Citation Nr: 0003991 Decision Date: 02/15/00 Archive Date: 02/23/00 DOCKET NO. 93-25 484 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for migraine headaches. 2. Entitlement to service connection for pain in the chest (claimed as residual of fracture of the chest bone). 3. Entitlement to service connection for hearing loss, right ear. 4. Entitlement to service connection for scar, right upper eyelid (claimed as residual of head injury). 5. Entitlement to service connection for a back disorder, including pain and numbness of the legs. 6. Whether new and material evidence has been submitted to reopen a claim of entitlement to service connection for varicose veins. 7. Entitlement to a compensable disability rating for hearing loss, left ear, on appeal from the initial grant of service connection, to include the issue of entitlement to an extraschedular evaluation. 8. Whether an appeal has been perfected from the grant of service connection and assignment of a 30 percent disability rating for post-traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Veteran and his spouse ATTORNEY FOR THE BOARD M. L. Kane, Associate Counsel INTRODUCTION The veteran had active military service from September 1964 to September 1966 and from August 1969 to February 1974. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. A July 1993 rating decision "reopened" the veteran's claims for headaches, hearing loss, chest pain, eyelid scar, and a back disorder based on new and material evidence in the form of service medical records and then denied each claim on the merits. This was the rating decision certified to the Board as on appeal. However, the Board concludes that these claims are on appeal from an October 1992 rating decision. After receiving notice of the October 1992 rating decision, the veteran submitted a statement within the appeal period indicating that he wanted to appeal his "claim" for VA disability, and the accompanying memorandum from his representative identified this statement as the veteran's notice of disagreement. The veteran's statement was, without doubt, a notice of disagreement with the October 1992 rating decision, although not accepted as such by the RO. See 38 C.F.R. § 20.201 (1999). After the July 1993 rating decision, which confirmed and continued the October 1992 rating decision, the veteran submitted another notice of disagreement and was provided a statement of the case. Since his substantive appeal was received within one year of notification of the October 1992 rating decision, he has perfected his appeal as to that decision. See 38 C.F.R. §§ 20.200, 20.202, and 20.302 (1999). In February 1994, the veteran had a hearing before a Member of the Board. Under VA regulations, a claimant is entitled to have final determination of his claim made by the Board member who conducted a hearing. 38 C.F.R. § 20.707 (1999). However, the Board member who held the veteran's hearing is no longer with the Board. In February 1996, the Board notified the veteran of this fact and gave him an opportunity to request a hearing before another Member of the Board. The veteran responded that he did not want another hearing. In March 1996, the Board found that new and material evidence had been submitted to reopen the veteran's claims for service connection for a back disorder and pain in the chest. These claims, as well as the veteran's other claims, were remanded to the RO for additional development. In the March 1996 remand, the Board noted inconsistent references in the record to claims for the left eyelid versus right eyelid. In May 1996, the RO requested that the veteran clarify whether his claim for a scar of the eyelid referred to the left or right eyelid. He did not respond. Because the evidence reflects a scar of the right eyelid and the veteran referred to the right eyelid in his notice of disagreement, the Board construes his claim to be for a scar on the right eyelid. During the February 1994 hearing, the veteran indicated that the leg cramps claimed as a discrete disability were a symptom of his varicose veins, and that the left knee and left ankle conditions claimed as discrete disabilities were symptoms of his back disorder. He agreed that the claims for the left knee and the left ankle should be subsumed in the claim for a back disorder, and the claim for leg cramps subsumed in the claim for varicose veins. Accordingly, the issues on appeal have been characterized as above. Also, the issue listed in the March 1996 Remand as a "claim related to hearing loss" has been divided into the two issues shown above in order to reflect more accurately the benefits that the veteran is seeking (i.e., entitlement to service connection for right-sided hearing loss and entitlement to a compensable rating for left-sided hearing loss). In February 2000, the veteran's representative filed a claim for an extraschedular evaluation for left ear hearing loss. The question of an extraschedular rating is a component of the veteran's claim for a higher rating. See Bagwell v. Brown, 9 Vet. App. 337 (1996); see also VAOPGCPREC 6-96. Accordingly, the issues on appeal have been characterized as above. The July 1993 rating decision also denied the veteran's claim of entitlement to nonservice-connected pension, and this claim was remanded by the Board in 1996. However, a January 1998 rating decision granted this claim; therefore, this issue is no longer before the Board. In July 1998, the Board again remanded this case for evidentiary development. The requested development has been accomplished, and this case is ready for appellate review. FINDINGS OF FACT 1. The veteran does not currently have a chronic headache disorder, an ascertainable chest disorder, or right ear hearing loss as defined by applicable law. 2. The veteran's current scar above the right eyebrow did not result from disease or injury in service. 