Citation Nr: 0004480 Decision Date: 02/18/00 Archive Date: 02/23/00 DOCKET NO. 98-19 694A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Whether new and material evidence has been submitted to reopen the claim of entitlement to service connection for post-traumatic stress disorder (PTSD). 2. Entitlement to service connection for hearing loss. 3. Entitlement to service connection for an eye disorder. 4. Entitlement to a compensable evaluation for scar, postoperative removal of ganglion cyst of the right wrist. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARINGS ON APPEAL The veteran INTRODUCTION The veteran had active service in the United States Navy from December 1969 to November 1973. The veteran served on the USS America. This matter is before the Board of Veterans' Appeals (Board) on appeal from an October 1998 rating decision of the Columbia, South Carolina, Department of Veterans Affairs (VA) Regional Office (RO). The issue of entitlement to a compensable evaluation for right wrist scar is addressed in the remand portion of this decision. At his December 1999 hearing, the veteran raised the issue of service connection for headaches as secondary to service- connected disability. Hearing transcript (T.), page 23. The record otherwise raises the matter of unemployability benefits. These matters, which are not inextricably intertwined with the issues on appeal, are referred to the RO for appropriate action. At his December 1999 hearing, the veteran submitted a folder of additional evidence. He signed a statement waiving initial RO review of this evidence. 38 C.F.R. § 20.1304 (1999). He also requested that the record remain open for 60 days so that further evidence could be submitted. The requested time period elapsed and the Board received no additional evidence. Therefore, the Board will proceed with the appeal at this time. A May 1997 rating decision denied service connection for PTSD. The veteran did not timely appeal that decision, and it became final. 38 U.S.C.A. § 7105(c) (West 1991); 38 C.F.R. § 20.1103 (1999). In the instant appeal, the RO did not discuss the issue of whether new and material evidence had been submitted to warrant reopening the appellant's claim. However, the Board is required to consider the issue of finality prior to any consideration on the merits. 38 U.S.C.A. §§ 7105(c), 5108 (West 1991); see Barnett v. Brown, 8 Vet. App. 1 (1995). Accordingly, the Board will address the issue of entitlement to service connection for PTSD on a finality basis. FINDINGS OF FACT 1. In a rating decision dated in May 1997, the RO denied service connection for PTSD; the veteran did not perfect an appeal therefrom. 2. The evidence received subsequent to the May 1997 rating decision does bear directly and substantially upon the specific matter under consideration, and is, by itself or in connection with evidence previously assembled, so significant that it must be considered in order to fairly decide the merits of the claim. 3. The record contains a diagnosis of PTSD, which has been related by competent professionals to the veteran's in- service stressors. 4. No competent evidence has been submitted that links a current eye disability or hearing loss to service. CONCLUSIONS OF LAW 1. New and material evidence sufficient to reopen the claim of entitlement to service connection for PTSD has been received. 38 U.S.C.A. § 5108 (West 1991); 38 C.F.R. § 3.156(a) (1999). 2. PTSD was incurred in service. 38 U.S.C.A. §§ 5107(a), 1110 (West 1991); 38 C.F.R. § 3.304(f) (1999). 3. A well-grounded claim of entitlement to service connection for an eye disorder and hearing loss has not been submitted. 38 U.S.C.A. § 5107 (West 1991 & Supp. 1996). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service connection may be established for a disability resulting from personal injury suffered or disease contracted in the line of duty or for aggravation of a preexisting injury suffered or disease contracted in the line of duty. 38 U.S.C.A. § 1110 (West 1991). A decision of a duly constituted rating agency or other agency of original jurisdiction shall be final and binding on all VA field offices as to conclusions based on evidence on file at the time VA issues written notification in accordance with 38 U.S.C.A. § 5104. (West 1991). If no notice of disagreement is filed within the prescribed period, the action or determination shall become final and the claim will not thereafter be reopened or allowed, except as otherwise provided by regulation. 38 U.S.C.A. § 7105(c) (West 1991); 38 C.F.R. § 20.1103 (1999). If new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. 