Citation Nr: 0000251 Decision Date: 01/05/00 Archive Date: 01/11/00 DOCKET NO. 98-09 400 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to service connection for osteochondroma of the right femur. 2. Whether new and material evidence has been submitted to reopen a claim of entitlement to service connection for disability manifested by neck pain. REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD John Kitlas, Associate Counsel INTRODUCTION The veteran served on active duty from March 1986 to May 1988. The osteochondroma claim is before the Board of Veterans' Appeals (Board) on appeal from a January 1989 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas, which denied the claim. The veteran's claim of entitlement to service connection for neck pain was denied by an April 1990 rating decision. The veteran was informed of this decision, and did not appeal. This claim is currently before the Board on appeal from a July 1997 rating decision by the RO, which found that new and material evidence had not been submitted to reopen the claim. This case was previously before the Board in December 1998, at which time it was remanded for consideration of additional issues and application of new legal precedent. It has now been returned to the Board for further appellate consideration. As a preliminary matter, the Board finds that the RO has substantially complied with the directives of the December 1998 remand. Accordingly, a new remand is not required to comply with the holding of Stegall v. West, 11 Vet. App. 268 (1998). As an additional matter, it is noted that when the osteochondroma claim was previously before the Board, the issue was identified as whether new and material evidence had been submitted to reopen the veteran's claim. The Board mistakenly found that the veteran had not perfected his appeal to the January 1989 rating decision. However, after a Statement of the Case was issued in October 1989, the veteran presented additional contentions regarding his osteochondroma claim in a statement dated in March 1990. Upon further review of this document, the Board finds that it is sufficient to qualify as a timely Substantive Appeal in lieu of a VA Form 9 pursuant to 38 C.F.R. § 20.202. Therefore, the veteran's osteochondroma claim never became final, and the Board will address whether he is entitled to a grant of service connection for osteochondroma of the right femur on a de novo basis. In September 1999 the Board requested a VA medical opinion regarding the osteochondroma claim pursuant to 38 U.S.C.A. § 7109 and Veterans Health Administration (VHA) Directive 10-95-040 dated April 17, 1995. The requested opinion, dated in November 1999, was received by the Board and sent to the veteran's accredited representative that same month. In a letter dated in December 1999 the representative waived the period for submission of additional evidence and argument, and requested that the Board enter a decision in the veteran's case. The Board also notes that the veteran's appeal initially included a claim for a disability rating in excess of 10 percent for somatoform pain disorder, manifest by lumbosacral discomfort. When the case was before the Board in December 1998, an increased rating of 30 percent was granted for this disability. Accordingly, this issue is no longer on appeal. FINDINGS OF FACT 1. The veteran was not noted to have an osteochondroma of the right femur at the time of his enlistment into active duty. 2. The veteran was diagnosed with an osteochondroma of the right femur in October 1987, while on active duty. 3. A December 1987 Medical Evaluation Board determined that the osteochondroma arose from the epiphyseal plate, and, therefore, existed prior to service. 4. Following his discharge from service, the veteran had surgery to remove the osteochondroma of the right femur in January 1989. 5. A medical opinion, dated in November 1999, is to the effect that the veteran's osteochondroma preexisted service, and was not aggravated therein. 6. In an August 1990 rating decision, the RO, among other things, denied the veteran's claim of entitlement to service connection for neck pain. The veteran was informed of this decision, and did not appeal. 7. The evidence introduced into the record since the August 1990 rating decision denying service connection for neck pain either does not bear directly and substantially upon the specific matter under consideration, or it is either cumulative or redundant, or it is not 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 veteran's claim of entitlement to service connection for neck pain. CONCLUSIONS OF LAW 1. The presumption of soundness at the time of entry into service regarding the osteochondroma of the right femur has been rebutted. 38 U.S.C.A. §§ 1111, 1137 (West 1991 & Supp. 1999); 38 C.F.R. 3.304(b) (1999). 2. The veteran's osteochondroma of the right femur was not incurred in or aggravated by his active military service. 38 U.S.C.A. §§ 1110, 1131, 1111, 1153 (West 1991 & Supp. 1999); 38 C.F.R. §§ 3.303, 3.306 (1999). 