3. The veteran's spina bifida occulta is a congenital defect. 4. The superimposed disease or injury to the veteran's back that was allegedly incurred during his military service did not result in chronic back disability apart from the congenital spina bifida. 5. There is no competent medical evidence linking the veteran's current degenerative disc disease of the lumbar spine and herniated discs to an inservice disease or injury. 6. In a March 1988 rating decision, the RO denied service connection for varicose veins on the merits. The veteran was notified of that decision in March 1988 and did not appeal. 7. The evidence received since March 1988 is not new and material. 8. The veteran's left ear hearing loss is manifested by puretone threshold averages of 15-28 decibels, with speech recognition ability of 96-100 percent, resulting in Level "I" hearing. 9. The veteran's left ear hearing loss does not present an exceptional or unusual disability picture rendering impracticable the application of the regular schedular rating criteria. 10. The veteran had until no later than April 26, 1999, to perfect an appeal from the evaluation assigned to PTSD on the initial grant of service connection, or to request an extension of time to file an appeal. 11. No written request for extension of time to file an appeal is of record. 12. A VA Form 9 was received in June 1999. 13. The VA Form 9 did not contain any allegations of error of fact or law. CONCLUSIONS OF LAW 1. The veteran has not presented well-grounded claims for service connection for migraine headaches; pain in the chest (claimed as residual of fracture of the chest bone); right ear hearing loss; scar, right upper eyelid (claimed as residual of head injury); and a back disorder, including pain and numbness of the legs, and there is no statutory duty to assist him in developing facts pertinent to these claims. 38 U.S.C.A. § 5107 (West 1991). 2. The March 1988 RO rating decision denying service connection for varicose veins is final. 38 U.S.C.A. § 7105(b) and (c) (West 1991); 38 C.F.R. § 3.160(d) (1999). 3. New and material evidence has not been received, and the veteran's claim for service connection for varicose veins is not reopened. 38 U.S.C.A. §§ 5108 and 7105 (West 1991); 38 C.F.R. § 3.156(a) (1999). 4. The veteran has stated a well-grounded claim for a compensable disability rating for left ear hearing loss, and VA has satisfied its duty to assist him in development of this claim. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.103 (1999). 5. The criteria for a compensable disability rating for the veteran's service-connected left ear hearing loss have not been met since the grant of service connection. 38 U.S.C.A. §§ 1155 and 5107 (West 1991); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.85, and 4.87, Diagnostic Code 6100 (1998 and 1999). 6. The evidence does not warrant referral for consideration of an extraschedular rating for the veteran's left ear hearing loss. 38 C.F.R. § 3.321(b)(1) (1999). 7. The veteran did not perfect an appeal from the denial of a higher evaluation for PTSD on the initial grant of service connection, and the Board has no jurisdiction to consider this issue. 38 U.S.C.A. §§ 7105(a), (b)(2), (d)(3), (d)(5), and 7108 (West 1991); 38 C.F.R. §§ 20.200, 20.202, 20.203, 20.302, 20.303, 20.305 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Factual Background In October 1966, the veteran filed a claim for service connection for a back disorder. He indicated that he had been treated by E.E. Coleman, Jr., M.D., for a back condition prior to service (from 1960 to 1964) and that his back was aggravated by an injury in 1965 when he was hit with a cable and boom. He submitted a copy of a physical profile dated in December 1965 showing limitations due to chronic low back strain. The RO requested the veteran's medical records from Dr. Coleman, who responded that he had treated the veteran for pain in the lumbar spine and right hip in October 1960 following an injury incurred while playing football. There had been no further treatment. The veteran's service medical records showed that he complained of back pain in October 1964, and he reported stiffness at times, especially after exercise. In January 1965, he indicated that he had a long history of back trouble with recurrent low back pain. He stated that over the past several months his legs went "to sleep" with prolonged sitting or standing. The examiner's impression was muscle strain. X-rays showed spina bifida of S1-2 with a transitional vertebra partially fused on the right at the lumbosacral junction. Four days later, it was noted that the veteran had been doing well until he carried a foot locker up some stairs. He indicated that a civilian doctor had stated that he might have a slipped disc. Throughout February 1965, he was treated for mild lumbosacral strain. He was referred to the orthopedic clinic to rule-out disc or vertebral pathology. The orthopedic consultation report dated in