38 U.S.C.A. § 5108 (West 1991); see also Hickson v. West, 12 Vet. App. 247 (1999). Only evidence presented since the last final denial on any basis (either upon the merits of the case, or upon a previous adjudication that no new and material evidence had been presented), will be evaluated in the context of the entire record. Evans v. Brown, 9 Vet. App. 273 (1996). New and material evidence is defined as evidence not previously submitted to agency decisionmakers 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). In Hodge v. West, 155 F.3d 1356, 1363 (Fed. Cir. 1998), the Federal Circuit noted that new evidence could be sufficient to reopen a claim if it could contribute to a more complete picture of the circumstances surrounding the origin of a veteran's injury or disability, even where it would not be enough to convince the Board to grant a claim. In determining whether to reopen previously and finally denied claims, a three-step analysis was announced by 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"). Elkins v. West, 12 Vet. App. 209 (1999). Under the Elkins test, the Board must first determine whether the veteran has presented new and material evidence under 38 C.F.R. § 3.156(a) in order to have a finally denied claim reopened under 38 U.S.C.A. § 5108. Second, if new and material evidence has been presented, immediately upon reopening the claim, the Board must determine whether, based upon all the evidence of record in support of the claim, the claim as reopened (as distinguished from the original claim) is well grounded pursuant to 38 U.S.C.A. § 5107(a) (West 1991). Third, if the claim is well grounded, the Board may then proceed to evaluate the merits of the claim but only after ensuring the VA's duty to assist under 38 U.S.C.A. § 5107(b) (West 1991) has been fulfilled. Winters v. West, 12 Vet. App. 203 (1999). Generally, for a claim to be well grounded, there generally must be (1) a medical diagnosis of a current disability; (2) medical or, in certain circumstances, lay evidence of in- service occurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between an in-service injury or disease and the current disability. See Anderson, supra; Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (table). Service connection for PTSD The RO, in its May 1997 decision, denied service connection for PTSD. As the veteran did not timely appeal, that determination became final. Thus, new and material evidence is required to reopen the veteran's claim. The basis for the RO's May 1997 denial was that the evidence did not establish that a stressful incident occurred sufficient to support a diagnosis of PTSD. Since that time, the veteran testified in great detail at 2 personal hearings, and service connection has been established for removal of a ganglion cyst that was incurred during the veteran's duties on the flight deck. Additionally, numerous VA treatment records were submitted that link PTSD to the veteran's service. The Board has carefully reviewed the additional evidence received since the RO's May 1997 denial and finds that evidence is sufficiently new and material to warrant reopening the veteran's claim. A well grounded claim for PTSD requires evidence of the disability; lay evidence (presumed to be credible for well- grounded purposes only) of an in-service stressor; and medical evidence of a nexus between service and PTSD. Gaines v. West, 11 Vet. App. 353, 357 (1998). Service connection for PTSD requires medical evidence diagnosing the condition in accordance with the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), a link, established by medical evidence, between current symptoms and an in-service stressor, and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f), as amended, see 64 Fed. Reg. 117 (June 18, 1999). See Cohen v. Brown, 10 Vet. App. 128, 138 (1997). The existing record contains a diagnosis of PTSD related by competent medical personnel to incidents of service as reported by the veteran. As such, the claim is well grounded. Once the claim is found to be well grounded, the presumption that it is credible and entitled to full weight no longer applies. In the adjudication that follows, the Board must determine, as a question of fact, both the weight and credibility of the evidence. Equal weight is not accorded to each piece of material contained in a record; every item of evidence does not have the same probative value. The Board must account for the evidence which it finds to be persuasive or unpersuasive, analyze the credibility and probative value of all material evidence submitted by and on behalf of a claimant, and provide the reasons for its rejection of any such evidence. See Struck v. Brown, 9 Vet. App. 145, 152 (1996); Caluza v. Brown, 7 Vet. App. 498, 506 (1995); Gabrielson v. Brown, 7 Vet. App. 36, 40 (1994); Abernathy v. Principi, 3 Vet. App. 461, 465 (1992); Simon v. Derwinski, 2 Vet. App. 621, 622 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164, 169 (1991). In this case, the veteran's military occupational specialty was as a mechanical equipment repairman. His decorations included the National Defense Service Medal, Vietnam Service Medal, Vietnam Campaign medal and Meritorious Unit Commendation. His training completed during service included a Crash Fire Fighting Course. In Zarycki v. Brown, 6 Vet. App. 91 (1993), the Court set forth the analytical framework and line of reasoning for determining whether a veteran was exposed to a recognizable stressor during service. The Court in Zarycki noted that, under 38 U.S.C.A. § 1154(b) and 38 C.F.R. § 3.304(d) and (f), the evidence necessary to establish the incurrence of a recognizable stressor during service to support a claim of service connection for PTSD will vary depending on whether the veteran "engaged in combat with the enemy." See Hayes v. Brown, 5 Vet. App. 60 (1993). The determination as to whether the veteran "engaged in combat with the enemy" is made by considering military citations that expressly denote as much and/or other service department or lay evidence that is credible. See Doran v. Brown, 6 Vet. App. 283, 289 (1994). In Cohen v. Brown, 10 Vet. App. 128 (1997), the Court noted