Citation Nr: 0001794 Decision Date: 01/21/00 Archive Date: 01/28/00 DOCKET NO. 98-08 244A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUES 1. Whether new and material evidence has been submitted to reopen a claim of entitlement to service connection for residuals of a cerebral concussion. 2. Entitlement to service connection for bilateral hearing loss. 3. Entitlement to service connection for a low back disorder. 4. Entitlement to service connection for post-traumatic stress disorder. REPRESENTATION Appellant represented by: John Stevens Berry, Attorney ATTORNEY FOR THE BOARD D. J. Drucker, Counsel INTRODUCTION The veteran had active military service from January 1942 to October 1945. This matter comes to the Board of Veterans' Appeals (Board) on appeal from November 1997 and May 1998 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Lincoln, Nebraska. A preliminary review of the claims folder reveals that, in a May 1998 letter to the RO, the veteran's attorney incorrectly stated that the rating determination earlier in the month denied service connection for a respiratory condition, hepatitis and residuals of a broken nose and expressed the veteran's wish to appeal the denial. Thereafter, in his April 1999 substantive appeal, the veteran's list of appealed issues included entitlement to service connection for a respiratory condition, hepatitis, and residuals of a broken nose. In an August 1999 letter to the veteran, the RO said that an unappealed March 1991 determination denied service connection for hepatitis, a respiratory condition and residuals of a fractured nose and that the veteran had to submit new and material evidence to reopen those claims. Accordingly, the Board will confine its determination to the issues as set forth on the title page. FINDINGS OF FACT 1. All evidence necessary for an equitable disposition of the veteran's claims has been obtained by the RO. 2. An unappealed March 1991 RO decision denied service connection for a concussion. 3. The evidence added to the record since the March 1991 rating decision that denied service connection for a concussion is either cumulative or redundant or does not bear directly and substantially upon the specific matter under consideration and is so insignificant as to not warrant reconsideration of the merits of the claim on appeal. 4. Left ear hearing loss and bilateral tinnitus cannot be dissociated from the veteran's period of active military service. 5. No competent evidence has been submitted to demonstrate that the veteran has right ear defective hearing. 6. No competent evidence has been submitted to demonstrate that the veteran has a low back disorder, including arthritis, related to his period of active military service. 7. The veteran's claim of entitlement to service connection for post-traumatic stress disorder (PTSD) is plausible. 8. The appeal does not involve any question of such medical complexity or controversy as to necessitate an advisory medical opinion. CONCLUSIONS OF LAW 1. The March 1991 rating decision that denied service connection for a concussion is final; new and material evidence has not been submitted to reopen the claim of entitlement to service connection for residuals of a concussion. 38 U.S.C.A. §§ 5107, 7105 (West 1991); 38 C.F.R. § 3.156(a) (1999). 2. Left ear defective hearing and bilateral tinnitus were incurred during active military service. 38 U.S.C.A. §§ 1154, 5107 (West 1991); 38 C.F.R. §§ 3.303, 3.304, 3.385 (1999). 3. The veteran has not submitted evidence of well-grounded claims for service connection right ear defective hearing and a back disorder, including arthritis. 38 U.S.C.A. §§ 1110, 5107 (West 1991); 38 C.F.R. §§ 3.303, 3.304, 3.385 (1999). 4. The obtaining of an independent medical opinion is not warranted. 38 U.S.C.A. § 5109 (West 1991); 38 C.F.R. § 20.901 (1999). 5. The claim of entitlement to service connection for PTSD is well grounded. 38 U.S.C.A. § 5107 (West 1991). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. New and Material Evidence to Reopen A Claim of Entitlement to Service Connection for Residuals of a Cerebral Concussion The RO, in a decision dated in March 1991, denied the veteran's claim of entitlement to service connection for a concussion. The RO found at that time that there was no evidence that a concussion was incurred during active duty. The veteran did not appeal the RO's decision and it became final based on the evidence then of record. The evidence of record at the time of the March 1991 RO decision that denied service connection for a concussion included a July 1990 notice from the National Personnel Records Center (NPRC) to the effect that there were no medical records on file for the veteran and that the records may have been destroyed in a 1973 fire at the NPRC. The notice further indicates that there were SGO records (in- service hospitalization extracts pertaining to the veteran that had been developed by the Surgeon General's