of service. 5. There is no competent medical evidence of a nexus between the veteran's rhinitis and his period of service. 6. There is inconclusive medical evidence that the veteran's headaches are related to his nasal fracture in service. 7. There is no competent medical evidence that the veteran's anxiety and depression are related to his fractured nose. CONCLUSIONS OF LAW 1. Hearing loss was not incurred or aggravated in service. 38 U.S.C.A. § 1110 (West 1991); 38 C.F.R. § 3.303(a) (1999). 2. There is no probative medical evidence that the veteran's tinnitus is due to military service. 38 U.S.C.A. § 1110 (West 1991); 38 C.F.R. § 3.303(a) (1999). 3. The claim for service connection for PTSD is not well grounded. 38 U.S.C.A. § 5107 (West 1991). 4. The claim for service connection for sinusitis, secondary to fractured nose, is not well grounded. 38 U.S.C.A. § 5107 (West 1991). 5. The claim for service connection for rhinitis, secondary to fractured nose, is not well grounded. 38 U.S.C.A. § 5107 (West 1991). 6. The claim for service connection for headaches, secondary to fractured nose, is well grounded. 38 U.S.C.A. § 5107 (West 1991). 7. The claim for service connection for depression and anxiety, secondary to fractured nose, is not well grounded. 38 C.F.R. § 5107 (West 1991). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service connection for hearing loss and tinnitus As a preliminary matter, the Board notes that the claims for service connection for hearing loss and tinnitus were previously determined to be well grounded in the Board's June 1998 remand opinion. See 38 U.S.C.A. § 5107(a). Furthermore, given that the RO scheduled the veteran for two recent VA examinations, and he failed to report, the Board concludes that the duty to assist has been satisfied. 38 U.S.C.A. § 5107(a); 38 C.F.R. § 3.103(a). The service medical records show no complaints of hearing loss or tinnitus and no injuries or disease of the ear during service. It appears that no audiology test was performed at the veteran's separation examination in April 1968. However, the veteran reported no history of hearing loss, running ears or ear trouble. The first post-service medical evidence pertaining to hearing loss and tinnitus is the VA audiology examination dated in January 1995. The veteran reported a long-standing hearing loss. He denied any history of ear pathology or related illnesses. He reported working in a battalion maintenance unit and truck-driving capacity in service. He also reported a periodic tinnitus in the right ear, described as a buzzing or ringing. He believed it began in 1983. On examination, the right ear had a mild sensorineural hearing loss from 2000 Hz to 8000 Hz and the left ear had a mild to moderate sensorineural loss from 2000 Hz to 8000 Hz. The examiner stated that the report of tinnitus was consistent with hearing loss and noise exposure. On an undated tinnitus worksheet, the veteran stated that he first started having tinnitus in January 1983, and that at that time he had experienced a cold and head injury. The weight of the medical evidence of record is that there is no etiological relationship between the veteran's hearing loss and tinnitus and his period of service. Although the veteran has developed hearing loss and tinnitus both consistent with past noise exposure, there is no indication in the record that these conditions are due specifically to noise in service. It is noted that the Board remanded this issue in 1998 to have the veteran examined and obtain a medical opinion which could be helpful to his claim. The veteran failed twice to appear for the examination. He is reminded that the duty to assist is not a one way street. Given the substantial gap in time between the onset of hearing loss, first diagnosed in 1996, and tinnitus, first observed by the veteran in 1983, and the period of service, which ended in 1968, the Board is led to conclude that hearing loss and tinnitus are likely due to some intervening factors, such as vocational or environmental noise. Service connection is therefore not warranted for either condition. Service connection for PTSD A veteran is entitled to service connection for a disability resulting from a disease or injury incurred in or aggravated in the line of duty while in the active military, naval, or air service. See 38 U.S.C.A. § 1110 (West 1991); 38 C.F.R. § 3.303 (1998). The threshold question in evaluating a claim for service connection is whether the claim is well grounded. A well-grounded claim is one that is plausible, capable of substantiation or meritorious on its own. See 38 U.S.C.A. § 5107(a); Grivois v. Brown, 6 Vet. App. 136, 140 (1994); Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). While the claim need not be conclusive it must be accompanied by supporting evidence. Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992). In the absence of evidence of a well-grounded claim there is no duty to assist the claimant in developing the facts pertinent to his claim and the claim must fail. Epps v. Gober, 126 F.3d 1464, 1467-68 (1997). For a claim for service connection for PTSD to be well grounded, there must be (1) medical evidence establishing a clear diagnosis of PTSD; (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a causal link between current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304(f) (1998); Cohen v. Brown, 10 Vet. App. 128 (1997). A clear diagnosis is an unequivocal diagnosis made by a mental health care professional. See Cohen, 10 Vet. App. at 140. The regulations governing service connection for PTSD differ somewhat from those for other conditions because they require evidence of an in-service stressor, as opposed to evidence that a disease or injury was incurred or aggravated during service or within a presumptive post-service period. Compare 38 C.F.R. § 3.304(a) with 38 C.F.R. § 3.304(f); see Moreau v. Brown, 9 Vet. App. 389, 396 (1996). The type of evidence which will be accepted to verify the existence of the in- service stressor varies, depending on whether or not the veteran was engaged in combat with the enemy. If it is determined through military citation or other supporting evidence that a veteran engaged in combat with the enemy, and that the claimed stressors are related to combat, the veteran's testimony regarding the reported stressors is accepted as conclusive evidence as to the occurrence of the stressor. 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d)-(f). If, however, a veteran did not engage in combat or the claimed stressor is unrelated to combat, then there must be additional credible supporting evidence to verify the occurrence of the alleged stressor. 38 C.F.R. § 3.304(f). In such cases, the record must contain service records or other corroborative evidence that substantiates or verifies the veteran's testimony or statements as to the occurrence of the claimed stressors. Moreau v. Brown, 9 Vet. App. 389, 396 (1996); Dizoglio v. Brown, 9 Vet. App. 163, 166 (1996), Zarycki v. Brown, 6 Vet. App. 91, 98 (1993). The RO requested that the veteran furnish a detailed description of the specific traumatic incidents causing his PTSD, including dates and places the incidents occurred, the unit to which he was assigned at the time, and medals or citations received as the result of the events, and names of anyone involved in the incidents. The veteran reported four specific stressors during his period of Vietnam service. While assigned to the 185th maintenance battalion and stationed at Long Binh in August 1967, the veteran was part of a group transporting a tank to a salvage yard. After transporting the tank they were told that there were U.S. service members bodies in the tank. The second incident, also in August 1967, occurred when the veteran was traveling from Long Binh to Saigon, and while en route he saw the bodies of three children lying on the ground. On his return trip he observed that the bodies had not been touched and were becoming bloated. The veteran was hospitalized due to pneumonia in Long Binh in October or November 1967. While hospitalized, he was witness to service members with arms blown off and he smelled burnt flesh and the "smell of death". He also recalled the sound of young service men screaming. He felt depressed at that time and wished he were in a combat unit so he could die. Finally, during the Tet offensive of 1968, in Long Binh, he was several miles away from the ammunition dump when it was attacked and exploded. He was knocked backward from the shock wave, but was not injured. He later learned that officers in his company had been killed in the attack. The RO contacted the U.S. Army and Joint Services Environmental Support Group (ESG) in order to obtain any information which would support the veteran's description of stressors. U.S. Army military records verified that the Long Binh ammunition dump was attacked in February 1968. Furthermore, it is confirmed in the veteran's medical records that he was hospitalized with pneumonia in August 1967. The other incidents described by the veteran cannot be confirmed with the information provided. In July 1995, the veteran was hospitalized at Richard H. Young Hospital, due to a suicidal attempt. On examination, the veteran discussed a history of sexual abuse as a child and family problems. There was no discussion of his experiences in service. A diagnosis of PTSD was given, but the cited stressor was the history of sexual abuse. A statement from the veteran's wife, dated in September 1995 notes the veteran's decreased sexual drive and long periods of depression, but does not state that these are related to experiences in Vietnam. The veteran had a VA PTSD examination in February 1996. The veteran reported