that the VA had adopted a final rule in October 1996, effective November 7, 1996, revising 38 C.F.R. §§ 4.125 and 4.126 (1996). The effect of these revisions was to change the diagnostic criteria for mental disorders from the Diagnostic and Statistical Manual for Mental Disorders (DSM), third edition and the third edition, revised, to the fourth edition (DSM-IV). The criteria in DSM-IV for determining sufficiency of stressors is no longer based solely on usual experience and response but are individualized (geared to the specific individual's actual experience and response). Id. As such, the standard to be used to establish in-service stressors depends upon whether the veteran engaged in combat, i.e., the veteran had personally participated in events constituting an actual fight or encounter with a military foe, hostile unit, or instrumentality. VAOPGCPREC 12-99 (October 18, 1999). If the veteran engaged in combat, his lay testimony regarding lay stressors will be accepted as conclusive evidence of the presence of in-service stressors, unless VA produces clear and convincing evidence to the contrary. 38 U.S.C.A. § 1154(b) (West 1991); Fossie v. West, 12 Vet. App. 1 (1998); Gaines, 11 Vet. App. 353; 38 C.F.R. § 3.304(f). If, however, the veteran was not engaged in combat, he must introduce corroborative evidence of his claimed in-service stressors. See Fossie and Cohen, both supra; 38 C.F.R. § 3.304(f). In this case, the evidence shows that the veteran had not engaged in combat with the enemy. While in service, the veteran did not have a combat military occupational specialty. It is noted that the veteran's medals and decoration awards do not include any that are generally awarded in recognition of significant actions of valor. The veteran was awarded the Vietnam Campaign Medal and the Vietnam Service Medal. He was not awarded the Purple Heart, Combat Infantryman Badge, or any other similar combat citation. See VAOPGCPREC 12-99; see also Gaines, 11 Vet. App. at 359; M21-1. Also, the veteran's service medical records do not show that he was engaged in combat or that he incurred any wounds or injuries therefrom. The record is devoid of any post-service competent evidence demonstrating that the veteran was engaged in combat activity. The Board recognizes that the veteran stated that he had inservice direct combat during his VA hospitalization in February to April 1998. As herein discussed, contemporaneous records do not support that the veteran participated in an actual fight or encounter with a military foe or hostile unit or instrumentality so as to constitute engaging in combat with the enemy. VAOPGCPREC 12-99. Thus, the evidence in this respect is against the veteran's claim and is not in equipoise. VAOPGCPREC 12-99. Because the veteran had not engaged in combat while in service, he is required to provide credible supporting evidence corroborating his alleged in-service stressors. Fossie, 12 Vet. App. 1. If the claimed stressor is not combat related, "the veteran's lay testimony regarding [an] in-service stressors is insufficient, standing alone, to establish service connection and must be corroborated by "credible evidence," Doran v. Brown, 6 Vet. App. 283, 289 (1994). In this matter, the Board finds that sufficient verification has been presented to confirm the veteran's stressors. Specifically, in his December 1999 testimony, the veteran described in detail the nature of his military duties on the flight deck, and that he felt endangered for his life. T. 3- 5. He explained how the duties were specifically frightening to him. T. 19-20. Additionally, he indicated the he injured his right wrist during service while performing his duties on the flight deck. T. 21-22. (Also April 1999 hearing, T. 12). The veteran's testimony is otherwise corroborated in several ways. First, the service medical records show that he sought treatment on various occasions for incidents experienced on the flight deck. Moreover, service connection is in effect for residuals of the right wrist ganglion removal. The Board further notes that a May 1997 communication from the U.S. Army & Joint Services Environmental Support Group confirmed the veteran's previous report of a fire aboard ship. The veteran also described a fire at his December 1999 hearing. T. 9. As noted above, the criteria in DSM-IV for determining sufficiency of stressors is based on individualized responses (geared to the specific individual's actual experience). Accordingly, the Board finds that for this veteran, the duties during service produced stressors and that such stressors have been sufficiently verified. The element of 38 C.F.R. § 3.304(f) that must now be considered for a grant of PTSD is whether there is a diagnosis of PTSD and if there is medical evidence of a causal nexus between current symptomatology and the specific claimed in-service stressor. See West v. Brown, 7 Vet. App. 70 (1994). During VA hospitalization in March to April 1996, PTSD was noted to be newly diagnosed. During VA examination of September 1996, the examiner noted that the veteran described his stressor as the job that he had while in the military. The veteran further described his witnessing one of his friends on the flight deck get blown overboard by the exhaust of a jet. The impression was PTSD. The veteran's Axis I diagnosis following VA hospitalization from September to November 1996 was PTSD. It was