February 1965 indicated that the veteran had had back pain for years without known injury and had previously been rejected by the Navy due to his back pain. Examination showed pain on rotation of the spine with no neurological deficits. The examiner noted that spina bifida is usually not the cause by itself for symptoms, although some felt that this was associated with increases in degenerative disc disease (i.e., a "weak back"). It was recommended that the veteran limit his activity, and he was assigned a physical profile due to spina bifida. In March and April 1965, the veteran continued to complain of back pain and was again referred to the orthopedic clinic. The orthopedic consultation report dated in April 1965 indicated that physical examination was negative with no neurological changes, no atrophy, and no reflex changes. The examiner concluded that the veteran was eligible for retention with a physical profile. The veteran continued to complain of back pain through July 1965. He was evaluated by the orthopedic clinic in November 1965, and he reported a history of having had intermittent low back pain since he was seven years old. The examiner's impression was chronic lumbosacral strain, and it was again recommended that the veteran be given a physical profile. In September 1966, the veteran completed a Report of Medical History in conjunction with his separation examination. He reported a history of cramps in his legs and recurrent back pain and indicated that he used a back brace. He reported injuring his back and his legs "all at the same time" in the Army, for which he stated that he was given a brace. Clinical evaluation of all systems was normal. In conjunction with his claim for compensation, the veteran underwent a VA physical examination in December 1966. He complained of problems with his legs and back. He stated that he had first injured his back prior to service when a car hit him. He indicated that he then injured his back in 1964 when some boxes fell on him. Examination showed that the veteran walked without a marked limp. There were no abnormalities of the neck, shoulders, elbows, wrists, knees, ankles, or hands. His chest was well muscled and moved well with respiration. He had a fairly normal curvature of the spine. There was possibly a little spasm of the erector spinae muscles on the right in the lumbar region. He had good range of motion of the back without much pain. Reflexes were normal. Both legs were of equal length and circumference. X-rays of the lumbosacral spine were within normal limits other than a spina bifida occulta of S1. Diagnoses included history of low back injury, lumbosacral strain, and mild lumbar myositis. A February 1967 rating decision denied service connection for a back condition, finding that there was no aggravation of the preexisting congenital defect (spina bifida). In February 1974, the veteran filed claims for service connection for his back, legs, chest pains, and headaches. He had had another period of service from 1969 to 1974. With respect to his back and leg claims, the veteran indicated on the Report of Medical History completed in conjunction with his enlistment examination in 1969 that he had back trouble and leg cramps. It was noted that he had back pain with heavy lifting only and leg cramps with walking. Clinical evaluation of all systems was normal. X- rays of the lumbar spine conducted in May 1972 showed slight lumbar scoliosis and spina bifida occulta of S1. In October 1973, he reported a past history of a back injury and indicated that he wanted a medical discharge. On the Report of Medical History completed in conjunction with his separation examination in 1974, the veteran complained of recurrent back pain and leg cramps. He reported a history of dislocating a disc and having "pulled vertebra" in 1965. He also indicated that he had noticed his legs going to sleep in 1965 or 1966. He reported a history of wearing a back brace and stated that he had been offered disability for his back in 1965. Clinical evaluation of his spine was normal. With respect to his headache claim, service medical records from the veteran's first period of service showed that he indicated on the Report of Medical History completed in conjunction with his separation examination in September 1966 that he had frequent or severe headaches. On the Report of Medical History completed in conjunction with his enlistment examination in 1969, the veteran denied having frequent or severe headaches. In May 1971, he complained of headache, as well as various other symptoms, which were due to the flu. On the Report of Medical History completed in conjunction with his separation examination in 1974, the veteran complained of frequent or severe headaches. He reported incurring a head injury in 1964 when he was unconscious for fifteen minutes after being hit by a car door. Clinical evaluation of his neurological system was normal. With respect to his chest pain claim, service medical records from the veteran's first period of service contained no relevant information. In June 1972, he complained of sudden onset of chest pain in the sternal area that did not radiate to the left or down the arms. He had marked tenderness over the costochondral junctions bilaterally. X-rays were negative. The examiner's impression was costochondritis. The following day, the examiner noted that there was no explanation for the veteran's chest pain