3. The August 1990 rating decision denying service connection for neck pain is final. 38 U.S.C. § 4005(c) (1988) (38 U.S.C.A. § 7105 (West 1991 & Supp. 1999)); 38 C.F.R. § 19.192 (1990) (38 C.F.R. § 20.1103 (1999)). 4. New and material evidence to reopen the veteran's claim for service connection for neck pain has not been submitted; the claim is not reopened. 38 U.S.C.A. §§ 5108, 7105 (West 1991 & Supp. 1999); 38 C.F.R. § 3.156(a) (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS General Background. The veteran's lower extremities were clinically evaluated as normal on his January 1986 enlistment examination. The service medical records show that the veteran was treated on numerous occasions for back pain beginning in April 1987. The veteran was subsequently referred for evaluation of his chronic back pain in September 1987. A Narrative Summary, dictated October 26, 1987, noted that the veteran complained of right hip pain associated with his back pain. Consultations were obtained from Orthopedic Surgery, Physical Medicine and Rehabilitation, Urology, Neurology, and Behavioral Psychology. Among other things, it was noted that a scanogram conducted as part of the Physical Medicine and Rehabilitation consult showed an osteochondroma of the right femur. However, review by the Orthopedic Surgery Service resulted in a finding that this was not responsible for the veteran's complaint. Therefore, it was recommended that the tumor not be removed during that hospitalization, but that the veteran have it removed, if required, after evaluation of his back pain was completed. Final diagnoses included small herniated disc, L4-L5 area, with no evidence of nerve root involvement; and osteochondroma of the right femur. A Medical Evaluation Board examination was conducted in December 1987. On this examination, the veteran's head, face, neck and scalp were clinically evaluated as abnormal. This finding was due to bilateral temporomandibular joint (TMJ) clicking with episodic pain. Furthermore, the veteran's lower extremities, spine and other musculoskeletal were clinically evaluated as abnormal as well. An accompanying Narrative Summary noted that consultations had been obtained from Orthopedics, Urology, and Physical Medicine Rehabilitation. Among other things, it was noted that X-rays and a CT scan were performed as part of the evaluation of the right osteochondroma of the right femur. It was determined that this evaluation showed that the lesion arose from the epiphyseal plate, and, therefore, existed prior to service. A January 1988 Medical Board Report included the following diagnoses: somatoform pain disorder; dependent, narcissistic and histrionic personality traits noted and thought to have a direct bearing on the somatoform pain disorder; and osteochondroma of the right lesser Trochanter that arose from the Epiphyseal Plate, which was considered an incidental finding during evaluation. The Medical Board recommended referral to the Physical Evaluation Board. An undated statement from the veteran makes reference to a Physical Evaluation Board that was to convene in February 1988. The veteran took exception to a number of findings by the Medical Evaluation Board regarding the osteochondroma tumor. He contended that a finding that it existed prior to service was questionable. Furthermore, he believed, despite the Medical Evaluation Board's findings, that the tumor could have been aggravated by the pressure to the back of the thigh through hours of sitting at terminals. Thus, causing numbness throughout the entire right leg. While no Physical Evaluation Board report is of record, the veteran's DD Form 214 shows that he received an honorable discharge as a result of disability, and that he was entitled to severance pay. The service medical records show no treatment for or a diagnosis of a neck disorder. In September 1988, the veteran submitted his original claims of entitlement to service connection for back and neck pain radiating down the legs and arms, and a tumor on the right hip. A VA orthopedic examination was conducted in December 1988. At this examination, the veteran reported that he had an onset of back pain while lifting in April 1987. Following physical examination, the examiner's diagnostic impression was chronic lumbosacral discomfort with poor response to conservative management, but no apparent neurological deficit at the time of examination. Also on file is a December 1988 VA general medical examination. Among other things, it was noted that the veteran's neck was supple. In a January 1989 rating decision, the RO, among other things, denied service connection for osteochondroma of the right femur. In a statement dated in January 1989, but received in April 1989, the veteran's representative reported that the veteran was hospitalized and surgery was to be performed for one of the orthopedic problems that caused his discharge from the military. Therefore, the representative requested that a temporary total rating be assigned due