noted that his primary duty during service was in aviation fuels and that he had recurring images of incidents aboard ship. Subsequent VA treatment records refer to the veteran's diagnosis of PTSD. At the time of VA hospitalization for PTSD in February to April 1998, the veteran indicated that he was always fearful that something might happen aboard ship. A VA treating examiner's opinion in November 1998 was that the veteran had PTSD, which had appeared on numerous hospitalization discharge summaries and was a diagnosis since 1996. A VA psychologist in March 1999 provided an assessment of PTSD, following the veteran's noted history of events on the flight deck. The veteran's mother provided a statement to the RO in April 1999, to the effect that the veteran had flashbacks after service and he seemed mentally sick. The veteran's sisters submitted similar statements regarding the veteran having flashbacks and having mental problems. The veteran provided testimony at a hearing at the RO in April 1999. He also presented testimony at the Board in December 1999. Transcripts of those hearings are of record. In the instant case, the record supports the veteran's claim that he has PTSD as a result of his in-service experiences. Various VA examiners have diagnosed PTSD, but the record also shows that the veteran's flight deck duty was a consideration in formulating the diagnosis. The March 1999 psychologist specifically referred to the veteran's duties in the context of the PTSD diagnosis. Consequently, the Board finds that service connection is warranted for PTSD. Service connection for an eye disorder and hearing loss The threshold question to be answered with respect to claims of service connection is whether there is evidence that the claim is well grounded. "[A] person who submits a claim for benefits under a law administered by the Secretary shall have the burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that the claim is well grounded." 38 U.S.C.A. § 5107(a); Carbino v. Gober, 10 Vet. App. 507 (1997); Anderson v. Brown, 9 Vet. App. 542, 545 (1996). A well-grounded claim is "a plausible claim, one which is meritorious on its own or capable of substantiation. Such a claim need not be conclusive but only possible to satisfy the initial burden of [section 5107(a)]." Murphy v. Derwinski, 1 Vet. App. 79, 81 (1990). In Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992), the Court held that a claim must be accompanied by supportive evidence and that such evidence "must 'justify a belief by a fair and impartial individual' that the claim is plausible." The Board reiterates the three requirements for a well grounded claim: (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of inservice incurrence or aggravation of a disease or injury; and, (3) medical evidence of a nexus between the claimed inservice injury or disease and a current disability. See Caluza, supra. The Board finds that the veteran has not submitted a well-grounded claim for service connection for an eye disorder and hearing loss at issue in the instant appeal. The veteran contends that the eye disorder and hearing loss currently on appeal are linked to his military service. He testified that debris from jets went into his eyes and affected them. T. 9 (RO hearing). He also testified that exposure to jet noise resulted in hearing loss. T. 11 (RO hearing). The Board notes that, generally speaking, lay persons are not competent to offer evidence that requires medical knowledge. Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992) (holding that a witness must be competent in order for his statements or testimony to be probative as to the facts under consideration). The record does not show that the veteran has any medical background so as to provide a competent opinion about medical causation and diagnosis. In the instant case, service medical records show that the veteran entered service with a right ear hearing loss: his August 1969 entry examination revealed 40 decibels at 4000 Hertz. The threshold for normal hearing is from 0 to 20 decibels, and higher threshold levels indicate some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). The veteran will be considered to have been in sound condition when examined, accepted and enrolled for service except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable evidence demonstrates that an injury or disease existed prior thereto. Only such conditions as are recorded in examination reports are to be considered as noted. 38 C.F.R. § 3.304(b) (1999). Since the entry examination revealed a hearing loss of the right ear, the presumption of soundness to this extent does not apply. In order for a grant of service connection, it must be shown that the preexisting disorder was aggravated. A preexisting injury or disease will be considered to have been aggravated by active military, naval, or air service, where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. Clear and unmistakable evidence (obvious or manifest) is required to rebut the presumption of aggravation where the preservice disability underwent an increase in severity during service. This includes medical facts and principles which may be considered to determine whether the increase is due to the natural progress of the condition. Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during and subsequent to service. 