or the location of his symptoms. In October 1972, he complained of constant chest pain radiating through his chest on the right side, and he reported incurring a "crushing" injury to the chest in 1970 while in Vietnam. The examiner noted that these symptoms had no temporal relation to meals, position, exertion, or muscular strain. Examination showed that the veteran was very tender to palpation over the costochondral junctions to the left of the sternum, but moderate pressure with the stethoscope did not produce pain. The examiner concluded that the veteran had psychogenic pain and was malingering; he also had atypical costochondritis. X-rays of the chest and thoracic spine conducted in October 1972 were negative. On the Report of Medical History completed in conjunction with his separation examination in 1974, the veteran complained of pain or pressure in the chest. He stated that his chest bone was "cracked" in Vietnam when a truck hit him. Clinical evaluation of his chest was normal. The veteran's service personnel records showed that he served in Vietnam from January 1966 to September 1966 and from May 1970 to April 1971. He was a supply handler during his first tour of duty and an armorer/welder during the second. Special orders indicated that he had received a hardship discharge at his request. In conjunction with his claims, the veteran underwent a VA physical examination in July 1974. He reported a history of incurring a back injury while loading a ship during his first period of service. He stated that he had also had headaches for many years with "blackouts." The headaches occurred at irregular intervals. He reported that after Vietnam, he developed chest pain, for which he was hospitalized and told that he had fractured his "chest bone" in a motor vehicle accident in Vietnam. He stated that since then he had had occasional twinges of chest pain, the last being six months earlier. He complained of backache with weakness in the knees and tired legs. Physical examination was essentially normal. The examiner noted that the veteran only vaguely described his alleged back condition, and it did not fit any particular clinical picture. The chest pains were also nondescript and of no organic basis. The description of his headaches seemed real, although the loss of consciousness was open to question in view of the briefness and failure to sustain any injury from falling during these episodes. X- rays of the chest were normal. X-rays of the back showed congenital spina bifida from unfused spinous processes at S1 and partial lumbarization of the upper sacrum. There was minimal curvature of the lumbar spine to the left due to postural or muscle imbalance. The diagnoses were spina bifida occulta S1 and cluster headache (migraine equivalent). An August 1974 rating decision, inter alia, denied service connection for (1) a back condition, finding that there was no evidence of injury or aggravation during the veteran's second period of service; and (2) chest pains and headaches, finding that there were no clinical findings supporting his complaints. The notification letter of August 1974 failed to inform the veteran of the denial of service connection for headaches. In August 1974, the veteran submitted a statement indicating that he wanted to appeal the August 1974 rating decision. In September 1974, the RO sent him a letter asking him to clarify the issues with which he disagreed. No response was received. In January 1988, the veteran filed claims for service connection for varicose veins, dislocated disc, pulled vertebra, and cracked bone in chest. He submitted a statement that while on active duty in 1965, he slipped on the deck of a ship and was told that he had pulled a vertebra and slipped a disc. He stated that he was offered 40 percent disability, but he refused. He stated that while in Vietnam, the percussion from a rocket knocked a truck out of gear, and it rolled forward pinning him between it and a jeep. He was put in braces for his legs, back, and chest, and x-rays showed a cracked chest bone. With respect to the veteran's varicose veins claim, he indicated on the Report of Medical History completed in conjunction with his separation examination in September 1966 that he had cramps in the legs. The report of the VA physical examination conducted in December 1966 showed complaints of varicose veins. However, examination showed no varicose veins in the lower extremities. A rating decision of March 1988 denied service connection for varicose veins and found that the veteran had not submitted new and material evidence to reopen his claims for back and chest disabilities. The veteran was notified of that decision in March 1988 and did not appeal. In February 1992, the veteran filed claims for service connection for a back condition, migraine headaches, fracture in chestbone, cramps in legs, head injury, hearing loss, and varicose veins. With respect to his hearing loss claim, the service medical records from the veteran's first period of service showed no complaints. On the Report of Medical History completed in conjunction with his separation examination in September 1966, the veteran denied having hearing loss. On the audiological evaluation, puretone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 0 0 0 25 35 LEFT 15 5 0 15 5 The report of the VA examination conducted in December 1966 showed that the veteran reported having a hole in his left