to the veteran's hospitalization. Of record is a VA hospitalization report that shows the veteran was hospitalized from January to February 1989 for excision of osteochondroma. In a June 1989 deferred or confirmed rating decision, the RO found, in part, that the hospitalization report was not new and material evidence sufficient to permit service connection for the right femur. By correspondence dated in that same month, the RO informed the veteran that the evidence he submitted to reopen his previously disallowed claim was not new and material because the evidence did not provide a new basis for reconsideration of his claim. The veteran's representative submitted a Notice of Disagreement in July 1989, and a Statement of the Case was subsequently issued to the veteran in October 1989. As stated above, the veteran subsequently submitted additional arguments regarding his osteochondroma claim in March 1990, and the Board finds that this statement qualifies as a timely Substantive Appeal in lieu of a VA Form 9 pursuant to 38 C.F.R. § 20.202. However, it was mistakenly determined that his claim became final, and was treated accordingly. Also in March 1990, the veteran underwent VA neurological and orthopedic examinations. At the VA neurological examination, the examiner noted that the veteran's past medical records were not available. The veteran reported that he had back problems during service beginning in April 1987. He stated that while being treated for his back problems, X-rays revealed an osteochondroma in the right hip. According to the veteran, he was discharged from service on the basis that his problem existed prior to military service. Further, the veteran noted that he had had the tumor removed from his right hip in January 1989. He reported that this had helped, but that he continued to have pain primarily in his neck radiating into the left shoulder and in his low back which radiated into both legs. The veteran stated that the pain was constant in his neck, shoulder, and low back. However, he was not involved in any active treatment or medication at that time. Following neurological examination, the diagnoses included history of pain and parostosis neck, left shoulder, and low back without objective neurological findings. At the VA orthopedic examination, the veteran reported that after one month of hospitalization for his back problems, he was found to have osteochondroma of his right femur. He reported that he was discharged as this condition was considered preexisting and that his back problems were attributed to this lesion. Following the orthopedic examination, the veteran was diagnosed with status post excision of osteochondroma of the right femur with increased pain, and chronic recurrent lumbosacral sprain with moderate disability. Also in March 1990, X-rays were taken of the veteran's right hip and proximal femur. It was noted that the proximal femoral structures showed a slightly different configuration than was normally anticipated. There was a broadening and relative foreshortening of the length of the femoral head. The broadening was particularly apparent at the base of the neck or in the vicinity of the intercondylar ridge. The superior neck cortex was coincident and continuous with the upper cortex of the greater trochanter. Also, it was noted that the lesser trochanter was more posteriorly positioned and flatter than usual. There was some slight change in the cancellous structures in that they were not quite so smooth and continuous as was normally the case in the proximal femur. It was stated that one might even suspect that the veteran might have experienced a stress type fracture with reparative changes producing the variance in the anatomy. In addition, on the anterior aspect of the surgical neck, there was a flat, exostotic-like prominence with a tiny calcareous shadow in the adjacent soft tissues. It was opined that this could very easily represent an injury to a muscle insertion. There were other small calcifications in the juxtacortical aspects of the neck anteriorly, and the trochanter posteriorly, that it was opined could have been changes resulting from old injuries to the periarticular soft tissues. It was stated that it was not at all impossible that the veteran might have had a fracture dislocation at some time in the very distant past. The proximal two-thirds of the shaft of the femur were found to be intact. The hip joint was also intact, and showed no significant pathologic variations. However, it was stated that without previous films and/or films of the opposite hip for comparative purposes, a definite conclusion was not possible. It was further stated that this could be nothing more than an anatomical variant of the structures, although the soft tissues calcifications would more strongly indicate the possibility of an old injury. Additionally, an osteochondroma was not visible in the portion of the femur included for the X-ray studies. In an August 1990 rating decision, the RO, in part, denied service connection