Office (SGO)) on file. In a February 1991 response to the RO's request for the veteran's records, NPRC indicated that it had searched S/Rs (sick reports?) for the 783rd QM (Quartermaster) Truck(ing) Co(pany) from April to June 1942 and from July to October 1942 and from the 1971st QM Truck Co. from December 1943 to May 1944. Some morning reports from the 783rd QM for July to October 1942 indicated the veteran was evidently hospitalized for approximately two weeks in September 1942. The nature of his complaint(s) or illness(es) was not described. Also of evidence at the time of the March 1991 RO decision were treatment records, dated from November 1988 to November 1989, from Dr. Richard M. Fruehling. The records are not referable to complaints or treatment of residuals of a concussion. In November 1988, Dr. Fruehling described the veteran as relatively healthy in the past with no significant medical problems, good auditory acuity and some left ear tinnitus. Neurologic examination findings showed cranial nerves two through twelve grossly intact and the assessment was healthy male. In November 1989, Dr. Fruehling reported grossly adequate auditory acuity with slight high frequency loss. The assessment was a healthy male with well-controlled hypertension and a history of chronic obstructive pulmonary disease. According to statements from Laurice A. Bell and Evelyn K. Behrends, received in May 1990, the veteran was hospitalized after sustaining injuries in a truck accident in service. An August 1990 statement from the veteran is to the effect that he sustained a concussion in a truck accident in January 1944 while serving in Sicily. He was treated in the Army Field Hospital in Gela, Sicily. The March 1991 rating decision was final based upon the evidence then of record. However, the claim will be reopened if new and material evidence is submitted. 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156(a). If the Board determines that the evidence is new and material, the case is reopened and evaluated in light of all the evidence, both new and old. Manio v. Derwinski, 1 Vet. App. 140, 145 (1991). In making this determination, the Board must look at all of the evidence submitted since the time that the claim was finally disallowed on any basis, not only since the time that the claim was last disallowed on the merits. In the present case, this means that the Board must look at all the evidence submitted since the March 1991 decision that was the final adjudication that disallowed the veteran's claim. The United States Court of Appeals for Veterans Claims (known as the United States Court of Veterans Appeals prior to March 1, 1999) (hereinafter, "the Court") recently set forth a three step-process for reopening claims in accordance with the holding in Hodge v. West, 155 F.3d 1356 (Fed. Cir. 1998). See Elkins v. West, 12 Vet. App. 209 (1999); see also Winters v. West, 12 Vet. App. 203 (1999). In Elkins, the court held that, first, the Secretary must determine whether new and material evidence has been presented under 38 C.F.R. § 3.156 (a); second, if new and material evidence has been presented, immediately upon reopening, the Secretary must determine whether, based upon all the evidence and presuming its credibility, the claim as reopened, is well grounded pursuant to 38 U.S.C.A. § 5107; and third, if the claim is well grounded, the Secretary may evaluate the merits after ensuring the duty to assist under 38 U.S.C.A. § 5107(b) has been fulfilled. New and material evidence means evidence not previously submitted to agency decision makers which bears directly and substantially upon the specific matter under consideration which is neither cumulative nor redundant and which by itself or in connection with evidence previously assembled is so significant that it must be considered in order to fairly decide the merits of the claim. 38 C.F.R. § 3.156(a). See Hodge v. West, 155 F.3d. 1356 (Fed. Cir. 1998). Evidence that is solely cumulative or repetitious in character will not serve as a basis for reconsideration of a previous decision. Moreover, Hodge stressed that under the regulation new evidence that was not likely to convince the Board to alter its previous decision could be material if that evidence provided "a more complete picture of the circumstances surrounding the origin of a veteran's injury or disability, even where it will not eventually convince the Board to alter its rating decision." Id. The Federal Circuit noted that "any interpretive doubt must be resolved in the veteran's favor" and that "the regulation imposes a lower burden to reopen than the Colvin test." Hodge at 1361, n. 1. An application to reopen the veteran's claim was received by the RO in March 1997. The evidence associated with the claims file subsequent to the March 1991 decision that was the final adjudication of the veteran's claim includes VA and private medical records and examination reports and the