eardrum that did not give him any trouble. Diagnoses included history of a draining perforated left eardrum. On the Report of Medical History completed in conjunction with his enlistment examination in 1969, the veteran denied having hearing loss. The audiological evaluation in June 1969 showed puretone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 0 0 15 10 LEFT 5 5 0 5 5 The report of a periodic physical examination conducted in July 1972 indicated that the audiological evaluation showed puretone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 20 20 [not given] 20 20 LEFT 20 20 [not given] 20 20 On the Report of Medical History completed in conjunction with his separation examination in 1974, the veteran complained of hearing loss, particularly on the left. On the audiological evaluation in January 1974, puretone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 5 15 15 20 LEFT 25 25 25 25 20 No hearing loss was noted during the 1974 VA physical examination. In conjunction with his claims, the veteran underwent a VA audiological examination in March 1992. He stated that he had noticed a decrease in hearing acuity since 1964. He indicated that he was exposed to excessive artillery noise for two years while in Vietnam, as well as industrial noise from a paper mill for ten years. On the authorized audiological evaluation, puretone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 20 10 15 30 35 LEFT 20 15 15 35 45 The puretone threshold average was 23 decibels for the right ear and 28 decibels for the left ear. Speech audiometry revealed speech recognition ability of 96 percent bilaterally. The examiner indicated that the veteran's hearing was within normal limits for the right ear, and there was mild to moderate sensorineural hearing loss for the left ear. The veteran also underwent a VA general examination in March 1992. He reported sustaining a crushing injury of the left knee and of the left ankle between a jeep and a truck while in Vietnam. He stated that he had hit his head with a boom and suffered a laceration above the right eye, and he now had constant headaches. He reported that he had had low back pain since his injury with the truck and jeep in Vietnam. He also reported incurring an injury at work in 1990. He stated that he had varicose veins during service that caused pain in both lower legs. He stated that he had weakness in the right lower leg, which had increased since the injury in 1990. Upon physical examination, the veteran's posture was slightly stooped, and he walked with a slapping gait of the right leg. He had a one and a half inch linear scar above [sic] the right eyebrow. His hearing was grossly normal. There were mild bilateral varicose veins without ulceration. There was a tremor of both lower extremities. He had poor balance and was unable to squat. He had full range of motion of the low back. There was poor muscle mass in the lower extremities. The neurological examination was normal. X-rays of the skull and chest were normal. X-rays of the lumbar spine showed partial lumbarization of S1 and early degenerative changes with slight narrowing of L5-S1. Diagnoses included history of head injury, scar above the right eye, low back pain, persistent headaches, mild varicose veins, and chest wall pain. With respect to the veteran's eyelid claim, the report of the veteran's induction examination dated in July 1964 indicated that he had a one-inch scar over the right eye. The report of his separation examination dated in January 1974 indicated that he had a half-inch scar over the right eye. An October 1992 rating decision, inter alia, found that the veteran had not submitted new and material evidence to reopen his claims for service connection for a back condition, migraine headaches, scar over the left [sic] upper eyelid as a residual of head injury, varicose veins, and chest pains due to fractured chest bone. Service connection was granted for left ear hearing loss, with assignment of a zero percent disability rating. The veteran was notified of this decision in October 1992. The veteran apparently submitted additional medical evidence in April 1992 that was not associated with the claims file until after the October 1992 rating decision. In January 1993, the veteran submitted a notice of disagreement with the October 1992 rating decision, accompanied by additional medical evidence. The medical records submitted by the veteran were from Robert White, M.D., Springhill Memorial Hospital, Mobile Infirmary Medical Center, ProHealth Fitness and Rehabilitation Center, Donna Kline, P.T., Fairview Park Hospital, James Price, M.D., Industrial Medical Center, and Curtis Graf, M.D., and were dated from June 1989 to November 1991. This evidence concerned treatment for his back condition. None of this evidence showed a history of back injury or symptoms prior to the initial work-related injury, as discussed in more detail below. At no time did the veteran report injuring his back during military service. This evidence showed no complaints of or treatment for chest pain, headaches, varicose veins, hearing loss, or scars. The records submitted by the veteran indicated that he had injured his back at work in May 1989 when he was pulling out some shower heads and he noticed a pull and pop in his back. He was initially told that he had pulled a muscle. He continued to have back pain and then "jumping" of the right leg and was hospitalized