Citation Nr: 0003968 Decision Date: 02/15/00 Archive Date: 02/23/00 DOCKET NO. 98-18 984 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to an increased evaluation in excess of 10 percent for residuals of an injury to the left mandibular- maxillary joint. 2. Whether new and material evidence has been presented to reopen a claim of entitlement to service connection for a heart disorder, to include arteriosclerotic heart disease with sclerotic aortitis and angina pectoris. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Amanda Blackmon, Counsel INTRODUCTION The appellant served on active duty from January 1945 to April 1946. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 1996 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO), which denied entitlement to an increased evaluation for the service-connected disability, and determined that new and material evidence sufficient to reopen the previously denied claim for service connection for cardiovascular disease had not been presented. The appellant filed a notice of disagreement with this rating decision later that month, in December 1996. A statement of the case relative to these issues was forwarded to the appellant in October 1998. The appellant filed his substantive appeal in this matter in November 1998. A preliminary review of the record discloses that the appellant had requested a hearing before a traveling Member of the Board in connection with this case. This request was subsequently withdrawn by the appellant in January 1999. 38 C.F.R. § 20.704 (1999). This case was thereafter certified to the Board for appellate review. FINDINGS OF FACT 1. The evidence of record demonstrates that the appellant's residuals of injury to the left mandibular-maxillary joint are characterized by pain, popping, and slight crepitus with slight lateral movement of the left temporomandibular joint, with some functional impairment on use of that joint. 2. In June 1976, the RO issued a rating decision which denied the appellant's claim for entitlement to service connection for arteriosclerotic heart disease with sclerotic aortitis and angina pectoris. The appellant was provided notice of the decision and his appellate rights. A notice of disagreement to the denial was not filed. 3. In April 1996, the appellant sought to reopen his claim for service connection for a heart condition. 4. The new evidence added to the record, including VA and private medical records, and testimonial evidence bears directly and substantially upon the subject matter now under consideration (i.e. whether the appellant currently has a cardiovascular disability that is related to military service) and, when considered alone or together with all of the evidence, both old and new, has a significant effect upon the facts previously considered. 5. The claim for entitlement to service connection for a heart disorder, to include arteriosclerotic heart disease with sclerotic aortitis and angina pectoris, is not supported by cognizable evidence showing the claim is plausible or capable of substantiation. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for residuals of injury to the left mandibular-maxillary joint have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.7, 4.150, Diagnostic Code 9999-9905 (1999). 2. Evidence received since the unappealed June 1976 RO decision, which denied the appellant's claim of entitlement to service connection for arteriosclerotic heart disease with sclerotic aortitis and angina pectoris, is new and material, and the claim for this benefit is reopened. 38 U.S.C.A. §§ 5108, 7105 (West 1991); 38 C.F.R. §§ 3.104, 3.156 (1999). 3. The claim for entitlement to service connection for a heart disorder, to include arteriosclerotic heart disease with sclerotic aortitis and angina pectoris, is not well- grounded. 38 U.S.C.A. § 5107(a) (West 1991). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Increased Evaluation Initially, the Board has found that the appellant's claim for an increased evaluation for residuals of injury to the left mandibular-maxillary joint is well grounded pursuant to 38 U.S.C.A. § 5107. This finding is predicated upon the appellant's assertion that his jaw disability has increased in severity. Drosky v. Brown, 10 Vet. App. 251, 254 (1997) (citing Proscelle v. Derwinski, 2 Vet. App. 629 (1992)). Once it has been determined that a claim is well grounded, VA has a statutory duty to assist in the development of evidence pertinent to the claim. 38 U.S.C.A. § 5107. The Board is satisfied that all available evidence necessary for an equitable disposition of this aspect of the appeal has been obtained. Medical History Service connection for residuals of injury to the left mandibulo-maxillary joint was granted in November 1950. A noncompensable evaluation was assigned for this disability. It was noted that VA examination, conducted in October 1950, showed no definite limitation of motion associated with this condition. A VA examination report, dated in May 1976, indicated there was no evidence of restriction of motion as the appellant opened his mouth for examination of the oral cavity. There was no crepitus in the left maxillary joint. The appellant reported broken tissue over this joint which caused him pain, although the examiner reported that this was not visualized on examination. A June 1976 rating decision continued the assigned rating evaluation for this disability under Diagnostic Code 9999. In April 1995, the appellant sought an increased evaluation for his service-connected disability. During a February 1995 examination, the appellant reported a history of arthritis associated with the jaw. There was no clinical finding noted relative to his jaw