veteran's written statements, dated from August 1997 to March 1999. In his March 1997 application to reopen his claim, the veteran amended his compensation claim to apply for (service connection for) labyrinthitis, tinnitus and organic brain syndrome (OBS) as secondary to his head injury. An August 1997 notice from NPRC indicates that all records, if any, in its custody regarding the veteran were lost in a July 1973 fire. According to the medical history provided in an August 1997 VA orthopedic examination, the veteran, who was 75 years old, said he was injured in a 1943 motor vehicle accident during active duty in World War II. A truck he drove down a mountain road in Sicily was hit by another truck and caused him to be thrown off the road. A tree was knocked over in the process, he lost consciousness for approximately one half-hour and was hospitalized in a field hospital for approximately five days. Thereafter, the veteran returned to duty as a truck driver and continued active duty until the war ended. An August 1997 VA neurologic examination report indicates that the veteran did not sustain any weakness or paralysis as a result of the head injury described above and after five days returned to duty as a truck driver. Subjectively, the veteran had constant ringing in his ears since 1950 and rarely had headaches. There were no abnormal findings at the time of examination. The diagnosis was history of cerebral concussion in 1943. On an August 1997 VA tinnitus questionnaire that asked for circumstances that occurred when the veteran first started having tinnitus that may have caused it, he described a head injury in a truck accident. In an August 1997 VA report of audiometric tests, the audiologist said the veteran's audiometric test results and report of tinnitus were consistent with a history of noise exposure. In November 1997, the RO requested that the NPRC provide morning reports for the 1971st QM Trucking Company (Aviation) for May, June and August 1943. In March 1998, the NPRC advised the RO that its search of medical records of the 1971st QM Trucking Co. (AVN) for May, June and July 1943 brought negative results. David D. Parrish, M.D., a psychiatrist, examined the veteran in July 1998. According to Dr. Parrish, the veteran said that while driving a truck in Italy, he was hit in the back by another truck and pushed off a mountainous road. This caused a closed head injury for which he was hospitalized for approximately five to six days. In a statement received in October 1998, the veteran said he landed at Gela, Sicily with (General) Patton's troops. He said the truck accident occurred shortly after the island had been secured by those troops and British troops commanded by General Montgomery. The veteran has asserted that he has the residuals of a concussion that had its origins during his period of active military service. Service medical records are unavailable for the veteran, and morning reports show a two-week hospitalization for an unknown cause in September 1942. There is absolutely no post service medical evidence reflecting complaints or diagnosis of labyrinthitis or OBS. Tinnitus, initially noted in the 1980s, appears to be attributed to exposure to acoustic trauma. In sum, the evidence received since the March 1991 decision to deny service connection for a concussion consists of VA and private examination reports and the veteran's statements asserting his contention that he suffered a concussion in service that caused OBS, tinnitus and labyrinthitis. Nevertheless, the veteran is not qualified as a lay person to furnish etiological opinions or medical diagnoses, as this requires medical expertise. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993); Espiritu v. Derwinski, 2 Vet. App. 492, 494-495 (1992). Consequently, the Board finds the evidence received since the March 1991 rating decision regarding the claim for service connection for residuals of a concussion does not bear directly and substantially upon the specific matter under consideration and is so insignificant as to not warrant reconsideration of the merits of the claim on appeal. As the evidence received since the March 19991 rating decision to deny service connection for residuals of a concussion is not new and material, it follows that the claim for service connection for a concussion is not reopened. II. Entitlement to Service Connection for Bilateral Hearing Loss and a Low Back Disorder The veteran is seeking service connection for bilateral defective hearing and a low back disorder, including arthritis. The legal question to be answered, initially, is whether the veteran has presented evidence of well-grounded claims; that is, claims that are plausible. If he has not presented well-grounded claims, his appeal must fail with respect to these claims and there is no duty to assist him further in the development of his claims. 