in June 1989. Magnetic resonance imaging (MRI) of the lumbar spine showed findings consistent with degenerative disc disease at L4-5. An MRI of the brain was conducted because the veteran reported falling at various times without history of a head injury; the MRI showed a cystic lesion in the medial portion of the left uncus of doubtful clinical significance. A letter from Dr. Graf indicated that this was probably a benign lesion. Discharge diagnoses from June 1989 were low back pain with radicular symptoms into right leg, mostly in the L5 or S1 distribution, rule-out degenerative disc disease with herniation, rule-out spinal stenosis, rule-out foraminal compression, and possible clonus of right leg. A letter from Dr. Graf dated in August 1989 indicated that the problems with the veteran's right foot were not at all related to his low back condition. A record from Dr. White dated in September 1989 indicated that the veteran had a bulging disc at L4-5. The veteran again injured his back at work in August 1990 when he was lying on the ground pulling a chain and using a tool in the other hand. He thereafter complained of lumbar and right lower extremity pain. MRI and computerized tomography (CT) of the lumbar spine showed central disc herniation at L4-5. He underwent a series of epidural steroid blocks by Dr. White. A letter from Dr. White dated in November 1991 indicated that myelogram and lumbar CT scan conducted after the veteran's second work-related injury showed changes from previous studies, in that they showed central disc herniation at L4-5, which was consistent with the veteran's complaints. The veteran underwent physical therapy in late 1991. MRI of the brain conducted in August 1992 showed very little change since the 1989 study discussed above. The veteran submitted copies of service medical records previously considered by the RO, and additional copies were also obtained from the National Personnel Records Center. The veteran's VA medical records dated from January to April 1993 showed treatment for complaints of chronic low back pain, with diagnosis of chronic pain syndrome. A July 1993 rating decision found that the veteran had not submitted new and material evidence to reopen his claims. In his substantive appeal, he stated that he was given a physical profile during service with restrictions on physical activity; that he had hearing loss due to loud artillery in Vietnam; and that he had chest problems due to injury in Vietnam. The RO obtained his VA medical records for treatment between January and October 1993, which showed continued treatment for complaints of back and leg pain. The veteran was hospitalized from October to November 1993, and CT myelogram of the lumbar spine showed herniated nucleus pulposus at L5-S1 with some compression of the S1 nerve root. Discharge diagnoses included lumbar stenosis with an L5-S1 herniated nucleus pulposus. The veteran had a personal hearing in February 1994. He testified that he did not recall having any problems with his back prior to service, and he denied receiving any treatment for his back prior to service. He stated that he had injured his back in 1965 when he was hit in the back with a cable. He stated that after this injury he had difficulty walking and recurrent back pain. He alleged that he was treated, given a profile, and was about to be discharged on a 40 percent disability when his unit was mobilized and he was sent to Vietnam. He stated that he had a continuous physical profile during his second period of service. He denied that onset of his back pain occurred in the jeep incident. With respect to his headache claim, the veteran testified that these began in 1966, and he had had them ever since. He stated that he went to sick call during service and was told that he had migraine headaches. He stated that he had headaches all the time, constantly, every day. With respect to his varicose veins, the veteran testified that he first noticed these after the accident in 1965 and thought maybe that was why he had trouble walking. He stated that he had leg cramps. Regarding chest pain, the veteran testified that he sustained a chest injury in the jeep/truck accident. He described the accident as occurring during a rocket attack when he "ran out of the hooch" and a rocket dislodged a truck, which then rolled and wedged him between the truck and a jeep. He stated that he went to the dispensary after the accident and was taped up with an ace bandage from his waist to his arms. He stated that the pain began after he returned from Vietnam, and he sought treatment at Fort Sill, where he was told that x-rays showed a fractured chest bone. He stated that he currently had constant pain. With respect to his hearing loss, the veteran testified that he was exposed to noise during service, including artillery noise in Vietnam. He stated that sometimes he had to look at a person when they were speaking. With respect to a head injury, the veteran testified that he went outside a bunker during an attack in Vietnam, and he hit the side of the bunker. He stated that he now had a scar that was tender. The veteran's wife testified that they were married in 1965, and the veteran wore a back brace before he went to Vietnam. She denied personal knowledge of a back injury, but she knew that the veteran did not wear a brace when they got married, but that he came to visit her on a weekend pass wearing a back brace. She