disability on examination. A March 1995 clinical report indicated that the appellant presented with complaints of pain in front of his ear, bilaterally. Examination showed the canals to be free of cerumen bilaterally. The nose and throat were clear. He denied episodes of ear ache or headaches. The examiner was able to reproduce pain on palpation of the temporomandibular joints (TMJ), bilaterally. The appellant reported the pain to be greater on the left side than the right side. An assessment of TMJ syndrome was indicated. The appellant was treated with Motrin for pain relief. A nursing notation indicated that the appellant was noted to have ill fitting dentures. A May 1995 clinical report indicated that the appellant reported subjective complaints of sore jaw bilaterally. He reported that he had dislocated tissues on the left side of this mouth that was affecting his right side. He also reported no relief with ibuprofen. On evaluation, the appellant reported pain at both TMJs. The examiner ruled out an assessment of TMJ syndrome. In a September 1995 rating action, the RO resolved all doubt in favor of the appellant, and granted an increased evaluation from 0 percent to 10 percent for the service- connected residuals of left mandibular-maxillary joint injury under Diagnostic Code 9999-9905. In December 1995, the appellant sought an increased evaluation for his service-connected disability. In support of this request, the appellant reported that he was seen for outpatient treatment at the VA medical center in March 1995. By letter, dated in January 1996, the RO advised the appellant that the referenced clinical reports were reviewed in conjunction with the September 1995 rating action which awarded the 10 percent rating for the service-connected disability, and that VA examination was not warranted in the absence of additional evidence documenting treatment for this disability. In May 1996, the appellant's representative requested, on behalf of the appellant, a hearing in connection with the September 1995 rating action which denied an increased rating for the service-connected jaw disability. During a November 1995 evaluation, the appellant reported a history of split tissue in the front of the left ear during service. On examination, the appellant was able to open and close his mouth without difficulty. There was no crepitus over the left or right temporo-mandibular joints. X-ray studies revealed an old trauma to the left temporo-mandibular joint. A May 1996 clinical report disclosed that the appellant presented with complaints of left jaw pain. Examination of the ear, nose, and throat (ENT) was noted to be within normal limits. The examiner noted that the reported area of pain was in the left TMJ area. An assessment of left TMJ syndrome was noted. The appellant was treated with Motrin for pain relief. During a September 1996 hearing, the appellant stated that he experienced numbness due to "split tissue that runs down the side of [his] ear." He described his pain as severe and constant in nature, and indicated that he experiences headaches of one hour in duration, four times weekly due to his pain. The appellant also reported that he experiences popping of the jaw, without locking, when he opens his mouth. He reported that he has difficulty opening his mouth. He denied symptoms of radiating pain. The appellant reported that he did not prefer to undergo surgical treatment for his jaw condition. He reported that he is currently receiving medical care for this disability at the VA medical facility, which includes medication for relief of pain. The appellant was afforded VA examination in October 1996. The medical examination report indicated that the appellant reported complaints of pain. It was noted that the appellant reported a history of injury to the jaw following a fall in service. He described a clicking in his jaw upon opening his mouth following the injury. The examiner noted that none of the appellant's teeth were fractured in connection with the injury. It was noted that the appellant had undergone extraction of all his teeth several years later, when he had dentures made in approximately 1966. Objective findings on examination showed some lateral movement when the mouth was opened widely. There was evidence of popping with pain at the left mandibular joint. It was the examiner's assessment that this condition was not debilitating in nature, but prevented the appellant from taking large bites. It was further noted that the appellant's condition affected him when eating and yawning. Based upon the clinical evidence, it was noted that the appellant's condition was manifested by slight crepitus with slight lateral movement of the left TMJ. There were no signs of displacement shown on x-ray studies. The diagnostic impression was broken condyle, left, which calcified on its own. In a December 1996 rating decision, the RO confirmed and continued the assigned rating evaluation for the service- connected disability. The appellant presented with complaints of chronic left TMJ pain during a June 1998 examination. A nursing notation indicated that the appellant initially reported pain in the left temple with dizziness. When evaluated by the physician, the appellant was noted to report symptoms of popping and clicking of the jaw, with radiating pain into the left temporal region. He reported a constant sensation as if were spinning. On examination, there was no swelling of the jaw, or crepitus felt with movement. The assessment included chronic TMJ. A July 1998 clinical report referenced an assessment of chronic left TMJ pain. There were no findings relative to this condition noted on examination. A separate report, also dated in July 1998, indicated that the appellant's dentures were readjusted, and that he tolerated the procedure well. In October 1998, the RO confirmed and continued the assigned 10 percent evaluation for the service-connected disability. Analysis Disability ratings are determined by the application of a schedule of ratings which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. § Part 4 (1999). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21 (1999). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Where an increase in a service-connected disability is at issue, the present level of disability is of primary concern. Although review of the recorded history of a service- connected disability is important in making a more accurate evaluation (see 38 C.F.R. § 4.2), the regulations do not give past medical reports precedence over current findings. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). VA regulations require that disability evaluations be based on the most complete evaluation of the condition that can be feasibly constructed with interpretation of examination reports, in light of the whole history, so as to reflect all elements of disability. Medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. Functional impairment is based on lack of usefulness and may be due to pain, supported by adequate pathology and evidenced by visible behavior during motion. Many factors are for consideration in evaluating disabilities of musculoskeletal system and these included pain, weakness, limitation of motion, and atrophy. Painful motion with the joint or periarticular pathology which produces disability warrants the minimum compensation. 38 C.F.R. §§ 4.1, 4.2, 4.10, 4.40, 4.45, 4.59. The RO rated the appellant's residuals of an injury to the left mandibular-maxillary joint by analogy to limitation of motion of the temporomandibular articulation, under 38 C.F.R. § 4.150, Diagnostic Code 9905. This analogous rating is appropriate where an unlisted condition is encountered, and a closely related condition which approximates the anatomical localization, symptomatology and functional impairment is available. 38 C.F.R. §§ 4.20, 4.27; see Lendenmann v. Principi, 3 Vet. App. 345 (1992); Pernorio v. Derwinski, 2 Vet. App. 625 (1992). Under Diagnostic Code 9905, a 10 percent rating requires limitation of the range of lateral excursion from 0 to 4 millimeters or of limitation of the range of inter- incisal motion from 31 to 40 millimeters. A 20 percent rating is warranted for limitation of the range of inter-incisal motion from 21 to 30 millimeters. A 30 percent rating is warranted for limitation of the range of inter- incisal motion from 11 to 20 millimeters. A 40 percent rating is warranted for limitation of the range of inter- incisal motion from 0 to 10 millimeters. 38 C.F.R. § 4.150. The appellant's residuals of an injury to the left mandibular-maxillary joint is currently rated as 10 percent disabling. Loss of approximately one-half of the mandible, involving temporomandibular articulation, is required to warrant a 50 percent disability rating. 38 C.F.R. §4.150, Diagnostic Code 9902 (1999). Loss of part of or the whole ramus, involving bilateral loss of temporomandibular articulation warrants a 50 percent rating. 38 C.F.R. § 4.150, Diagnostic Code 9906 (1999). In evaluating the evidentiary record, the Board observes that according to the evidence of record the appellant has objectively confirmed pain in the area of the left TMJ. The record further reflects that the appellant has expressed complaints of radiating pain into the left temporal region, and the medical evidence does show findings of popping with pain in the left mandibular joint. Also, the record reflects that the appellant was able to open and close his mouth without difficulty, as shown by examination conducted in November 1995. According to the VA examiner in October 1996, however, the appellant was prevented from taking large bites, and the service-connected condition did affect him when eating and yawning. That notwithstanding, the VA examiner in October 1996 concluded that the appellant's service-connected condition was manifested by slight crepitus with slight lateral movement of the left TMJ, and opined that the condition was not considered to be debilitating in nature. Indeed, no evidence of swelling or crepitus with movement of the jaw was found on examination in June 1998. Therefore, given the totality of the pertinent medical evidence, particularly that which indicates pain on use of the left TMJ, the Board finds it reasonable to conclude that the disability picture more nearly approximates the criteria for a 10 percent evaluation under Diagnostic Code 9905, which is the minimum compensable evaluation for limitation of motion of temporomandibular articulation. See generally DeLuca v. Brown, 8 Vet. App. 202, 206 (1995); 38 C.F.R. §§ 4.40, 4.45. 4.59. However, since the evidence of record does not indicate limitation of motion to a degree to warrant a 20 evaluation under Diagnostic Code 9905 or other impairment indicated in Diagnostic Codes 9902-9904, and 9906-9915, relative to the left mandibular-maxillary joint, the Board further concludes that an evaluation in excess of 10 percent is not warranted under the rating schedule. In this case, consideration was given to the potential application of the various provisions of 38 C.F.R. Parts 3 and 4, whether or not raised by the appellant, as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). However, the Board finds that the evidence discussed above does not suggest that the appellant's service-connected disability presents such an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards so as to warrant the assignment of an extraschedular evaluation pursuant to the provisions of 38 C.F.R. § 3.321(b)(1). In that regard, the appellant's disability has not required frequent periods of hospitalization, nor present marked interference with employment which is not already contemplated by the current rating evaluation. New and Material Evidence The Court has held that the Department of Veterans Affairs (VA) is required to review for its newness and materiality only the evidence submitted by a claimant since the last final disallowance of a claim on any basis in order to determine whether a claim should be reopened and readjudicated on the merits. See Evans v. Brown, 9 Vet. App. 273 (1996). In the present appeal, the last final disallowance of the claim is the June 1976 RO decision. 