38 U.S.C.A. § 5107(a). As will be explained below, the Board finds that the claim for service connection for bilateral hearing loss is well grounded and the claim for service connection for a back disorder is not well grounded. The veteran's service medical records are apparently unavailable and may have been destroyed in a fire at the NPRC in 1973. Where service medical records are missing, VA's duty to assist the veteran, to provide reasons and bases for its findings and conclusions, and to consider carefully the benefit-of-the-doubt rule are heightened. Milostan v. Brown, 4 Vet. App. 250, 252 (1993); citing Moore v. Derwinski, 1 Vet. App. 401, 406 (1991); and O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). The court has further held that "[n]owhere do VA regulations provide that a veteran must establish service connection through medical records alone." Stozek v. Brown, 4 Vet. App. 457, 461 (1993), quoting Cartright v. Derwinski, 2 Vet. App. 24, 25-26 (1991). A. Factual Background As noted above, the RO made repeated, but unsuccessful, efforts to obtain the veteran's service medical records that were apparently destroyed in a fire. His service records indicate that his military occupational specialty was truck driver. Battles and campaigns in which he served included Tunisia, Sicily, Naples-Foggia and Rome-Arno during World War II. His separation qualification record indicates that the veteran was in charge of twelve trucks and eighteen men that carried supplies and equipment from the warehouse to the airfield. When examined by Dr. Fruehling in November 1988, the veteran had no past significant medical problems, good auditory acuity and some left ear tinnitus. Objectively, the veteran's auditory acuity was grossly adequate. There was no limitation of motion of his extremities. When examined in November 1989, the veteran's auditory acuity was described as grossly adequate with a slight high frequency loss. There was no limitation of motion of the extremities and the assessment was healthy male. At the August 1997 VA neurologic examination, the veteran reported having bilateral tinnitus since approximately 1950. In August 1997, the veteran underwent VA audiometric examination and a fee-based audio-ear disease examination. He complained of constant ringing in his ears with left ear hearing loss. The veteran gave a history of spending thirty- three months in combat in North Africa, Italy and Sicily and was a farmer as a civilian. The veteran said he sustained a concussion in a truck accident in Sicily for which he was hospitalized and had no history of ear pathology or related illness. The veteran reported a constant bilateral high- pitched tinnitus that was annoying and present for many years. Audiogram findings, in pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 10 5 35 35 LEFT 15 15 20 60 55 Speech recognition scores on the Maryland CNC word lists were 96 percent in the veteran's right ear and 90 percent in his left ear. Test results showed mild high frequency sensorineural loss in the right ear and a moderate high frequency sensorineural loss in the left ear with good discrimination, bilaterally. The VA audiologist said test results showed the veteran's right ear hearing was within normal limits for rating purposes from 250 Hz. to 4,000 Hz. Diagnoses included high frequency sensorineural hearing loss with tinnitus. Further, the VA audiologist commented that the veteran's audiometric configuration and report of tinnitus were consistent with a history of noise exposure. On an August 1997 VA tinnitus questionnaire, the veteran complained of constant ringing in his ears that he had for so long he could not recall when it started. According to the August 1997 VA orthopedic examination report, the veteran did not experience back pain until approximately 1947 or 1948 and, thereafter, had intermittent low back pain that required chiropractic back adjustment approximately once or twice a year with the last adjustment in 1994. A chiropractor ordered a back brace for him in the early 1960s that he wore for several years. In August 1996, the veteran was evaluated by Dr. Bejo, in Kearney, Nebraska, and underwent both a myelogram and post-myelogram computed tomography (CT) of the lumbar spine. Further, the examination report reflects that, in Dr. Bejo's opinion, the veteran had congenital narrowing of the lumbar spine canal. The veteran denied ever having back surgery. X-rays of the lumbosacral spine showed evidence of narrowing of the disc spaces of L4-5 and L5-S1 as well as mild degenerative change of the lumbar spine. Diagnoses were low back pain and degenerative arthritis of the lumbar spine. In his July 1998 report, Dr. Parrish noted that after the motor vehicle accident in service, the veteran experienced intermittent low back pain. B. Analysis According to 38 U.S.C.A. § 1110, a veteran is entitled to disability compensation for disability resulting from personal injury or disease incurred in or aggravated by