for neck pain as the service medical records and the December 1988 VA examination were completely negative for any complaint, treatment, or diagnosis of a neck disorder. The RO also stated that the January 1989 rating decision contained clear and unmistakable error by not disposing of the issue of neck pain with radiation down the arms. The veteran was informed of the August 1990 rating decision by correspondence dated in September 1990, and he did not initiate an appeal to the denial of service connection for neck pain. In November 1996, the RO received a statement from the veteran in which he reported that he had a painful and tender residual scar from the removal of the osteochondroma that had been found in service. The RO construed this as a request to reopen the osteochondroma claim. Consequently, the RO sent the veteran correspondence in December 1996, in which it was stated that his claim of service connection for osteochondroma, right femur, had been previously denied in rating decisions issued in January 1989, June 1989, and August 1990. Service connection had been denied as the cumulative evidence did not show that this condition, which pre-existed service, was aggravated during his military service. Therefore, in order to reopen his claim, the veteran needed to present new and material evidence which showed that this pre-existing condition was aggravated by service. In a statement dated in February 1997, the veteran requested that his service connection claims for osteochondroma of the right femur and neck pain be reopened based upon a clear and unmistakable error. He asserted there was clear and unmistakable error regarding the osteochondroma in that the claim was denied without obtaining a medical expert opinion as to whether the condition preexisted service, and, if so, whether the condition was aggravated by service. Regarding his neck pain with radiation into the left shoulder, the veteran asserted there were entries for this condition in his service medical records in August and November 1987. Moreover, he asserted that the December 1988 VA examination only addressed his back, and not his neck. He contended that he should have been granted a VA examination of his neck and a medical expert opinion. Medical records were subsequently obtained from the VA Medical Center (VAMC) in San Antonio, Texas, which covered the period from January 1989 to April 1991. These records show treatment on numerous occasions for back, neck, and right hip pain. Treatment records were also obtained from the VA Outpatient Clinic (VAOPC) in Austin, Texas, for the period from November 1996 to February 1997. These records show that the veteran sought treatment in December 1996 for low back pain, for which a TENS unit was prescribed. In February 1997, the veteran sought treatment for pain in the right hip, shoulder, lower back, and neck. In a July 1997 rating decision, the RO, in part, found that new and material evidence had not been submitted to reopen the claims of service connection for osteochondroma of the right femur and neck pain. The RO stated that to justify a reopening of a claim on the basis of new and material evidence there must be a reasonable possibility that the new evidence, when viewed in the context of all the evidence, both new and old, would change the outcome. Regarding the osteochondroma of the right femur, the RO found that the additional evidence submitted essentially duplicated evidence which had been previously considered and was merely cumulative. With respect to the neck pain, the RO found that there was no reasonable possibility that the new evidence submitted in connection with the current claim would change the previous decision. Specifically, the RO found that the evidence of treatment for neck pain did not serve to establish that this condition was incurred in or aggravated by military service. The veteran appealed the adverse July 1997 rating decision to the Board. The veteran underwent a VA mental disorders examination in October 1997. The VA examiner noted that the claims folder had been reviewed prior to making the report, and noted various facets of the veteran's medical and occupational history. Among other things, it was noted that the veteran had an osteochondroma of his right proximal femur removed in 1989. Following mental status examination, the examiner found that the veteran's general medical conditions included status post osteochondroma of the right proximal femur. The veteran underwent a VA orthopedic examination in January 1998. Regarding his medical history, the veteran reported, among other things, that while he was hospitalized for back pain during service he was found to have an osteochondroma involving the right femur. This osteochondroma was removed after his discharge from active duty. It was also stated that the veteran had some evidence of cervical stiffness and soreness beginning in approximately 1987, but was not particularly treated. It was further noted that this stiffness and soreness was apparently