38 U.S.C.A. § 7105 (West 1991); 38 C.F.R. § 20.1100 (1999). Therefore, the Board must review, in light of the applicable law, regulations, and the Court cases regarding finality, the additional evidence submitted since the June 1976 rating decision. In order to do so, the Board will separately describe the evidence which was of record in August 1994, and the evidence presented since that decision. The prior evidence of record is vitally important in determining newness and materiality for the purposes of deciding whether to reopen a claim. Id. The "old" evidence Service medical records reflect that the entrance examination, conducted in January 1945, was negative for any clinical findings or diagnosis relative to the cardiovascular system. The service medical records reflect that the appellant was seen in July 1945 for complaints of pain in the front of the chest, on the right side, and pain in the right shoulder upon carrying. There were no findings made on examination relative to the cardiac system. The records reflect that a July 1945 x-ray study of the chest was significant for a lesion interpreted as an extremely minimal type of reinfection tuberculosis, stability undetermined. When seen in August 1945, the appellant reported that he had no complaints referable to the chest. A December 1945 examination report indicated that evaluation of the heart revealed a regular sinus rhythm, without murmurs. There was no clinical evidence of enlargement. When evaluated in December 1945 for an unrelated condition, a blood pressure reading of 152/105 was noted. A subsequent notation, dated in December 1945, indicated that blood pressure readings over a three day period consistently yielded recordings around 120/85. Service medical records reflect that radiographic studies of the chest, conducted in conjunction with the April 1946 separation examination, were negative. The report of physical examination indicated that the chest, heart and blood vessels were evaluated as normal. Blood pressure readings of 134/86 and 136/88 were recorded. An October 1950 medical report indicated that the appellant presented with multiple complaints, to include that his "heart did not beat right," and caused him pain on occasion. The physician did not document any clinical findings relative to the appellant's subjective complaint. A VA medical examination report, dated in October 1950, indicated that the appellant reported a history of changes in the rate of his heart beat. It was noted that he complained of episodic increased heart beats. Physical examination showed the cardiovascular system to be normal. X-ray studies of the chest revealed the heart to be enlarged slightly on the left side. It was noted that the study was otherwise negative. There was no diagnostic finding made relative to the cardiovascular system. An April 1955 hospital report indicated that x-ray studies of the chest were negative. The record discloses that the appellant was privately hospitalized in June 1961 for an unrelated condition. The medical report indicated that the heart was evaluated as normal. The heart rate was evaluated at 80 beats per minute. Examination showed the heart to be of normal size, with a regular rate and rhythm, and no evidence of murmurs. The appellant was seen in December 1966 with complaints of recurrent dull, aching pain across the front of the chest, and behind the breast bone. It was noted that earlier x-ray studies of the chest were suggestive of aortitis. On physical examination, the heart was evaluated within normal limits by percussion. Heart tones were of good quality, except for a markedly accentuated aortic second sound, which the physician noted to be consistent with sclerosis at the root of the aorta. The diagnostic impression was arteriosclerotic heart disease with angitis pectoris, class III, sclerotic aortitis. A private medical report indicated that the appellant was seen in March 1971 for complaints of chest pain. It was noted that the appellant had had a cold during the week prior to examination. An electrocardiogram (EKG) revealed probable incomplete bundle branch block. When seen days later, the appellant continued to complain of irritation in his chest. During an evaluation two days later, the appellant reported some improvement. It was noted that he continued to demonstrate some cough. Examination days later revealed some rhonchi. When seen later that month, the appellant was noted to be much improved, but reported some concern about a rapid heart beat. Physical examination revealed the heart rate to be 90 beats per minute. When examined days later, the appellant's blood pressure was recorded as 160/90. His heart was evaluated as normal. The appellant was next seen in December 1973, at which time, he reported experiencing a two to three day history of chest pain, primarily in the left chest area and radiating into the left arm. It was noted that