Citation Nr: 0002066 Decision Date: 01/27/00 Archive Date: 02/02/00 DOCKET NO. 98-09 016 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUES 1. Entitlement to service connection for bilateral defective hearing. 2. Entitlement to service connection for tinnitus. 3. Entitlement to service connection for peripheral neuropathy including claimed as secondary to exposure to herbicides. 4. Entitlement to service connection for an adjustment disorder with depressed moods and generalized anxiety disorder. 5. Entitlement to service connection for post-traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD Alice A. Booher, Counsel INTRODUCTION The veteran had active service from June 1969 to January 1972, and from January 1975 to November 1979. This appeal to the Board of Veterans' Appeals (the Board) is from rating action taken by the Department of Veterans Affairs (VA) Regional Office (RO) in Portland, Oregon, in June 1997. The RO denied entitlement to service connection for the disabilities at issue. The issues of entitlement to service connection for PTSD, adjustment disorder with depressed mood, and generalized anxiety disorder are addressed in the remand portion of the decision. FINDINGS OF FACT 1. The claim for service connection for bilateral defective hearing is not supported by cognizable evidence showing that the claim is plausible or capable of substantiation. 2. The claim for service connection for tinnitus is not supported by cognizable evidence showing that the claim is plausible or capable of substantiation. 3. The claim for service connection for peripheral neuropathy including claimed as secondary to exposure to herbicides is not supported by cognizable evidence showing that the claim is plausible or capable of substantiation. CONCLUSIONS OF LAW 1. The claim for service connection for bilateral defective hearing is not well-grounded. 38 U.S.C.A. § 5107 (West 1991). 2. The claim for service connection for tinnitus is not well-grounded. 38 U.S.C.A. § 5107. 3. The claim for service connection for peripheral neuropathy including claimed as secondary to exposure to herbicides is not well-grounded. 38 U.S.C.A. § 5107. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS General Criteria In Boeck v. Brown, 6 Vet. App. 14 (1993), 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") held that A(n appellant) claiming entitlement to VA benefits has the burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that the claim is well grounded. See 38 U.S.C.A. § 5107, and see Tirpak v. Derwinski, 2 Vet. App. 609, 610-11 (l992). The quality and quantity of the evidence required to meet this statutory burden of necessity will depend upon the issue presented by the claim. Where the issue is factual in nature, such as whether an incident or injury occurred in service, competent lay testimony, including an appellant's testimony, may constitute sufficient evidence to establish a well-grounded claim under 38 U.S.C.A. § 5107(a). See Cartright v. Derwinski, 2 Vet. App. 24 (1991). Lay statements retelling their own experiences cannot constitute evidence to render a claim well grounded under § 5107 (West 1991). Magana v. Brown, 7 Vet. App. 224, 227 (1994); Heuer v. Brown, 7 Vet. App. 379, 380 (1995). However, a lay statement may be made which relays the visible symptoms of a disease or disability [See Caldwell v, Derwinski, 1 Vet. App. 466, 469 (1991)]; after which a decision must be made as to the credibility thereof in the context of probative medical evidence [See Rowell v. Principi, 4 Vet. App. 9, 19 (1993)]. Where the determinative issue involves medical causation or a medical diagnosis, competent medical evidence to the effect that the claim is "plausible" or "possible" is required. See Murphy, op. cit. at 81 (1990). A claimant does not meet this burden imposed by section 5107(a) merely by presenting lay testimony because lay persons are not competent to offer medical opinions. Espiritu v. Derwinski, 2 Vet. App. 492 (1992). Consequently, lay assertions of medical causation cannot constitute evidence to render a claim well-grounded under section 5107(a). If the claim is not well-grounded, the claimant cannot invoke VA's duty to assist in the development of the claim. See 38 U.S.C.A. § 5107(a); Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992). It has also been determined that a well-grounded claim requires three elements: (1) medical evidence of a current disability; (2) lay or medical evidence of a disease or injury in service; and (3) medical evidence of a link between the current disability and the in-service injury or disease. Caluza v. Brown, 7 Vet. App. 498 (1995). In essence, then, the threshold question to be answered in any case is whether the appellant has presented evidence of a well grounded claim; that is, a claim which is plausible and meritorious on its own or capable of substantiation. If he has not, his appeal must fail. 38 U.S.C.A. § 5107(a); Murphy v. Derwinski, 1 Vet. App. 78 (1990). Case law provides that although a claim need not be conclusive to be well grounded, it must be accompanied by evidence. A claimant may submit some supporting evidence that justifies a belief by a fair and impartial individual that the claim is plausible. Dixon v. Derwinski, 3 Vet. App. 261, 262 (1992); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992). In determining whether a claim is well grounded, the claimant's evidentiary assertions are presumed true unless 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). Where the determinative issue involves the question of a medical diagnosis or causation, only individuals possessing specialized training and knowledge are competent to render a medical opinion. Espiritu v. Derwinski, 2 Vet. App. 192 (1992). Service connection may be established for disability incurred in or aggravated by active military service 38 U.S.C.A. §§ 1110, 1131 (West 1991). If not shown during service, service connection may be granted for organic disease of the nervous system if shown to a compensable degree within a year of service separation. 