treated in conjunction with some left trapezius pain at that time. Following examination, the examiner diagnosed postoperative status excision, osteochondroma, right femur. The examiner also diagnosed cervical stiffness and soreness in the right trapezius discomfort, musculoskeletal, the etiology of which was not neuropathy. Also in January 1998, X-rays were taken of the veteran that included anterior-posterior and lateral views of the right femur. The X-rays showed no gross abnormality. It was noted that the distal femur was not assessed. In his May 1998 Substantive Appeal, the veteran continued to assert that there was clear and unmistakable evidence in the denials of service connection for osteochondroma of the right femur and neck pain in that medical examinations were not conducted, and medical expert opinions were not obtained. When the case came before the Board in December 1998, it was noted that the Court of Appeals for the Federal Circuit (hereinafter, the Federal Circuit) had struck down the legal test which found that in order for newly submitted evidence to be considered material, "there must be a reasonable possibility that the new evidence, when viewed in the context of all the evidence, both new and old, would change the outcome." Hodge v. West, 115 F.3d 1356 (Fed. Cir. 1998). It was also noted that the Federal Circuit found that this test imposed a greater burden than what was contemplated by the law and regulations on the issue of "new and material evidence." The Board also noted that the veteran had contended that the prior rating decisions which had denied his claims were the subject of clear and unmistakable error. It was further noted that a favorable decision on the issue of clear and unmistakable error in the prior rating decisions would affect the issues of new and material evidence presently on appeal. Specifically, if there was clear and unmistakable error in the prior rating decision, then those decisions never became final. Consequently, the Board determined that these issues were "inextricably intertwined," and that the RO must adjudicate the issue of clear and unmistakable error prior to the Board's consideration of the new and material evidence issues certified on appeal. See Harris v. Derwinski, 1 Vet. App. 180 (1991). Accordingly, the case was remanded for the RO to consider the veteran's claim of clear and unmistakable error. If and only if the issue of clear and unmistakable error was not granted, the RO was to review the question of whether new and material evidence has been submitted to reopen the claims of service connection for osteochondroma of the right femur and neck pain in accordance with the criteria provided in 38 C.F.R. § 3.156(a) and the guidance of the Federal Circuit in Hodge. Following the Board's remand, the RO determined, in a February 1999 rating decision, that there was no clear and unmistakable error in the prior rating decisions of January 1989, June 1989, and August 1990. It was noted that the veteran alleged these decisions were clearly and unmistakably erroneous because a medical expert opinion was not requested to determine whether the conditions of osteochondroma of the right femur and neck pain preexisted service and if the conditions were aggravated by service. The RO found that there was no requirement for VA to obtain a medical opinion regarding the aggravation of a preexisting disability. Furthermore, the RO noted that the law allowed decision makers to make appropriate decisions based on all the evidence of record. The RO found that the decisions denying service connection for the claimed disabilities were based on all the evidence of record at that time, and was in accordance with the rules and laws in effect at that time. Therefore, the RO concluded that the veteran's claim of clear and unmistakable error was without merit. The RO informed the veteran of this decision by correspondence dated in March 1999. The evidence does not show that the veteran has since perfected, or even initiated, an appeal to this decision. Thereafter, in a March 1999 Supplemental Statement of the Case, the RO found that new and material evidence had not been submitted to reopen the claims of service connection for osteochondroma of the right femur and neck pain pursuant to the test prescribed at 38 C.F.R. § 3.156(a). For both issues, the RO found that the additional evidence submitted to reopen the claims essentially duplicated that evidence that was previously considered and was merely cumulative. Thereafter, the case was returned to the Board in September 1999, at which time the Board requested a medical expert opinion from the VHA regarding the veteran's osteochondroma of the right femur. Among other things, the Board noted that while the service medical records showed that the veteran's osteochondroma of the right femur was considered to have preexisted service because it arose from the epiphyseal plate, the basis for this conclusion was not set forth. The Board also noted that surgery was required to