stated that he told her that he had been told he would be discharged on a 40 percent disability. She stated he told her in a letter from Vietnam about hurting his chest when he was "squished" between a truck and a jeep, and he sent a photograph of himself without a shirt on and wrapped in bandages. She also stated that the veteran had had headaches for years. The veteran submitted a statement from a physician at the VA Medical Center in Tuscaloosa, which indicated that he was severely limited in his functional capacities due to degenerative lumbar disc disease. A March 1996 Board decision reopened the veteran's claims for service connection for a back condition and chest pain, based on receipt of new and material evidence, and remanded all claims for further evidentiary development. The RO obtained the veteran's VA medical records for treatment between October 1993 and July 1996. These records showed no complaints of or treatment for chest pain, varicose veins, hearing loss, or a scar above the eye. Chest x-rays conducted in September 1994 and January 1996, as well as a CT of the chest conducted in December 1995, showed no pertinent abnormalities. During an examination conducted in January 1994 for the purpose of determining disability due to Agent Orange exposure, the veteran reported incurring a back injury on duty with recurrent low back pain. The veteran was hospitalized in September 1994 to rule-out myelopathy, and MRI of the lumbar spine showed a right S1 and S2 conjoined nerve sheath with an L4-5 disc protrusion compressing the right L5 nerve. He was then readmitted in October 1994 so that a CT myelogram could be performed. This showed that the thoracic osseus, spinal canal, and subarachnoid space were developmentally large. There was no evidence of cord compression. The size and configuration of the lumbar spine was within normal limits. The thoracolumbar and lumbar osseus, spinal canal, and subarachnoid space were developmentally large. At the L5 transitional S1 level, there was a combination of posterior annular bulge and focal protrusion centered to the right of the midline, which deformed the caudal sac. A rudimentary disc space was present between the transitional S1 and S2. It was suspected that there were conjoined right S1 and S2 nerve sheaths. The discharge diagnosis was low back pain with spinal stenosis. A neuropsychological consultation report dated in September 1995 showed that the veteran reported a history of a left hemisphere brain tumor that had not grown since 1989, but this was not substantiated by the available medical documentation. It was noted that his medical history was significant for lumbar stenosis exacerbated by two work- related back injuries in 1989 and 1990, as well as bilateral hearing loss. In December 1995, the veteran reported a history of headaches secondary to a temporal lobe brain tumor. In January 1996, the veteran complained of chronic headaches "all day" of ten years' duration. It was noted that he did not have a tumor. In July 1996, the veteran complained of increased pain from chronic headaches. It was noted that he had had numerous CT scans of the head, x-rays, and an MRI, and he had been told that he had had three small strokes. In September 1996, the veteran was hospitalized for a psychiatric disorder. His complaints included chronic leg and back pain. In November 1996, the veteran underwent a VA general physical examination. He reported incurring a "combat injury" in Vietnam, wherein he hurt his chest and developed chest pain. He stated that x-rays had shown a hairline fracture of the sternum. He stated that he continued to have pain in the center of the chest, and it was tender to touch. He stated that this was diagnosed to be due to fracture of the chest wall bone. He reported a history of injuring his back in 1965 and incurring a lumbar disc problem and numbness of the legs. He stated that he injured his right eyebrow as a result of a shrapnel injury in Vietnam, and this had required two stitches. This did not currently bother him. He reported developing hearing loss from working around artillery in Vietnam. The veteran walked with a cane and used a wheelchair. He was unable to drive due to low back and leg pain. He stated that the low back pain radiated to the right leg, and he had no control over the right leg. He indicated that he tended to fall easily unless he supported himself. He reported a history of headaches for fifteen years, but these had resolved with use of medication. Examination showed a faint scar above the right eyebrow that was difficult to see. This looked pale, and it had actually resolved and assimilated with the rest of his skin. There were no abnormalities of the scar, and it did not limit eye movement. His chest was tender to palpation over the mid- sternal area. He had localized tenderness, especially on pressure. He reported feeling sharp pain. There was no evidence of varicose veins. He was not able to move the lumbosacral spine due to inability to stand up straight. He could lie down flat on the table with difficulty, and he had back pain when doing so. He needed help standing up. His gait was markedly unsteady. He had decreased sensation over the lower extremities, and reflexes were absent. The examiner's impressions included chronic low back pain, sciatica of the right leg, lumbar disc disease L4-5; right eyelid injury, old scar in 1970, combat injury of right