service. "A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or disease incurred in service." Watson v. Brown, 4 Vet. App. 309, 314 (1993). Even if there is no record of organic disease of the nervous system (e.g., sensorineural hearing loss) or arthritis in service, its incurrence coincident with service will be presumed if it was manifest to a compensable degree within one year after service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 1991 & Supp. 1999); 38 C.F.R. §§ 3.307, 3.309 (1999). While the disease need not be diagnosed within the presumptive period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree. Id. In the case of any veteran who has engaged in combat with the enemy in active service during a period of war, satisfactory lay or other evidence that an injury or disease was incurred or aggravated in combat will be accepted as sufficient proof of service connection if the evidence is consistent with the circumstances, conditions or hardships of such service, even though there is no official record of such incurrence or aggravation. 38 U.S.C.A. §§ 1154(b); 38 C.F.R. §§ 3.304(d); see generally Peters v. Brown, 6 Vet. App. 540, 543 (1994). The effect of this law is that service connection will not be precluded for combat veterans simply because of the absence of notation of a claimed disability in the official service records. However, the law does not create a presumption of service connection, and service connection remains a question that must be decided based on all the evidence in the individual case. See Smith v. Derwinski, 2 Vet. App. 137 (1992). See also Kessel v. West, 13 Vet. App. 9 (1999), appeal docketed (Fed. Cir.)(When adjudicating a claim on the merits under 38 U.S.C. § 1154(b), the combat veteran will be found to have established sufficient evidence of service incurrence or aggravation by his or her own testimony unless "there is 'clear and convincing evidence' that the disease or injury was not incurred or aggravated in service ...." [See Caluza v. Brown, 7 Vet. App. 498, 507 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table)].") Id. at 15- 16. A well-grounded claim is a plausible claim, one which is meritorious on its own or capable of substantiation. Murphy v Derwinski, 1 Vet. App. 78, 81 (1990). There must be more than an allegation, the claim must be accompanied by evidence that justifies a belief by a fair and impartial individual that the claim is plausible. Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992). Moreover, where a determinative issue involves a medical diagnosis or medical causation, competent medical evidence to the effect that the claim is plausible is required. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993); Espiritu v. Derwinski, 2 Vet. App. 492, 494-95 (1992). A well-grounded service connection claim generally requires medical evidence of a current disability; medical or, in certain circumstances, lay evidence of inservice incurrence or aggravation of a disease or injury; and medical evidence of a nexus between an inservice injury or disease and a current disability. See Epps v. Gober, 126 F.3d 1464 (1997). 1. Bilateral Hearing Loss For the purpose of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1,000, 2,000, 3,000, or 4,000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1,000, 2,000, 3,000, or 4,000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. Even though disabling hearing loss may not be demonstrated at separation, a veteran may, nevertheless, establish service connection for a current hearing disability by submitting evidence that the current disability is related to service. Hensley v. Brown, 5 Vet. App. 155 (1993). The threshold for normal hearing is from 0 to 20 decibels and higher threshold levels indicate some degree of hearing loss. See Hensley (citing Current Medical Diagnosis & Treatment, Stephen A. Schroeder, et. al. eds., at 110-11 (1988)). See also 38 C.F.R. § 3.385. a) Left Ear Hearing Loss and Bilateral Tinnitus The veteran has contended that service connection should be granted for bilateral defective hearing and has asserted that he suffers from tinnitus. He described exposure to acoustic trauma while in active service in Tunisia, Sicily and Italy for nearly three years as a truck driver during World War II. In 1988 and 1989, the veteran's private physician, Dr. Fruehling, noted the veteran's complaint of tinnitus for some time and reported a slight high frequency hearing loss. When examined by VA in 1997, the veteran gave a history of acoustic trauma in service, told a VA examiner that he experienced tinnitus starting in approximately 1950 and complained of left ear hearing loss. The VA audiologist did not find that the veteran's current left hearing loss and tinnitus were inconsistent with his history. In light of the foregoing, the Board finds that the evidence of record is consistent with the veteran's contentions. At the time of the 1997 VA examinations, the veteran reported a