remove the osteochondroma within one year after the veteran's release from service, and that this seemed to indicate that it was symptomatic and had increased in severity since he entered service. However, it was not clear whether or not the need for surgery indicated an increase in severity of the underlying condition beyond the natural progression of the condition. Therefore, the Board requested that a qualified medical professional provide an opinion as to the following: (a) Is there clear and unmistakable evidence that the osteochondroma of the right femur was present at the time the veteran began military service in March 1986? (b) In view of the fact that the veteran required surgery for excision of the osteochondroma shortly after his release from service, was there an increase in the severity of the osteochondroma during service, and was any increase in severity beyond the natural progression of the condition? An opinion was subsequently promulgated by a VA physician in November 1999. This opinion was as follows: 1. Is there clear and unmistakable evidence that the osteochondroma of the right femur was present at the time the veteran began military service in March 1986? Yes. This opinion is based on the following factors. An osteochondroma is a benign bone tumor with a cartilage cap that arises from the physeal plate area. As the individual grows the osteochondroma is oriented away from the growth plate. These tumors can enlarge with growth of the individual and may even enlarge subsequently slowly even after adulthood. Typically, these osteochondromas especially in the hip and pelvis region are not detectable until they've grown to a large size due to the thickness of the overlying body tissues. Thus, within reasonable probability, this osteochondroma that was present on the right proximal femur on [the veteran] was there prior to his beginning military service in March 1986. 2. In view of the fact that the veteran required surgery for excision of the osteochondroma shortly after his release from service, was there an increase in the severity of the osteochondroma during service, and was any increase in severity beyond the natural progression of the condition? Discussion: No. The incident that allowed the diagnosis of the osteochondroma was related to his having back pain. The osteochondroma was picked up by chance on the scanogram that was utilized. Thus, the osteochondroma was not considered by the Orthopedic Department at that time to have been a factor in his discomfort, but they suggested that he have it removed due to its position and size after the workup for his lumbar back pain was completed. Thus, the removal of this osteochondroma after he was released from the service is not an indication that it was a service- related condition or that it increased in severity due to his active duty service. In short the osteochondroma was merely following its natural history. The removal of the osteochondroma was an elective procedure. Thus within reasonable medical probability the allegation by the appellant that his sitting at terminals during his service time aggravated his osteochondroma, really is not supported by the records that suggest that he had most of his symptoms with exertional activities versus sitting activities. Moreover, there is no physiological data to support that the activities of life, including sitting in terminals or even going up and down stairs, or exertional activities increase the rate of growth of the osteochondroma or change it's natural history. 3. Follow-up radiographs noted successful removal of this osteochondroma without fracture of the femur or any tumor recurrence. I. Osteochondroma Legal Criteria. Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131 (West 1991); 38 C.F.R. § 3.303 (1999). Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b). Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d) (1999). A veteran who served during a period of war or during peacetime service after December 31, 1946, is presumed in sound condition except for defects, infirmities, or disorders noted when examined and accepted for service, or where clear and unmistakable (obvious or manifest) evidence demonstrates that a disease existed prior to service. 38 U.S.C.A. §§ 1111, 1137; 38 C.F.R. 3.304(b). A preexisting injury or disease will be considered to have been aggravated by active military service, where there is an increase in disability during such service, unless there is specific finding that the increase in disability is due to the natural progress of the disease. 38 C.F.R. § 3.306(a). Temporary flare-ups will not be considered to be an increase in severity. Hunt v. Derwinski, 1 Vet. App. 292, 295 (1991). Clear and unmistakable evidence is required to rebut the presumption of aggravation where the pre-service disability underwent an increase in severity during active service. Aggravation may not be conceded, however, where the disability underwent no increase in severity during service. 