that he had volunteered to go to Vietnam because he was depressed and hoped to be killed in action. He spent 12 months in combat areas, but not in direct combat. During his time in Vietnam he saw friends killed. He had increased depression, apprehension and nightmares, which continued after discharge. He had a number of symptoms associated with PTSD, such as avoidance of media with Vietnam content, feeling of detachment, sense of a foreshortened future, difficulty sleeping, irritability, hypervigilance and exaggerated startle response. The veteran reported his hospitalization in 1995 for depression. He also reported childhood sexual abuse by his uncle and father. In summarizing the examination, the examiner stated that the veteran's history of symptomatology was consistent with a diagnosis of chronic PTSD. He also had symptoms of major depression, and it appeared that the depression was active upon entry to service and may be due to early abuse and family history of affective disorders. The experiences in Vietnam appeared to have precipitated chronic PTSD of at least moderate severity. Another PTSD examination was performed in July 1997. The veteran described that he was initially stationed in Korea, but after he got in a fight, he requested to transfer to Vietnam where he was stationed for approximately a year. He related an incident where he was hauling water by truck and he ran over an 8 or 9 year old boy. He did not provide any identifying details. He also stated that in Vietnam life was cheap, friends got killed on the street and trucks got hit and burned. He appeared sad and depressed when making this statement. The veteran had been consistently employed since 1968. The impression of the examiner was that the veteran had chronic depression or dysthymia, mild to moderate to severe in intensity, depending upon his surroundings and situational stressors. This was highlighted by his focus on the sexual abuse he was subjected to in childhood. The depression was not related to the fractured nose in service, but to other stressors distinct from military service. Also, the veteran suffered from anxiety disorder related to current and previous stressors, but not to the fractured nose. The examiner did not believe that the veteran suffered from PTSD. As stated above, in order to establish a well-grounded claim the veteran must present a medical diagnosis of PTSD based on verified stressors in service. The veteran herein has failed to establish this element of a well-grounded claim. With respect to the veteran's July 1995 hospitalization, the diagnosis of PTSD appears to have been based on events in childhood. With respect to the PTSD diagnosis at the February 1996 VA examination, there is no discussion of specific incidents in service. Rather, the veteran only referred to experience in Vietnam in a general manner. He did mention witnessing the deaths of friends, and running over a child with his truck, however he failed to state any specific details such as names and dates of these incidents. As the veteran did not serve in a combat capacity, his PTSD diagnosis must be related to specific and verified stressful incidents. The February 1996 diagnosis of PTSD does not satisfy that standard. Moreover, the conclusion of the examiner in the most recent examination dated in July 1997, was that the veteran suffers from depression and anxiety linked to factors unrelated to military service, and does not suffer from PTSD. The Board finds that neither the July 1995 nor February 1996 diagnoses is sufficient to well ground the claim for PTSD, and the claim must be denied. Service connection for sinusitis and rhinitis A veteran is entitled to service connection for a disability resulting from a disease or injury incurred in or aggravated in the line of duty while in the active military, naval, or air service. See 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. The threshold question for the Board is whether the veteran has presented a well-grounded claim for service connection. A well-grounded claim is one that is plausible, capable of substantiation or meritorious on its own. See 38 U.S.C.A. § 5107(a); Grivois v. Brown, 6 Vet. App. 136, 140 (1994); Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). While the claim need not be conclusive it must be accompanied by supporting evidence. Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992). In the absence of evidence of a well-grounded claim there is no duty to assist the claimant in developing the facts pertinent to his claim and the claim must fail. Epps v. Gober, 126 F.3d 1464, 1467-68 (1997). To establish that a claim for service connection is well grounded the appellant must demonstrate the existence of a current disability, the incurrence or aggravation of a disease or injury in service, and a nexus between the current disability and the in-service injury. Lay or medical evidence, as appropriate, may be used to prove service incurrence. Id. at 1468. Medical evidence is required to provide the existence of a current disability and to fulfill the nexus requirement. Id. at 1467-68. Alternatively, a veteran may establish a well-grounded claim for service connection under the chronicity provision of 38 C.F.R. § 3.303(b), which is applicable where evidence, regardless of its date, shows that a veteran had a chronic condition in service or during an applicable presumption period, and that that same condition currently exists. This evidence must be medical unless the condition at issue is of a type for which case law considers lay observation sufficient. If the chronicity provision is not applicable, a claim still may be well grounded pursuant to the same provision if the evidence shows that the condition was observed during service or any applicable presumption period and continuity of symptomatology was demonstrated thereafter, and includes competent evidence relating the current condition to that symptomatology. Savage v. Gober, 10 Vet. App. 488, 495-98 (1997). Service connection may be granted for a disability that is proximately due to or the result of a service-connected disability. When service connection is established for a secondary condition, the secondary condition is considered as part of the original condition. 38 C.F.R. § 3.310(a). A claim for secondary service connection, like all claims, must be well grounded. Reiber v. Brown, 7 Vet. App 513, 516 (1995). The veteran claims that his sinusitis and rhinitis are secondary to the fractured nose he sustained in service. The veteran had several colds in service, but was not diagnosed with chronic sinusitis or chronic rhinitis. Service medical records show that the veteran sustained a fractured nose in February 1967. At his separation examination in April 1968, his sinuses and nose were noted to be normal. There are no post-service clinical medical records in the file pertaining to sinusitis or rhinitis. A VA compensation and pension examination was performed in February 1996. The veteran reported a history of intermittent watery eyes and nasal congestion for the past five to six years. He had not sought medical treatment but used over the counter sinus medications. On objective examination, there was no tenderness in the maxillary or frontal areas. There were no abnormalities of the external nose or nasal vestibule. There was bogginess of the nasal mucosa and edema in the turbinates. On x-ray of the paranasal sinuses there were no abnormalities noted. Diagnosis was possible allergic rhinitis. Another VA examination was performed in June 1997. The veteran stated he had a hard time breathing through his nose since the fracture in service. He stated he has a runny nose off and on and a reduced sense of smell. On physical examination, the veteran's external nose was slightly deviated to the left, his nasal vestibule was normal. Of the right and left nasal cavities, his septum was slightly deviated to the left, and the floor of the nose, inferior meatus, inferior turbinates, middle meati, middle turbinate, spheno-ethmoidal recess, olfactory area and superior turbinates were all normal. The paranasal sinuses had no tenderness and there were no abnormalities of the sinuses seen on x-ray. There was some deformity of the nasal bone seen on x-ray. Diagnoses were history of allergic rhinitis, history of sinusitis, history of nasal fracture with slight deviated nose and reduced sense of smell. There are no clinical treatment records in the claims file relating to sinusitis or rhinitis. The claims file does contain a May 1996 statement of the veteran's wife stating that the veteran has had continuous problems with sinus drainage, difficulty breathing through his nose, and headaches from the time she met him in 1972. There is also a May 1996 statement of the veteran's daughter stating that the veteran gets sinus headaches, sinus drainage, and rawness of the throat. The veteran was granted service connection for a nasal fracture in an April 1996 rating decision. The veteran contends that his sinusitis and rhinitis are proximately due to his service-connected nasal fracture. However, the record contains no medical evidence to this effect, and the veteran is not competent to testify as to the etiology of his medical disorders. See Espiritu v. Derwinski, 2 Vet. App. 492, 494- 95 (1992) (holding that lay persons are not competent to offer medical opinions). In fact, the diagnosis of allergic rhinitis indicates the etiology of rhinitis to be unrelated to nasal fracture. As there is no medical evidence that the veteran's sinusitis and rhinitis were incurred in service, and no evidence that such conditions are a result of the nasal fracture, the claim is not well grounded. Service connection for headaches