history of acoustic trauma during battles in Tunisia, Sicily and Italy during World War II. His service records corroborate his participation in battles in Tunisia, Sicily, Naples-Foggia and Rome-Arno. Accordingly, the Board finds that the veteran has established existence of an in-service noise exposure consistent with the conditions of combat under 38 U.S.C.A. § 1154(b); see also Peters v. Brown, 6 Vet. App. 540 (1994). In August 1997, a VA audiologist opined that the veteran's audiometric configuration and report of tinnitus were consistent with a history of noise exposure. The veteran told examiners that he was a farmer in civilian life and, in August 1997, a specialist who examined the veteran for VA found moderate high frequency sensory hearing loss in the left ear. The Board notes that the veteran has variously asserted that he has tinnitus directly due to noise exposure in service or that is a residual of a concussion in service, as discussed above. Resolving the benefit of the doubt in the veteran's favor to the extent noted, service connection is established for left hearing loss and bilateral tinnitus. 38 U.S.C.A. §§ 1110, 1154, 5107; 38 C.F.R. §§ 3.303, 3.385. b) Right Ear In August 1997, the VA audiogram results showed a mild high frequency sensorineural loss in the right ear. The VA audiologist said test results showed that veteran's right ear hearing was within normal limits for rating purposes from 250 Hz. to 4,000 Hz. Accordingly, as the most recent VA audiometric test results failed to show that veteran had impaired right ear hearing, see 38 C.F.R. § 3.385; Hensley, the preponderance of the evidence is against a grant of service connection for right ear defective hearing. Service connection for right ear defective hearing is denied. See 38 U.S.C.A. § 1110; 38 C.F.R. §§ 3.303, 3.385; see also Hensley. 2. Low Back Disorder The veteran has also contended that service connection should be granted for a back disorder. Although the evidence shows that the veteran currently has low back pain and degenerative arthritis of the lumbar spine, no competent medical evidence has been submitted to show that this disability is related to service or any incident thereof. On the other hand, the first post service evidence of record of low back pain and arthritis is from 1997, more than fifty years after the veteran's separation from service. In short, no medical opinion or other medical evidence relating the veteran's low back pain and degenerative arthritis to service or any incident of service has been presented. The veteran is certainly capable of providing evidence of symptomatology, but a layperson is generally not capable of opining on matters requiring medical knowledge, such as the degree of disability produced by the symptoms or the condition causing the symptoms. See Robinette v. Brown, 8 Vet. App. 69, 74 (1995); Heuer v. Brown, 7 Vet. App. 379, 384 (1995); Espiritu v. Derwinski, 2 Vet. App. at 494. See also Harvey v. Brown, 6 Vet. App. 390, 393-94 (1994). Here, the veteran has not submitted any medical opinion or other medical evidence that supports his claim. The evidence now of record fails to show that the veteran currently has a back disorder, including arthritis, related to service or any incident thereof. Thus, this claim may not be considered well grounded. 38 U.S.C.A. §§ 1110, 5107(a); 38 C.F.R. §§ 3.303, 3.304, 3.385. Since the claim is not well grounded, they must be denied. See Edenfield v. Brown, 8 Vet. App. 384, 390 (1995). Although the Board has disposed of the claim of entitlement to service connection for a low back disorder, including arthritis, on a ground different from that of the RO, that is, whether the veteran's claim is well grounded rather than whether he is entitled to prevail on the merits, the veteran has not been prejudiced by the Board's decision. In assuming that the claim was well grounded, the RO accorded the veteran greater consideration than his claim warranted under the circumstances. Bernard v. Brown, 4 Vet. App. 384, 392-94 (1993). III. Entitlement to Service Connection for PTSD As previously noted, before the Board may proceed to examine the merits of the veteran's claim, it must determine whether the veteran has submitted a well-grounded claim as required by 38 U.S.C.A. § 5107(a). The Board finds that the veteran's claim for service connection for post-traumatic stress disorder is well grounded within the meaning of 38 U.S.C.A. § 5107(a) IV. Request for an Independent Medical Examination With respect to the requests in November 1997 and May 1998 that an opinion from an independent medical expert be obtained, the Board notes that it may obtain an advisory medical opinion from a medical expert who is not a VA employee when, in its opinion, a medical opinion is warranted by the medical complexity or controversy involved in the appeal. 