38 C.F.R. § 3.306(b). The determination whether a preexisting disability was aggravated by service is a question of fact. Doran v. Brown, 6 Vet. App. 283, 286 (1994). The threshold question that must be resolved is whether the veteran has presented evidence of a well-grounded claim. A well-grounded claim is a plausible claim, that is, a claim which is meritorious on its own or capable of substantiation. An allegation that a disorder is service connected is not sufficient; the veteran must submit evidence in support of a claim that would "justify a belief by a fair and impartial individual that the claim is plausible." See 38 U.S.C.A. § 5107(a) (West 1991); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992); Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). The quality and quantity of the evidence required to meet this statutory burden of necessity will depend upon the issue presented by the claim. Grottveit v. Brown, 5 Vet. App 91. 92-93 (1993). In order for a claim to be well grounded, there must be competent evidence of a current disability (a medical diagnosis); evidence of incurrence or aggravation of a disease or injury in service (lay or medical evidence); and evidence of a nexus between the in-service injury or disease and the current disability (medical evidence). Caluza v. Brown, 7 Vet. App. 498, 506 (1995). In addition to the general standard set forth in Caluza v. Brown, chronicity and continuity standards can also establish a well-grounded claim. Savage v. Gober, 10 Vet. App. 488 (1997). The chronicity standard is established by competent evidence of the existence of a chronic disease in service or during an applicable presumption period; and present manifestations of the same chronic disease. The continuity standard is established by medical evidence of a current disability; evidence that a condition was noted in service or during a presumption period; evidence of post- service continuity of symptomatology; and medical, or in some circumstances, lay evidence of a nexus between the present disability and the post- service symptomatology. This type of lay evidence, for purposes of well groundedness, will be presumed credible when it involves visible symptomatology that is not inherently incredible or beyond the competence of a lay person to observe. Savage, supra. Where the determinant issue involves a question of medical diagnosis or medical causation, competent medical evidence is necessary to establish a well-grounded claim. Lay assertions of medical causation or a medical diagnosis cannot constitute evidence to render a claim well grounded. Grottveit, 5 Vet. App. at 93. Analysis. Initially, the Board finds that the veteran's claim of service connection for osteochondroma of the right femur is well grounded in that it is plausible. Tirpak, supra; Murphy, supra. VA has a statutory duty to assist a claimant once a well grounded claim has been submitted. 38 U.S.C.A. § 5107(a). The RO has obtained medical records concerning the veteran's osteochondroma, and has had him examined. Moreover, a medical expert opinion was obtained from the VHA regarding the veteran's claim. There does not appear to be any pertinent medical evidence that is not of record or requested by the RO. Thus, the Board finds that VA has fulfilled its duty to assist the veteran in developing the facts pertinent to this claim. No further assistance to the veteran is required to comply with the duty to assist mandated by 38 U.S.C.A. § 5107(a). In the instant case, the veteran's osteochondroma was not diagnosed at the time of the veteran's entry into active service. Nevertheless, the Board finds that there is clear and unmistakable evidence that the osteochondroma preexisted service and was not aggravated therein. Specifically, the December 1987 Medical Evaluation Board examination report, and the November 1999 VHA medical expert opinion. 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") has held that a physician's "unequivocal and uncontradicted opinion" can itself serve as clear evidence to rebut the presumptions of soundness and aggravation. Harris v. West, 11 Vet. App. 456, 461 (1998) (The physician found that a veteran's medical condition, which was not noted at enlistment, preexisted service, and that the worsening during service was commensurate with the natural progression of the condition.). However, in Miller v. West, 11 Vet. App. 345 (1998), the Court held where a bare conclusion, even one written by a medical professional, without a factual predicate in the record does not constitute clear and unmistakable evidence sufficient to rebut the statutory presumption of soundness. Here, the Board finds that the November 1999 VHA opinion is unequivocal in the findings that the veteran's osteochondroma preexisted service and was not aggravated therein. Furthermore, the VHA physician provided a detailed rationale for his conclusions. Moreover, no contradictory evidence is on file. In fact, the only other competent medical evidence to address these issues is the December 1987 Medical Evaluation Board examination report. As noted above, this report also concluded that the veteran's osteochondroma preexisted service and was not aggravated therein. For the reasons stated above, the Board finds that the preponderance of the evidence is against the claim, and it must be denied. As the preponderance of the evidence is against the claim, the reasonable doubt doctrine is not for application. See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990). II. Neck Pain Legal Criteria. Despite the finality of a prior decision, a claim will be reopened and the former disposition reviewed if new and material evidence is presented or secured with respect to the claim which has been disallowed. 