38 U.S.A. §§ 1101, 1112, 1113 (West 1991 & Supp. 1999); 38 C.F.R. §§ 3.307, 3.309 (1999). For a showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Continuity of symptomatology is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (1999). 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 disease was incurred in service. 38 C.F.R. § 3.303(d) (1999). A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or disease incurred in service. Watson v. Brown, 4 Vet. App. 309, 314 (1993). In this, and in other cases, only independent medical evidence may be considered to support Board findings. If the medical evidence of record is insufficient, or, in the opinion of the Board, of doubtful weight or credibility, the Board is always free to supplement the record by seeking an advisory opinion, ordering a medical examination or citing recognized medical treatises in its decisions that clearly support its ultimate conclusions. However, it is not free to substitute its own judgment for that of such an expert. See Colvin v. Derwinski, op. cit. Moreover, it remains the duty of the Board as the fact finder to determine credibility of the testimony and other lay evidence. See Culver v. Derwinski, 3 Vet. App. 292, 297 (1992). Lay persons are not competent to render testimony concerning medical causation. See Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). Service connection may be established through competent lay evidence, not medical records alone. Horowitz v. Brown, 5 Vet. App. 217 (1993). But a lay witness is not capable of offering evidence requiring medical knowledge. Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). The credibility and weight to be attached to medical opinions are within the province of the Board as adjudicators. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). The Board is not bound to accept medical opinions that are based on history supplied by the veteran where that history is unsupported by the medical evidence. Black v. Brown, 5 Vet. App. 177 (1993); Swann v. Brown, 5 Vet. App. 229 (1993); Reonal v. Brown, 5 Vet. App. 458 (1993) and Guimond v. Brown, 6 Vet. App. 69 (1993). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 61 (1991). When, after consideration of all of the evidence and material of record in an appropriate case before VA, there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b) (West 1991); 38 C.F.R. §§ 3.102, 4.3 (1999). Special Criteria For purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies of 500, 1,000, 2,000, 3,000 or 4,000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1,000, 2,000, 3,000, or 4,000 Hertz are 26 decibels or greater, or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385 (1999). If a veteran currently meets the criteria of 38 C.F.R. § 3.385, he has a hearing loss disability. The veteran does not have to have a hearing loss disability during service in order to warrant a grant of service connection. Rather, the issue is whether, pursuant to 38 C.F.R. § 3.303(d), any current hearing loss disability is a chronic disorder attributable to service. Further, in Hensley v. Brown, 5 Vet. App. 155 (1993) and others, in general, the Court has found that "normal" hearing exists when the thresholds are between 0 and 20 decibels, and "hearing loss" exists when the threshold is from 25 decibels. Presumptive periods are not intended to limit service connection to diseases so diagnosed when the evidence warrants direct service connection. The presumptive provisions of the statute and VA regulations implementing them are intended as liberalizations applicable when the evidence would not warrant service connection without their aid. See Horowitz v. Brown, 5 Vet. App. 217, 222 (1993). In addition to law and regulations regarding service connection, the Board notes that a disease associated with exposure to herbicide agents listed in 38 C.F.R. § 3.309 (1999) will be considered to have been incurred in service under the circumstances outlined in that section, even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307(a) (1999). [For purposes of this discussion, herbicide agent or herbicide, dioxins, Agent Orange, etc., are all terms that are used fairly interchangeably to reflect the basic properties of the chemicals to which a veteran may have been subjected while in Southeast Asia during a given period of time, and which was the alleged source of alleged given (stated) disability.] If a veteran was exposed to an herbicide agent during active military, naval, or air service, the following diseases shall be service connected if the requirements of 38 C.F.R. § 3.307(a)(6)(1999) are met, even though there was no record of such disease during service, provided further that the rebuttable presumption provisions of 38 C.F.R. § 3.307(d) (1999) are also satisfied: Chloracne or other acneiform disease consistent with chloracne; Hodgkin's disease; non- Hodgkin's lymphoma; porphyria cutanea tarda; prostate cancer, acute and subacute peripheral neuropathy, multiple myeloma; respiratory cancers (cancers of the lung, bronchus, larynx or trachea), and soft tissue sarcoma. 