38 C.F.R. § 20.901(d). For the reasons discussed above, the Board concludes that no complex or controversial medical question warranting an independent medical expert opinion has been presented with respect to any of the issues on appeal. ORDER New and material evidence having not been submitted, the application to reopen a claim of entitlement to service connection for residuals of a concussion is denied. Service connection is granted for left ear hearing loss and bilateral tinnitus. Service connection for right ear hearing loss is denied. Service connection for a low back disorder, including arthritis, is denied. The claim of entitlement to service connection for PTSD is well grounded. REMAND The veteran has presented a claim that is plausible. VA has a duty to assist a veteran in developing facts pertinent to a well-grounded claim. 38 U.S.C.A. § 5107(a) (West 1991); see Murphy v. Derwinski, 1 Vet. App. 78 (1990); Littke v. Derwinski, 1 Vet. App. 90 (1990). Service connection for PTSD requires medical evidence establishing a clear diagnosis of the condition, credible supporting evidence that the claimed inservice stressor actually occurred and a link, established by medical evidence between the current symptomatology and the claimed inservice stressor. 38 C.F.R. § 3.304(f); Cohen v. Brown, 10 Vet. App. 128 (1997). If the claimed stressor is related to combat, service department evidence that the veteran engaged in combat or that he 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 inservice stressor. 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(f). The evidence on file indicates that VA clinically diagnosed the veteran with PTSD in September 1997 and, in July 1998, David D. Parrish, M.D., a private psychiatrist, diagnosed PTSD. However, there are several problems that require additional evidentiary development. In August 1998, the veteran submitted a copy of what he asserted was one page from the company clerk's daily diary for the 1971st Quartermaster (QM) Trucking Company (Aviation) to which he was assigned in service. It appears to describe the company's participation in the African Campaign, starting in November 1942, and participation in the Battle of Fondouk Gap and the Battle of Hill 609 in April 1943. In written statements, the veteran said he served with the 1971st Trucking Company and that, in January 1943, it provided support to the 334th Infantry Division in North Africa, that included driving supplies to the front. The veteran indicated that convoys were often attacked and that, in April 1943 on Easter Sunday, German aircraft attacked Hill 609, a battle in which he participated. He described seeing dead and maimed bodies and said his friend Bill Burgy disappeared from a truck near Bone, Algeria. Further, the veteran said he was in a truck accident in Gila (Gela?), Sicily, shortly after the British and American troops took over. The veteran's discharge certificate shows that he participated in battles and campaigns in Tunisia, Sicily, Naples-Foggia and Rome-Arno. His military occupational specialty was motor transportation and he was assigned to the 1971st QM Trucking Company, 12th Air Force located in Sicily, Italy and Africa for thirty-three months. The veteran's separation qualification record shows he was in charge of twelve trucks and eighteen men that carried supplies and equipment from the warehouse to an airfield. He was awarded a Good Conduct Medal. The veteran also indicated that he served with the 783rd QM Co. in 1942 when hospitalized at Will Rogers A.F.B. Hospital. In February 1997, NPRC advised the RO that there were no service medical records on file for the veteran and, in August 1997, the NPRC said that all records, if any, in its custody regarding the veteran, were lost in a 1973 fire. The RO requested the assistance of the U.S. Armed Services Center for Research of Unit Records (USASCRUR) (formerly known as the U.S. Army and Joint Services Environmental Support Group) in attempting to locate corroborative evidence of the veteran's claimed inservice stressors. In April 1998, USASCRUR advised the RO that an extensive search failed to locate any unit records or Daily Staff Journals for the 1971st Quartermaster Truck Company during 1943-1944. However, the RO has not asked USASCRUR to verify the information recently submitted by the veteran and purported to be a page from the company clerk's diary that described the 1971st company's activities from November 1942 to May 1943. The Board believes this should be done. If USASCRUR is able to corroborate at least one of the veteran's claimed inservice stressors, e.g., participation in a battle in the African campaign, exposure to rocket fire in Sicily, Tunisia or Italy or death of Bill Burgy, the next question presented is whether such a stressor is clinically considered to be of sufficient severity to warrant a valid diagnosis of PTSD. The descriptive definition of a stressor in the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders, 4th ed. (1994) (DSM- IV) provides that a valid diagnosis