examination was not remarkable, except for some course rales which the physician opined to be chronic infection and chronic pulmonary fibrosis. A blood pressure reading of 170/100 was indicated. Results from an EKG were normal. A December 1974 notation indicated that the appellant reported relief with medication. It was noted that he described angina type chest pain. A blood pressure reading of 160/94 was recorded. Physical examination showed the chest to be clear, with good heart sounds. The appellant underwent VA hospitalization in March 1976 for complaints of chest pain. The medical report indicated that the appellant presented with a two day history of substernal chest pain, recurring about three times daily, and lasting five minutes in duration. These episodes occurred when performing work, and were associated with shortness of breath, dizzy spells, weakness, and nausea. Examination upon admission showed the heart sounds to be split at the second heart sound. EKG results revealed a normal sinus rhythm, with complete right bundle branch block with secondary "STT" changes. It was noted that review of the appellant's medical history was suggestive of angina pectoris, secondary to ischemic heart disease. A final diagnosis of chest pain, probably secondary to chronic ischemic heart disease was indicated. The appellant underwent VA examination in May 1976. X-ray studies of the chest were noted to be essentially within normal limits. On examination, the appellant reported symptoms that were noted to be referable to an old pulmonary tubercular infection and recurrent chest pain that was cardiac in origin, anginal in type, occurring twice daily. The appellant reported episodes of shortness of breath accompanying his chest pain. On physical examination, by auscultation, there was an apical murmur detected. The heart rate was noted to be elevated. A blood pressure reading of 120/90 was noted. The heart rate was evaluated at 98 beats per minute. The medical examination report reflects a diagnostic impression of arteriosclerotic heart disease and sclerotic aortitis, angina due to chronic ischemic heart disease, and right bundle branch block. It was noted that hypertension was not found on examination. The June 1976 rating decision By rating action, dated in June 1976, service connection for arteriosclerotic heart disease with sclerotic aortitis and angina pectoris was denied. This determination was predicated upon the RO's finding that the evidence did not establish that his cardiovascular disability was incurred during service. The additional evidence The supplemental medical evidence generally consists of VA medical examination report, private and VA outpatient treatment records dated from 1979 to 1997, and testimonial evidence presented during a September 1996 hearing. Private medical reports, dated from 1979 to 1994, reflect intermittent evaluation for complaints of occasional chest pain, relieved with Nitroglycerin. These treatment reports document a history of hypertension since 1976, with a myocardial infarction in 1976 as well. The appellant was noted to continue to experience approximately three episodes of angina weekly, manifested by left sided, non-radiating chest pain which was relieved with rest and medication. In March 1988, the appellant reported a more frequent need for Nitroglycerin, and it was noted that he was not in compliance with medications for control of his blood pressure. By March 1989, the appellant's blood pressure was noted to be well controlled with medication. A March 1995 clinical report indicated that the appellant presented with complaints of precordial pain three times weekly since 1976, that is relieved with Nitroglycerin. It was noted that the appellant was being followed for coronary artery disease with angina, and that he had a history of myocardial infarction in 1974 and 1976. X-ray studies of the chest were negative. EKG results revealed normal sinus rhythm, right bundle branch block, and right apex deviation. An assessment of coronary artery disease with angina, and a history of myocardial infarction was indicated. The appellant was thereafter referred to the nutrition clinic for evaluation and assessment. The clinical report indicates that the appellant was instructed in low calorie, cholesterol, and sodium dietary intake. The appellant was next evaluated in May 1995 following complaints of right side chest pain. He also reported episodes of dizziness. The report noted that the appellant reported no relief with Nitroglycerin, and requested a higher dosage. He denied any radiating pain, or associated symptoms of shortness of breath or diaphoresis. Examination showed a regular heart rate and rhythm, without murmurs. It was noted that chest pain was reproduced on palpation of the ribs. Results of an EKG study were noted to remain unchanged from the previous (March 1995) study results. An assessment of costochondritis was indicated. The appellant was instructed to take ibuprofen for pain relief. Clinical records further disclose that the appellant was seen intermittently between 1995 and 1996. These reports show that the appellant was seen in July 1995 for complaints of chest pain on exertion, which subsided with Nitroglycerin. The appellant denied symptoms of shortness of breath, weakness, edema, and dizziness. A blood pressure reading of 150/90 was recorded. EKG results revealed a normal sinus rhythm. Examination of the heart revealed no gallops or murmurs. The clinical impression was arteriosclerotic heart disease, stable angina, status post myocardial infarction, and essential hypertension. When seen later that month, the appellant was evaluated with improving hypertension, and essentially