38 U.S.C.A. § 1153 (West 1991); 38 C.F.R. § 3.306(a)(b) (1999). The subsequent service medical records show no findings of hearing loss of either ear, including at the time of the veteran's separation examination in November 1973. Accordingly, the service records do not tend to show that a hearing loss was incurred in or aggravated by service. Where a veteran served continuously for 90 days or more during a period of war and sensorineural hearing loss becomes manifest to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309 (1999). Subsequent to service, the medical records do not show treatment or findings of a hearing loss until 1998, more than 2 decades after service separation. Thus, there has been no competent evidence submitted that tends to show that service connection is warranted on a presumptive basis. Further, the Board notes that the 1998 VA treatment records, which reveal hearing loss and that the veteran was fitted for hearing aids, do not contain an opinion that links the post- service hearing loss to any incident during service. Without such medical nexus evidence, the veteran's claim for service connection for hearing loss is not well grounded. See Savage v. Gober, 10 Vet. App. 489 (1997); Caluza, supra. At his December 1999 hearing, the veteran testified that a doctor at the VA facility in Tuskegee related his hearing loss to military service. T. 14. Initially, that assertion, "filtered as it (is) through a layman's sensibilities, of what a doctor purportedly said is simply too attenuated and inherently unreliable to constitute 'medical' evidence." Robinette v. Brown, 8 Vet. App. 69, 77 (1995). Further, the RO obtained the VA treatment records from the Tuskegee facility, and as stated above, there is no opinion in those, or other, records that links the veteran's hearing loss to service. Consequently, the VA's duty under 38 U.S.C.A. § 5103(a) (West 1991 & Supp. 1995) is satisfied, and the claim for service connection for hearing loss must be denied. With regard to the claim for an eye disorder, the veteran entered service with bilateral visual acuity of 20/20; his separation examination in November 1973 also shows 20/20 in each eye. He was treated on one occasion for asthenopia in September 1971, at which time his visual acuity was also noted to be 20/20. These findings, which reveal normal visual acuity, do not tend to indicate that an eye disability was incurred in service. Subsequent to service, the post-service VA medical records dated in February 1998 first show that the veteran needed reading glasses. In October 1998, he was again seen regarding a request for eyeglasses. However, the post- service medical evidence does not contain a medical opinion that links the need for reading glasses, or any eye abnormality, to service. In the absence of medical nexus evidence, the claim for service connection for an eye disorder must be denied. Caluza, supra. At his hearing, the veteran was not clear as to whether a doctor at the VA facility in Tuskegee related his current eye disorder to service. T. 16. In any event, the RO associated the Tuskegee records with the claims file, and those records do not have a medical nexus opinion that shows any relationship between an eye disorder and service. As discussed above, in this situation, there is no duty under 38 U.S.C.A. § 5103(a). For the aforementioned reasons, the Board does not find the claims for service connection for an eye disorder and hearing loss to be well grounded. Although where a claim is not well grounded, the VA does not have a statutory duty to assist the claimant in developing facts pertinent to the claim, the VA may be obligated under 38 U.S.C.A. § 5103(a) (West 1991 & Supp. 1995) to advise a claimant of evidence needed to complete the application, including by taking appropriate action when the claim contains references of other known and existing evidence that may well ground the claim. Epps v. Gober, 126 F.3d 1464 (Fed. Cir. 1997). The Board is not aware of any other medical records that would render the veteran's claim capable of substantiation. Therefore, no further development is warranted. 38 U.S.C.A. § 5103(a) (West 1991 & Supp. 1995). The Board also provided the veteran with an additional 60 days from the date of his December 1999 hearing in which to submit any additional evidence. ORDER Service connection for PTSD is granted. Service connection for an eye disorder and hearing loss is denied. REMAND At the veteran's December 1999 hearing, the veteran testified that his service-connected scar was always tender and painful. T. 23. He explained that the aching and pain limited his activities. T. 23. He acknowledged that the prior VA examination did not reveal that the scar was painful or tender. T. 24. The veteran's representative also maintained that the examination did not address any functional loss due to pain, and he asked for separate ratings for the scar and the other disability caused from the residuals of ganglion removal. T. 25. He requested consideration of the Court's cases of DeLuca v. Brown, 8 Vet. App. 202 (1995) and Esteban v. Brown, 6 Vet. App. 259 (1995). In DeLuca v. Brown, 8 Vet. App. 202 (1995), the Court held that where evaluation is based on limitation of motion, the question of whether pain and functional loss are additionally disabling must be considered. Disability of the musculoskeletal system is the inability to perform normal working movement with normal excursion, strength, speed, coordination, and endurance, and that weakness is as important as limitation of motion, and that a part which becomes disabled on use must be regarded as seriously disabled. However, a little-used part of the musculoskeletal system may be expected to show evidence of disuse, through atrophy, for example. 