The veteran also contends that his headaches are proximately due to his service-connected nasal fracture. At his February 1996 VA examination, the veteran complained of sinus headaches for the past 5 to 6 years. A VA examination was performed in July 1997 particularly to assess headaches. The veteran stated he had had headaches for 30 years which come on in the evening in the back of his neck and around his nose and eyes. He sometimes feels the pain in his sinuses. The headaches can last all day and through the night at times. He had a family history of migraines. After the nasal fracture in service he had terrible headaches for a while. On physical examination, the history of fractured nose was evident. There were no neurological symptoms. Assessment was musculoskeletal headaches, possible migraines, and septal deviation. The examiner stated that it is known that septal deviation does sometimes contribute to headaches and the veteran clearly has had a broken nose and now has a deviated septum. His headaches do not appear to be related to any sort of increase in intracranial pressure. Based on the statement of the examiner in July 1997, the Board finds that the claim for service connection for headaches secondary to nasal fracture is well grounded, as set forth at 38 U.S.C.A. § 5107(a). The Board further finds that additional medical expertise would be helpful in adjudicating the claim, as requested below in the remand portion of this opinion. Service connection for anxiety and depression Medical evidence pertaining to mental disorders is set forth above in the section of this opinion addressing the claim for service connection for PTSD. The legal analysis pertaining to a well-grounded claim for service connection for anxiety and depression, secondary to a nasal fracture, is set forth in the section addressing service connection for sinusitis and rhinitis. To summarize, in order to establish a well- grounded claim, the veteran must show competent evidence: i) of current disability (a medical diagnosis); ii) of incurrence or aggravation of a disease or injury in service (lay or medical evidence), and; iii) of a nexus between the inservice injury or disease and the current disability (medical evidence). Epps v. Gober, 126 F.3d 1464, 1468 (Fed. Cir. 1997); Caluza v. Brown, 7 Vet.App. 498, 506 (1995). There is no evidence in service of any psychiatric condition. As described above, at the veteran's VA examinations, he described being depressed both prior to and during service, due to, in part, his history of childhood sexual abuse. However, there is no medical evidence of record to link the veteran's chronic depression to events of service. The veteran was diagnosed with an anxiety disorder in July 1997, but this was believed to stem from current and previous stressors, but not from the fractured nose. In sum, both the veteran's depression and anxiety are unrelated to the service-connected nasal fracture. Nor is there evidence of these conditions in the service medical records. Thus, the claim for service connection for depression and anxiety lacks a nexus to service and is not well grounded. Ancillary Issues On a VA Form 9, dated in February 1998, the veteran listed as issues entitlement to an advisory/independent medical opinion, entitlement to a thorough and contemporaneous examination, and entitlement to an adequate reasons and bases. Notwithstanding the veteran's characterization of these issues as separately appealable issues, the issues of entitlement to an advisory/independent medical opinion, a new compensation examination, and adequate reasons and bases are ancillary issues to the veteran's underlying claims; and are not separately appealable issues. These ancillary issues may be contested only as part of an appeal on the merits of the decision rendered on the primary issue. Therefore, the denial of the veteran's procedural and "duty to assist" contentions are included within the present appeals, and do not require a separate notice of disagreement, statement of the case or supplemental statement of the case (SSOC) on these issues. The RO correctly treated these as ancillary issues and not as separately appealable issues. With regard to these ancillary procedural issues which relate to VA's duty to assist the veteran, as the veteran has not presented well-grounded claims as to the issues of service connection for PTSD, sinusitis, rhinitis and depression and anxiety, the duty to assist the veteran does not arise. See Slater v. Brown, 9 Vet. App. 240 (1996); Franzen v. Brown, 9 Vet. App. 235 (1996). The United States Court of Appeals for the Federal Circuit held that only a person who has submitted a well-grounded claim can be determined to be a claimant for the purpose of invoking the duty to assist provisions of 38 U.S.C.A. § 5107(a). See Epps v. Gober, 126 F.3d 1464, 1468- 69 (1997). Specifically with regard to the request for an independent/advisory medical opinion, the controlling regulation specifically prohibits consideration of this part of an appeal as a separately appealable issue. "A determination that an independent medical opinion is not warranted may be contested only as part of an appeal on the merits of the decision rendered on the primary issue by the agency of original jurisdiction." 