unchanged hyperlipidemia. A blood pressure reading of 166/84 was recorded in conjunction with this evaluation. Examination of the heart revealed normal first and second heart sounds. In October 1995, the appellant reported unchanged complaints of chest pain. It was noted that the appellant also had cold symptoms. A blood pressure reading of 186/110 was recorded. The examiner noted normal first and second heart sounds on examination of the cardiovascular system, without evidence of gallop or murmurs. The assessment included findings of coronary artery disease with angina pectoris, uncontrolled hypertension, and hyperlipidemia. During a November 1995 examination, the appellant reported a history of occasional chest pain relieved by Nitroglycerin. He denied symptoms of shortness of breath, weakness, dizziness, syncope, or palpitations. A blood pressure reading of 150/90 was recorded. The examiner noted that the appellant had a risk factor for hypertension. EKG results revealed a normal sinus rhythm. Examination of the cardiovascular system showed a regular rate and rhythm, without gallop or murmurs. The chest was clear to percussion and auscultation. The clinical assessment was arteriosclerotic heart disease, stable angina, status post myocardial infarction, and essential hypertension. It was noted that the appellant had an improved blood pressure reading of 150/74 during an evaluation later that month, in November 1995. When seen in January 1996, the appellant was evaluated with coronary artery disease with angina, hypertension, hyperlipidemia, and degenerative joint disease of the right shoulder. A blood pressure reading of 176/88 was noted. Evaluation of the cardiovascular system was essentially normal. Finally, the appellant reported left lower chest pain during an April 1996 examination. He also reported occasional chest pain relieved by Nitroglycerin. A blood pressure reading of 168/84 was recorded at that time. Examination of the cardiovascular system revealed no murmurs. There was mild tenderness noted over the anterior left chest wall, with some right shoulder pain manifested by loss of motion. The examiner noted a clinical impression of coronary artery disease with stable angina, and hypercholesteremia due to non-compliance with diet. The appellant offered testimonial evidence during a September 1996 hearing concerning the onset and severity of his heart condition. He stated that he initially experienced chest pains during service. He described this pain as sharp, but without radiation. He reported that he was twice seen in sick bay for complaints of chest pain. He was administered medication, and hospitalized for one day for treatment of hypertension. The appellant indicated that he was thereafter returned to light duty, but continued to experience chest pain. He reported that he suffered heart attacks in 1974 and 1976. He reported no change in symptoms he experienced in service in comparison to symptoms he experienced preceeding the reported heart attacks. A diagnosis of arteriosclerotic heart disease was made following the second heart attack. The appellant reported that he is receiving ongoing treatment for his heart condition at the VA medical facility, and is maintained on prescribed medication (Nitroglycerin). The appellant indicated that he currently experiences symptoms of shortness of breath. When queried by the hearing officer regarding his in service treatment, the appellant reported that he was advised by service medical personnel that x-ray films showed something, described as about the size of a stick pin. The appellant acknowledged that no diagnostic impression was offered concerning his reported chest pains. Although he continued to experience chest pain, he was not medically evaluated for this symptom within the first year following his release from service. He indicated that the was seen by a private physician in 1946, but noted that this physician did not offer an opinion with respect to his chest pain complaints. The appellant further noted that he was not taking any prescribed medication for hypertension prior to his first heart attack. He indicated that he was seen at the VA medical facility for treatment following his heart attack. During VA examination in October 1996, the appellant reported a history of episodic chest pain since service. He reported post service treatment for this condition as well as hypertension. The examination report noted subjective complaints of chest pain on exertion, sometimes relieved with Nitroglycerin and rest. On examination, the appellant was evaluated with a regular heart rate and rhythm. There was no evidence of gallops or murmurs. A blood pressure reading of 170/96 was recorded. EKG results revealed a normal sinus rhythm. X-ray studies of the chest revealed the heart to be of normal size. The diagnostic impression was arteriosclerotic heart disease; angina pectoris, stable; and essential hypertension. Clinical records, dated from January 1998 to June 1998 reflect that the appellant presented with continued complaints of chest pain relieved by Nitroglycerin. Analysis I. Materiality of the Evidence Service connection may be established for disability resulting from injury or disease incurred in service or for a preexisting injury or disease that was aggravated by service. 38 U.S.C.A. §§ 1110, 1131 (West 1991). For veterans who had ninety (90) days or more during a war period or peacetime service after December 31, 1946, and arteriosclerosis or cardiovascular-renal disease (including hypertension) is manifest to a compensable degree within a year thereafter, there is a rebuttable presumption of service origin, absent affirmative evidence to the contrary, even if there is no evidence thereof during service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137 (West 1991); 38 C.F.R. §§ 3.307, 3.309 (1999). Service connection may also be granted for a disease which was diagnosed after discharge from military service, when the evidence establishes that such disease was incurred in service. 