38 C.F.R. § 4.40 (1999). The provisions of 38 C.F.R. § 4.45 and 4.59 (1999) contemplate inquiry into whether there is crepitation, limitation of motion, weakness, excess fatigability, incoordination, and impaired ability to execute skilled movements smoothly, and pain on movement, swelling, deformity, or atrophy of disuse. Instability of station, disturbance of locomotion, and interference with sitting, standing, and weight-bearing are also related considerations. It is the intention of the rating schedule to recognize actually painful, unstable, or mal-aligned joints, due to healed injury, as at least minimally compensable. Id. The provisions of 38 C.F.R. § 4.14 (1999) preclude the assignment of separate ratings for the same manifestations under different diagnoses. The critical element is that none of the symptomatology for any of the conditions is duplicative or overlapping with symptomatology of the other conditions. Esteban v. Brown, 6 Vet. App. 259 (1995). Impairment associated with the veteran's service-connected disability may be rated separately unless it constitutes the same disability or the same manifestation. Esteban, 6 Vet. App. 261. The critical element is that none of the symptomatology is duplicative or overlapping; the manifestations of the disabilities must be separate and distinct. Esteban, 6 Vet. App. at 261, 262. The VA has a duty to assist the veteran in the development of facts pertinent to his claim. 38 U.S.C.A. § 5107(a). The Court has held that the duty to assist the veteran in obtaining and developing available facts and evidence to support his claim includes obtaining adequate VA examination. This duty is neither optional nor discretionary, Littke v. Derwinski, 1 Vet. App. 90 (1990), and includes providing additional VA examinations by a specialist when recommended. See Hyder v. Derwinski, 1 Vet. App. 221 (1991). The fulfillment of the statutory duty to assist includes conducting a thorough and contemporaneous medical examination, one which takes into account the records of prior medical treatment, so that the evaluation of the claimed disability will be a fully informed one. Green v. Derwinski, 1 Vet. App. 121, 124 (1991). To ensure that VA has met its duty to assist the veteran in developing the facts pertinent to the claim, the case is REMANDED for the following development: 1. The veteran is advised that he has the right to submit additional evidence and argument on the matter the Board has remanded to the RO, to include, but not limited to, evidence and/or information previously requested by the RO or the Board. Kutscherousky v. West, 12 Vet. App. 369 (1999). 2. The RO should ensure that all treatment records of the veteran's right wrist since February 1999 have been secured and associated with the claims file. 3. The veteran should be afforded a VA examination by an appropriate specialist in order to determine the nature of all disability associated with the scar, postoperative removal of ganglion cyst of the right wrist. Once all disability of the right wrist has been identified, the examiner should provide an opinion as to whether each identified disability is related to the service-connected disability. The examiner should discuss whether the service-connected disability involves inability to perform normal working movement with normal excursion, strength, speed, coordination, and endurance; whether there is crepitation, limitation of motion, weakness, excess fatigability, incoordination, and impaired ability to execute skilled movements smoothly, and pain on movement, swelling, deformity, or atrophy of disuse. The examiner should also describe whether there is pain and tenderness, involving the scar or otherwise, and whether there is objective pathology to support any reports of pain. The claims folder must be made available to the examiner for review before the examination. 4. Thereafter, the RO should review the claims file to ensure that all of the foregoing requested development has been completed. In particular, the RO should review the requested examination reports and required opinions to ensure that they are responsive to and in complete compliance with the directives of this remand. If they are not, the RO should implement corrective procedures. Stegall v. West, 11 Vet. App. 268 (1998). The RO should then readjudicate the claim and consider all pertinent diagnostic criteria as well as the cases of DeLuca, Esteban, supra, and Fenderson v. West, 12 Vet. App. 119 (1999). If the decision remains adverse to the veteran, he and his representative should be furnished with a supplemental statement of the case and afforded the applicable time to respond. Thereafter, the case should be returned to the Board, if in order. The Board intimates no opinion as to the ultimate outcome of this case. The appellant need take no action unless otherwise notified. 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 Veterans Appeals 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. 1996) (Historical and Statutory Notes). In M. Sabulsky Member, Board of Veterans' Appeals