38 C.F.R. § 3.307(e) (1999). These diseases shall become manifest to a degree of 10 percent or more at any time after service, except that chloracne, or other acneiform disease consistent with chloracne, and porphyria cutanea tarda shall have become manifest to a degree of 10 percent or more within a year, and respiratory cancers within 30 years, after the last date on which the veteran was exposed to an herbicide agent during active military, naval, or air service. 38 C.F.R. § 3.307(a)(6) (1999). Additions were made effective November 7, 1996 to add presumptive service connection for acute and subacute peripheral neuropathy and prostate cancer. [The Secretary has also determined that there was no positive association between exposure to herbicides and any other condition for which he has not specifically determined a presumption of service connection is warranted. 59 Fed. Reg. 341-46 (January 4, 1994); and 64 Fed. Reg. 211 (November 2, 1999)]. Provisions of 38 C.F.R. § 3.307(6)(iii) (1999) further state that such a veteran who served in the Republic of Vietnam during the Vietnam era and has such a (listed) disease shall be presumed to have been exposed to the herbicides...and that the last date on which such a veteran shall be presumed to have been exposed to an herbicide will be the last date on which he or she served in the Republic Of Vietnam during the Vietnam era. Service in the Republic of Vietnam includes service in the waters offshore and service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam. In that regard, the Court has also held that if the listed disease is not present, there is no presumption of a nexus by virtue of the service. See, e.g., McCartt v. West, 12 Vet. App. 164 (1999). In such a case, of course, special presumptions, etc. and/or other standards do not necessarily preclude a veteran from establishing service connection with proof of actual direct causation. See Combee v. Brown, 34 F.3d 1039 (1994). In a case that coincidentally also provides significant supportive data regarding claims with regard to dioxin exposure and the legislative and other machinations associated therewith, the Court held that plausible medical evidence of the existence of a current presumptively service- connected disease with an open-ended presumption period is sufficient to present a well-grounded service connection claim as to that disease. The case also holds that the presence of the disease would carry with it the presumption of nexus to service as well. See Brock v. Brown, 10 Vet. App. 155, 162 (1996). Factual Background In short, service medical records show no pertinent disabilities other than specified below. At the time of the veteran's entrance examination in April 1969, he gave a history of prior head injury at age 7. Thereafter, he reported a long history of repeated pre- service head injuries with concussions, and said that he had developed headaches thereafter. The veteran reported that before service, on some occasions, along with these headaches, he had also had almost prodromal-type symptoms involving numbness of his hands, sometimes prior to other symptoms including visual impairment and headaches. In November 1970, the veteran had one of the aforecited episodes with left hand numbness, and then numbness in the right hand and arm, decreased right eye visual acuity and severe headache. At that time, the veteran reported that he had had a normal electroencephalogram (EEG) some 2 years before. It was felt that he might have a cervical vertebral disc or questionable petit mal seizures, and a further neurological evaluation was recommended. In May 1971, the veteran underwent the neurological consult requested in November 1970 after complaining of similar symptoms to those claimed on that prior occasion. Examination was normal and it was felt that he was experiencing a classic migraine for which Cafergot was prescribed. Skull X-ray was negative. On examination for separation in December 1971, the veteran reported the visual disturbances and other symptoms associated with the preservice head injuries. On VA examination in July 1972 (between periods of service), the veteran had no pertinent complaints. There was said to be no hearing loss, and the neurological examination was normal. On an examination in January 1975 for his second entrance into service, the veteran again reported a history of head injuries including at age 7, but otherwise reported no particular disabilities and no pertinent abnormalities were described on examination. The examiner noted his history of head injury involving concussions in the 2nd, 3rd and 4th grades for which he had been seen by a civilian physician. No further disabilities were claimed or noted in service records. The veteran underwent the first of a series of civil service physical examinations for employment in March 1981 (for a security position). He was then described as generally healthy. Other than being overweight, his physical condition was said to be "good-excellent". On a National Guard related examination in August 1983, an authorized audiological evaluation showed pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 5 5 20 25 LEFT 10 5 5 15 15 On a physical examination in March 1985, the veteran reported having had concussions in the 1960's. An audiological evaluation showed pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 5 10 15 20 LEFT 5 5 0 10 15 There were no pertinent complaints or abnormal findings on examination. On examination in March 1987, there were no pertinent complaints or abnormal findings. On audiological evaluation, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 0 0 10 15 LEFT 5 5 5 10 20 And on a