38 C.F.R. § 3.303(d); Cosman v. Principi, 3 Vet. App. 303, 305 (1992). Pursuant to 38 U.S.C.A. § 7105(c), a final decision by the RO may not thereafter be reopened and allowed. The exception to this rule is 38 U.S.C.A. § 5108, which provides that "[i]f new and material evidence is presented or secured with respect to a claim which has been disallowed, the [Board] shall reopen the claim and review the former disposition of the claim." Therefore, once a RO decision becomes final under section 7105(c), absent the submission of new and material evidence, the claim cannot be reopened or adjudicated by the VA. 38 U.S.C.A. §§ 5108, 7105(c); Barnett v. Brown, 83 F.3d 1380, 1383 (Fed. Cir. 1996). In determining whether to reopen previously and finally denied claims, a three-step analysis was recently announced by 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, the claim as reopened (as distinguished from the original claim) is well grounded pursuant to 38 U.S.C.A. § 5107(a). 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, 206 (1999). 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 and, when considered 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. This overturned a previous test adopted by the Court which held 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." Colvin v. Derwinski, 1 Vet. App. 171, 174 (1991). The Court has held that the newly presented evidence need not be probative of all the elements required to award the claim, but need only tend to prove each element that was a specified basis for the last disallowance. See Evans v. Brown, 9 Vet. App. at 284; see also Hickson v. Brown, 12 Vet. App. 247, 251 (1999) (VA must review evidence since the last final disallowance). Accordingly, the focus of the Board's inquiry in this regard is upon whether the record now reflects that the appellant's current cardiovascular disease is related to the appellant's period of military service. As previously noted, the RO denied the appellant's claim for service connection for a heart condition in an unappealed rating decision of June 1976. That determination was based on a finding that the medical evidence of record did not establish that the current cardiovascular disease was related to the appellant's period of service. The Board observes, however, that the newly submitted evidence shows that the appellant continues to carry a post-service diagnosis of cardiovascular disease. Further, the appellant has provided testimonial evidence concerning the continuity of symptomatology relative to his cardiovascular complaints since service. The Board must presume the credibility of this evidence for purposes of determining whether new and material evidence has been submitted. See Kutscherousky v. West, 12 Vet. App. 369 (1999). Moreover, this evidence is not cumulative and redundant, and it bears directly and substantially on the question of whether the appellant currently has cardiovascular disability that is related to service, which was lacking at the time of the June 1976 rating action. Therefore, the Board finds that the additional medical reports, and testimonial evidence relating the appellant's current cardiovascular disorder to his period of service constitute new and material evidence for purposes of reopening the appellant's claim for entitlement to service connection for a heart condition. See 38 C.F.R. § 3.156(a). II. Well-grounded claim Having found that the appellant has submitted "new and material evidence" sufficient to reopen his claim for service connection, the threshold question that must now be resolved is whether the appellant has presented evidence of a well-grounded claim. A well-grounded claim is a plausible claim, that is, meritorious on its own or capable of substantiation. An allegation of a disorder that is service connected is not sufficient. In this context, the appellant must submit evidence in support of his 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); Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992). In order for a claim for service connection to be well- grounded, there must be (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. See Caluza v. Brown, 7 Vet. App. 489, 504, 506 (1995); see also Epps v. Gober 126 F.3d 1464, 1468 (Fed. Cir. 1997) (expressly adopting definition of well-grounded claim set forth in Caluza, supra). The second and third Caluza elements can be satisfied under 38 C.F.R. 3.303(b) by a (a) evidence that the condition was "noted" during service or during an applicable presumptive period; (b) evidence showing post-service continuity of symptomatology; and (c) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. See 38 C.F.R. 3.303(b); Savage v. Gober, 10 Vet. App. 488, 495-97 (1997). For the purpose of determining whether a claim is well grounded, the credibility of the evidence in support of the claim must be presumed. See Robinette v Brown, 8 Vet. App. 69, 75 (1995). Where the issue is factual in nature, e.g., whether an incident occurred during service or whether a clinical symptom is present, competent lay testimony may constitute sufficient evidence to establish a well grounded claim. Cartwright v. Derwinski, 2 Vet. App. 24 (1991). However, where the determinative issue involves a question of medical diagnosis or causation, only individuals possessing specialized training and knowledge are competent