38 C.F.R. § 3.328. Additionally, with regard to a request for an independent medical opinion, the Board notes that the veteran has not asserted that the evidence is medically complex or controversial, only that he wants an independent medical opinion. The veteran has not even stated as to which issue or issues he is requesting such opinion. The regulation, 38 C.F.R. § 3.328, provides that, when warranted by the medical complexity or controversy involved in a pending claim, an advisory medical opinion may be obtained from one or more medical experts who are not employees of VA. Approval shall be granted only upon a determination by the Compensation and Pension Service that the issue under consideration poses a medical problem of such obscurity or complexity, or has generated such controversy in the medical community at large, as to justify solicitation of an independent medical opinion. With regard to the veteran's request for a new medical examination for hearing loss and tinnitus, the Board notes that the RO scheduled examinations on two occasions and the veteran failed to report. With regard to the claims for PTSD, sinusitis, rhinitis, depression and anxiety claims, the Board finds that the examinations already performed were adequate. Moreover, as these claims are not well grounded, there is no duty to assist and no entitlement to a VA examination. An examination for the headaches claim is discussed below in the remand portion of this opinion. ORDER Service connection for hearing loss is denied. Service connection for tinnitus is denied. Service connection for PTSD is denied. Service connection for sinusitis is denied. Service connection for rhinitis is denied. The claim for service connection for headaches is determined to be well grounded. Service connection for depression and anxiety is denied. REMAND As noted above, the claim for service connection for headaches is well grounded. Thus, the VA has a duty to assist the veteran in developing the claim. 38 U.S.C.A. § 5107(a). The Board finds that the July 1997 opinion of the examiner who evaluated the veteran's headaches is somewhat ambiguous as to whether the veteran's headaches are a result of the nasal fracture and resultant septal deviation. In addition, the Board notes the claims file contains private medical records with a February 1971 entry stating that the veteran was involved in an automobile-train accident and suffered a fractured nose, confirmed by x-ray. The claims file does not contain any additional medical records pertaining to this injury. This fracture apparently occurred approximately three years after service. In light of the foregoing, this claim is REMANDED for the following additional development: 1. The RO should request that the veteran provide names and addresses for any medical providers who treated him for a nasal fracture in 1971. Further, the veteran should be asked to provide names and addresses for any medical providers who have treated him for headaches. Copies of records of such treatment should be obtained and associated with the claims file. 2. After completion of the above, the veteran should be scheduled for a VA examination for headaches. Prior to conducting the examination, the examiner should review the claims file, including any newly associated records. The examiner is asked to perform all necessary tests and studies to determine the etiology of the veteran's headaches. The examiner is further asked to respond to the following question: Is it at least as likely as not that the veteran's headaches are due to his nasal fracture in service? The examiner should set forth all findings and conclusions in a typed report. 3. After completion of the above, the RO should readjudicate the veteran's claim. If the decision is adverse to the veteran, both he and his representative should be furnished a supplemental statement of the case, and provided an appropriate period of time in which to respond thereto. Thereafter, the case should be returned to the Board for further appellate review. The purpose of this remand is to comply with the statutory duty to assist the veteran, and the Board intimates no opinion as to the merits of the claim at this time. The veteran and his representative have the right to submit additional evidence and argument on the matter or matters the Board has remanded to the regional office. Kutscherousky v. West, 12 Vet. App. 369 (1999). BRUCE KANNEE Member, Board of Veterans' Appeals