physical examination in March 1990, there were no pertinent complaints or abnormal clinical findings other than a diagnosis of mild high frequency hearing loss. On audiological evaluation, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 0 0 5 10 LEFT 0 0 5 15 10 The veteran's wife has provided a statement as to his condition, mentally and physically; this is of record. Also of record is a packet of private treatment records and reports from a military facility (the veteran's place of employment in part as a munitions inspector) from 1983-1996. There are several notations that he had continued migraine headaches on occasion similar to those described above. Migraines continued to be relatively well controlled with medication and therapy regimen including Elavil. In 1992 the veteran complained of some numbness in his fingers when he drove his truck. When he complained of atypical left facial and arm symptoms, a brain magnetic resonance imaging (MRI) in October 1992 was negative. On a neurological assessment in 1993, there were no sign or diagnoses of peripheral neuropathy. There was some indication of vascular anomalies and some of his headaches were said to be possibly due to vascular causes with associated paresthesias. Analysis Section 5107 of Title 38, United States Code unequivocally places an initial burden upon the claimant to produce evidence that a claim is well grounded; that is, that a claim is plausible. Grivois v. Brown, 6 Vet. App. 136, 139 (1994); Grottveit, 5 Vet. App. at 92. Because the veteran has failed to meet this burden, the Board finds that his claims for service connection for bilateral defective hearing, tinnitus, and peripheral neuropathy including claimed as secondary to exposure to herbicides are not well grounded and must be denied. Where the determinative issue involves causation or a medical diagnosis, competent medical evidence to the effect that the claim is possible or plausible is required. Murphy, 1 Vet. App. at 81. The claimant does not meet this burden by merely presenting his lay opinion because such evidence does not constitute competent medical authority. Espiritu, 2 Vet. App. 492. Consequently, lay assertions cannot constitute cognizable evidence, and as cognizable evidence is necessary for a well grounded claim, Tirpak, 2 Vet. App. at 611, the absence of cognizable evidence renders the veteran's claim not well grounded. The Board finds that there is no competent medical evidence that the veteran's claimed disabilities were incurred in service. In that regard, he is not shown to have defective hearing by VA definition. Neither is the veteran shown to have peripheral neuropathy, such disorder was not found on neurological examination in 1993. Peripheral neuropathy, acute or subacute as contemplated under the special Agent Orange statutes, has not been found or diagnosed by any competent medical expert. Tinnitus was not complained of or otherwise reported in service, and was first mentioned in the current claim. Such disorder, if present, has not been linked by competent medical opinion to the veteran's periods of service. In summary, the Board finds that the evidentiary record does not contain competent medical evidence of bilateral defective hearing, tinnitus, or peripheral neuropathy including claimed as secondary to exposure to herbicides, which have been linked by competent medical authority to the veteran's period of service on any basis. Although the Board considered and denied the appellant's claims on a ground different from that of the RO, which denied the claims on the merits, the appellant has not been prejudiced by the decision. This is because in assuming that the claims were well grounded, the RO accorded the appellant greater consideration that his claims in fact warranted under the circumstances. Bernard v. Brown, 4 Vet. App. 384 (1993). In light of the implausibility of the veteran's claims and the failure to meet his initial burden in the adjudication process, the Board concludes that he has not been prejudiced by the decision to deny his appeal for service connection for the disabilities at issue. Because the veteran has not submitted well grounded claims, VA is under no obligation to assist him in the development of facts pertinent to the claims. 38 U.S.C.A. § 5107(a). The Board is cognizant, however, that the Court has held that VA may have an obligation under 38 U.S.C.A. § 5103(a) (West 1991) to advise the veteran of evidence needed to complete a claim. Beausoleil v. Brown, 8 Vet. App. 459 (1996). The Court has held that the section 5103(a) duty requires that, when a claimant identifies medical evidence that may complete an application but is not in the possession of VA, VA must advise the claimant to attempt to obtain that evidence. Brewer v. West, 11 Vet. App. 228 (1998). In the veteran's case, the record indicates that the veteran has identified no such evidence. The Board further finds that the RO advised the appellant of the evidence necessary to establish a well grounded claim, and the appellant has not indicated the existence of any post service medical evidence that has not already been requested and/or obtained that would well ground his claims. 