to render an opinion. Espiritu v. Derwinski, 2 Vet. App. 492 (1992). Thus, the appellant's uncorroborated statements are not of sufficient probative weight nor are they competent evidence to establish a causal relationship between the claimed disability and his period of military service. The record shows that the RO has continued to deny the appellant's claim of service connection for arteriosclerotic heart disease, based upon its finding that the service medical records are negative for any complaints, treatment, or diagnosis of a heart condition. It was further noted that while post service records document that the appellant has been seen privately and at the VA outpatient for treatment of a heart condition, there was no evidence presented which relates the current condition to the appellant's period of military service. In this case, the record contains no service medical record of any complaints, treatment, or diagnosis referable to the cardiovascular system. Service medical records document elevated blood pressure readings, but reflect no contemporary clinical findings of cardiovascular abnormality. Further diagnostic tests results failed to disclose any radiographic defects associated with the heart. In this case, the appellant maintains that his current cardiovascular disease was incurred during service. Relative to the appellant's claimed disability, there is no competent medical evidence of record of a nexus between the appellant's cardiovascular pathology and his period of military service. What remains decisive in this case is not only is there no evidence of cardiovascular pathology during service or within one year thereafter, the record remains devoid of competent medical evidence or opinion demonstrating that the appellant's remotely manifested cardiovascular pathology is related to his period of service decades earlier. In that regard, the record on appeal contains no medical opinion or contemporaneous clinical findings linking any current heart disease to the appellant's service in the military. The assembled medical evidence of record contains clinical notations that the appellant was evaluated with arteriosclerotic heart disease in 1966. This is the earliest documented diagnostic assessment of a cardiovascular disorder. Subsequent treatment reports document continued complaints referable to the heart, with clinical and diagnostic findings consistent with the presence of cardiovascular disability. However, these records are conspicuously negative for any medical opinion which indicates any correlation between diagnosed cardiovascular pathology and the appellant's period of military service which ended decades earlier. See Savage and Caluza, both supra. The Board has carefully and thoroughly reviewed the evidence of record. The Board finds, however, that the record reflects no competent medical evidence containing an opinion that any current heart disease was clinically extant during service or within a year thereafter, or suggests that the current cardiovascular pathology is clinically linked with the appellant's service-connected disabilities. The only evidence which attributes an etiological relationship between such disability and service or service-connected disabilities, is the lay assertions of the appellant. Generally, evidentiary assertions must be accepted as true for the purpose of determining whether the claim is well grounded. Exceptions to this principle occur when the evidentiary assertion is inherently incredible or when the fact asserted is beyond the competence of the person making the assertion. King v. Brown, 5 Vet. App. 19, 21 (1993); See also, Espiritu v. Derwinski, 2 Vet. App. 492 (1992); and Tirpak, 2 Vet. App. at 611. In this case, the determinative issue is medical causation. The appellant is competent to make assertions as to concrete facts within his respective observations and recollection, that is, objective manifestations of the appellant's symptomatology. His assertions, however, are not competent to prove that which would require specialized knowledge or training. Layno v. Brown, 6 Vet. App. 465, 470 (1994); Espiritu, 2 Vet. App. at 494-95. Specifically, the Court has held that lay testimony is not competent to prove a matter requiring medical expertise. Fluker v. Brown, 5 Vet. App. 296, 299 (1993); Moray v. Brown, 5 Vet. App. 211, 214 (1993); Cox v. Brown, 5 Vet. App. 93, 95 (1993); Grottveit, 5 Vet. App. at 92-93; Clarkson v. Brown, 4 Vet. App. 565, 567 (1993). Thus, "lay assertions of medical causation cannot constitute evidence to render a claim well grounded..." Grottveit, 5 Vet. App. at 93. Accordingly, the claim is denied. When the Board addresses in a decision a question that had not been addressed by the RO, as in this case, the question whether the claim is well grounded, it must be considered whether the claimant has been given adequate notice of the need to submit evidence or argument on that question and an opportunity to respond and, if not, whether the claimant has been prejudiced thereby. Bernard v. Brown, 4 Vet. App. 384 (1993). In this instance, the Board does not find such prejudice because the appellant has not met the threshold obligation of submitting a well grounded claim. Meyer v. Brown, 9 Vet. App. 425 (1996). ORDER An increased evaluation for residuals of injury to the left mandibular-maxillary joint is denied. New and material evidence having been submitted, the claim for entitlement to service connection for a heart disorder, to include arteriosclerotic heart disease with sclerotic aortitis and angina pectoris, is reopened; however, the claim is not well grounded; and the appeal is denied. Deborah W. Singleton Member, Board of Veterans' Appeals