of PTSD requires that a person has been exposed to a traumatic event in which both of the following were present: (1) the person experienced, witness or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of himself or others, and (2) the person's response involved intense fear, helplessness or horror. If the veteran's claimed inservice stressor can be independently corroborated, it must be clinically evaluated in accordance with the provisions of DSM-IV. Further, service connection for PTSD requires a clear diagnosis of the condition. While the veteran has, in fact, received diagnoses of PTSD, these diagnoses are less than clear. The clinical evidence shows that, in July 1998, Dr. Parrish said the veteran developed a cluster of psychological symptoms classified as PTSD and also stated that the veteran's symptomatology included symptoms that would fall under a generalized anxiety disorder. The record does not indicate that the PTSD diagnosis was made on the basis of a verified history of the veteran's service stressors and, therefore, was inadequate for rating purpose. West v. Brown, 7 Vet. App. 70, 77-78 (1994). Further psychiatric evaluation is necessary. Accordingly, the veteran's claim is REMANDED to the RO for the following actions: 1. The RO should request the veteran to provide the names, addresses and approximate dates of treatment for all health care providers who may possess additional records, since 1998, pertinent to his claim. With any necessary authorization from the veteran, the RO should attempt to obtain and associate with the claims file any records identified by the veteran that are not already of record. 2. The veteran should be given the opportunity to submit additional evidence and argument in support of his claim, including the specifics of his alleged stressors in service. 3. The RO should review the file (including the veteran's written statements and page purported to be from the 1971st QM Trucking Company clerk's daily diary, received in April 1999) and prepare a summary of all the claimed stressors. That summary and all associated documents, including a copy the information submitted by the veteran and a copy of this remand, should be sent to U.S. Armed Services Center for Research of Unit Records (USASCRUR), 7798 Cissna Road, Springfield, Virginia 22150-3197. USASCRUR should again be requested to provide any information that might corroborate the veteran's alleged inservice stressors. 4. After the above information has been obtained, if, and only if, the RO determines that the record establishes the existence of a verified stressor or stressors, the RO must specify what stressor or stressors in service it has determined are established by the record. In reaching this determination, the RO should address any credibility questions raised by the record. 5. If, and only if, the RO determines that the record establishes the existence of a stressor or stressors, then the RO should schedule the veteran for an examination by a VA psychiatrist experienced in evaluating post-traumatic stress disorders to determine the nature and extent of any psychiatric disorders found to be present. Any and all studies deemed necessary by the examiner should be accomplished. The RO should furnish the examiner with a complete and accurate account of the stressor or stressors that it has determined are established by the record and the examiner must be instructed that only those events may be considered for the purpose of determining whether in- service stressors were severe enough to have caused the current psychiatric symptoms and whether the diagnostic criteria to support the diagnosis of PTSD have satisfied by the inservice stressors. The diagnosis should conform to the psychiatric nomenclature and diagnostic criteria contained in DSM-IV. If the veteran is found to have PTSD, the examiner is requested to identify the diagnostic criteria, including the specific stressor or stressors supporting the diagnosis. The rationale for any opinion should be provided. The claims folders should be made available to the examiner for review before the examination. 6. Then, the RO should undertake any other indicated development and readjudicate the veteran's claim based on the evidence of record. If the benefit sought on appeal is not granted to the veteran's satisfaction, the veteran and his attorney should be furnished a supplemental statement of the case and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The purpose of this REMAND is to obtain additional development and 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. The appellant has 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). This claim must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 1999) (Historical and Statutory Notes). In addition, VBA's Adjudication Procedure Manual, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44- 8.45 and 38.02-38.03. ROBERT E. SULLIVAN Member, Board of Veterans' Appeals