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156(a). 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") has held that, when "new and material evidence" is presented or secured with respect to a previously and finally disallowed claim, VA must reopen the claim. Manio v. Derwinski, 1 Vet. App. 140, 145 (1991). The provisions of 38 C.F.R. § 3.156(a), provide that "new and material evidence" is evidence not previously submitted which bears directly and substantially upon the specific matter under consideration, is not cumulative or 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. Furthermore, the Court of Appeals for the Federal Circuit has indicated that evidence may be considered new and material if it contributes "to 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 ratings decision." Hodge v. West, 115 F.3d 1356, 1363 (Fed. Cir. 1998). The Court has held that in order to reopen a previously and finally disallowed claim there must be new and material evidence presented 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. Evans v. Brown, 9 Vet. App. 273, 285 (1996). Analysis. As indicated above, service connection was previously denied because there was no medical evidence that the veteran had a neck disorder that was incurred in or aggravated by his period of active duty. The additional evidence submitted to reopen the veteran's claim essentially consists of medical records showing treatment for back, hip, and neck pain, as well as the January 1998 VA examiner's diagnosis of cervical stiffness. Although this evidence is "new" to the extent it was not available at the time of the last prior denial, the Board notes that there was evidence that the veteran had experienced neck pain. Accordingly, the Board finds that the additional evidence is cumulative or redundant of the evidence already of record. Furthermore, it does not bear directly and substantially upon the issue of whether the veteran had a neck disorder that was incurred in or aggravated by his period of active duty. See 38 C.F.R. § 3.156(a). The only evidence which tends to show that the veteran had a neck disorder that was incurred in or aggravated by his period of active duty consists of the veteran's own contentions. Such a determination requires competent medical evidence in order to have probative value. See Grottveit v. Brown, 5 Vet. App. 91, 93 1993); see also Caluza v. Brown, 7 Vet. App. 498, 504 (1995). Nothing on file shows that the veteran has the requisite knowledge, skill, experience, training, or education to render a medical opinion. See Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). Consequently, the Board finds that the additional evidence, in the form of the veteran's contentions, is not 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. See 38 C.F.R. § 3.156(a). The Board also finds that nothing in the additional evidence submitted to reopen the veteran's claim provides a more complete picture of the circumstances surrounding the origin of the veteran's disability. See Hodge at 1363. The additional evidence establishes no more than what was already previously known at the time of the last prior denial. Specifically, that the veteran has neck pain. While the additional medical evidence provides information as to the current severity of the veteran's neck pain, it does not provide a more complete picture as to the actual origin of this condition. Moreover, there is still no evidence that the veteran has a neck disorder that was incurred in or aggravated by his active service. For the reasons stated above, the Board concludes that new and material evidence has not been submitted to reopen the veteran's claim of entitlement to service connection for neck pain; the claim is not reopened. See 38 C.F.R. § 3.156(a). Inasmuch as the veteran has not submitted new and material evidence in support of his request to reopen, the Board does not have jurisdiction to consider the claim or to order additional development. See Barnett v. Brown, 83 F.3d. 1380 (Fed.Cir. 1996). ORDER Entitlement to service connection for osteochondroma of the right femur is denied. New and material evidence not having been submitted to reopen the claim of service connection for disability manifested by neck pain, the benefit sought on appeal is denied. Gary L. Gick Member, Board of Veterans' Appeals