38 U.S.C.A. § 5103(a) (West 1991); McKnight v. Gober, 131 F.3d 1483 (Fed. Cir. 1997); Epps v. Gober, 126 F.3d 1464 (Fed. Cir. 1997). As the appellant has not submitted well grounded claims of entitlement to service connection for bilateral defective hearing, tinnitus, or peripheral neuropathy including claimed as secondary to exposure to herbicides, the doctrine of reasonable doubt has no application to his case. ORDER The veteran not having submitted well grounded claims of entitlement to service connection for bilateral defective hearing, tinnitus, and peripheral neuropathy including as secondary to exposure to herbicides, the appeal is denied. REMAND This claim must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board of by the Court for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 1999) (Historical and Statutory Notes). In addition, VBA's Adjudication Procedure Manual, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44-8.45 and 38.02-38.03. The Board's review of the evidentiary record discloses that while the interviewer who conducted the Social and Industrial Survey had access to the veteran's claims file and reviewed these records, the VA psychiatric examiner specifically reported that the veteran reported for examination without a claims file or any records for review pursuant to the examination. The examiner nonetheless conducted the November 1996 examination without access to the veteran's evidentiary record thereby resulting in a serious procedural deficiency with respect to his claims for service connection for PTSD, adjustment disorder with depressed moods, and generalized anxiety disorder. The fact that the November 1996 examination was conducted without access to the appellant's claims file renders the subject examination inadequate for rating purposes. See e.g., 38 C.F.R. § 4.1 (1999) ("It is...essential both in the examination and in the evaluation of the disability, that each such disability be viewed in relation to its history.") See also Green v. Derwinski, 1 Vet. App. 121, 124 (1991). ('[F]ulfillment of the statutory duty to assist...includes the conduct of 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" (emphasis added)). Accordingly, further development is warranted. Therefore, in accordance with VA's duty to assist the veteran in the development of facts pertaining to his claims under 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.103(a) (1999), the Board is deferring adjudication of the issue of entitlement to service connection for PTSD, adjustment disorder with depressed moods, and generalized anxiety disorder pending a remand of the case to the RO for further development as follows. 1. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded to the RO. Kutscherousky v. West, 12 Vet. App. 369 (1999). 2. The RO should contact the veteran and request that he identify the names, addresses, and approximate dates of treatment for all medical care providers, VA and non-VA, inpatient and outpatient, who have treated him for PTSD, adjustment disorder with depressed moods and generalized anxiety disorder. After obtaining any necessary authorization or medical releases, the RO should request and associate with the claims file legible copies of the veteran's complete treatment reports from all sources identified whose records have not previously been secured. Regardless of the veteran's response, the RO should secure all outstanding treatment reports. 3. The RO, in light of any acquired additional evidence, should undertake any indicated development pursuant to the veteran's claim for service connection for a psychiatric disorder, especially in view of his claim for service connection for PTSD. Accordingly, the RO should determine whether a stressor statement and verification of any claimed stressors should be requested. 4. The RO should arrange for a VA special psychiatric examination of the veteran for the purpose of ascertaining the nature, extent of severity and etiology of any psychiatric disorders which may be present to include claimed PTSD, adjustment disorder with depressed moods, and generalized anxiety disorder. The claims file, and a separate copy of this remand must be made available to and reviewed by the examiner prior and pursuant to conduction and completion of the examination. Any further indicated special studies must be conducted. The examiner must be requested to determine whether any psychiatric disorder(s) found on examination is or are related to the veteran's period of active service, including but not limited to provision by the RO of verified stressors. Any opinions expressed must be accompanied by a complete rationale. If the examiner is not of the opinion that any psychiatric disorder(s) found on examination is or are related to the veteran's period of active service, the examiner must provide an opinion as to the most likely etiology of any psychiatric disorder(s). Any opinions expressed by the examiner must be accompanied by a complete rationale. 5. 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 report and required opinions to ensure that they are responsive to and in complete compliance with the directives of this remand and if they are not, the RO should implement corrective procedures. Stegall v. West, 11 Vet. App. 268 (1998). 6. After undertaking any development deemed essential in addition to that specified above, the RO should readjudicate the issues of entitlement to service connection for PTSD, adjustment disorder with depressed moods, and generalized anxiety disorder. If the benefits requested on appeal are not granted to the veteran's satisfaction, the RO should issue a supplemental statement of the case. A reasonable period of time for a response should be afforded. Thereafter, the case should be returned to the Board for final appellate review, if otherwise in order. By this remand, the Board intimates no opinion as to any final outcome warranted. No action is required of the veteran until he is notified by the RO. RONALD R. BOSCH Member, Board of Veterans' Appeals