eyelid, healed well, no sequela; tender sternum secondary to old injury, continues to have pain and tenderness over the sternum; hearing loss involving both ears; no history of significant head injury; and headache, resolved, no history of migraine headaches. X-rays of the chest showed no pertinent abnormalities. X-rays of the lumbar spine showed degenerative disc disease at L5-S1. In November 1996, the veteran underwent a VA audiological evaluation. The results were reported in a graph format. It was noted that hearing sensitivity was within normal limits for the right ear except at 250, 4000, and 6000 Hertz, where there was mild loss of hearing. Hearing sensitivity was within normal limits for the left ear except at 8000 Hertz where there was moderate loss of hearing. It was indicated that the veteran might experience difficulty hearing speech in the presence of noise or at a distance. In December 1996, the veteran underwent another VA audiological evaluation. He reported decreased hearing acuity since 1969. He had difficulty understanding speech over the telephone and at a distance. He stated that both ears were sore, and he frequently had blood drainage from the right ear. He stated that the left ear felt "stopped up" all the time. He stated that he was exposed to noise from artillery for three years and small arms weapons fire for nineteen months while in Vietnam. He also reported noise exposure from paper machines while working in mills for ten years. On the authorized audiological evaluation, puretone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 5 5 25 25 LEFT 10 5 0 25 30 The puretone threshold average was 15 decibels for both ears. Speech audiometry revealed speech recognition ability of 100 percent bilaterally. The examiner stated that the veteran's hearing was within normal limits bilaterally. The report of an examination for aid and attendance purposes conducted by a VA physician in October 1997 indicated that the veteran was using crutches and in a wheelchair. He had muscle weakness and problems walking, but the only disorder noted was traumatic arthritis of the cervical spine. The RO obtained the veteran's VA records for treatment between February 1997 and January 1998. These records showed no complaints of or treatment for chest pain, varicose veins, hearing loss, or a scar above the eyebrow. He continued to receive treatment for chronic back pain. He began having increased difficulty walking and was in a wheelchair. A mental health progress note dated in April 1997 indicated that the veteran had "debilitating pain and [history] of pinched nerves arthritis related to injury in the service (prior to going to [Vietnam])." In November 1997, the veteran was hospitalized for elevated blood pressure, and it was noted that symptoms of elevated blood glucose included a headache for several hours, which was a one-time occurrence. In July 1998, the Board again remanded this case for further evidentiary development. In September 1998, an audiological examiner reviewed the veteran's claims file and compared the hearing tests conducted in March 1992, November 1996, and December 1996. The examiner transferred the results of the November 1996 evaluation into the following numeric table. HERTZ 500 1000 2000 3000 4000 RIGHT 25 15 20 30 40 LEFT 25 25 20 25 30 The puretone threshold average was 26 decibels for the right ear and 25 decibels for the left ear. Speech audiometry revealed speech recognition ability of 100 percent bilaterally. The examiner stated that both the November and December 1996 audiometric results showed that the veteran's hearing was within normal limits bilaterally according to VA guidelines, and these two tests were in good agreement with each other. The hearing test conducted in 1992 showed normal hearing acuity in the right ear and only one frequency in the left ear (4000 Hertz) that was below the range of normal for VA purposes. The difference shown on the 1996 hearing tests was not statistically significant and might be accounted for by a temporary threshold shift or other behavioral factors by the veteran at the time of the 1992 test. The RO obtained the decision from the Social Security Administration awarding the veteran disability benefits as of 1990, as well as the medical evidence supporting this decision. The veteran was granted benefits based on degenerative disc disease of the lumbar spine with associated severe back and leg pain. The decision, as well as all of the supporting medical evidence, only discussed the veteran's two work-related back injuries; at no time did the veteran report a history of injuring his back during service or of experiencing significant back-related symptomatology prior to the initial work injury in 1989. The veteran's back-related complaints and the diagnosed back disorders shown in the medical evidence were consistent with that discussed above. Medical records from an unknown physician showed a complaint of headaches in 1987. The report of an impairment evaluation conducted by Dr. Keith Aldridge in August 1991 contained a detailed medical history for the veteran. On the examinee information completed by the veteran, he was asked to list all injuries he had ever had; he reported no injuries incurred during his periods of military service. He discussed his work and military history from 1960 on and reported the initial injury to his back had occurred in 1989. He indicated that he was discharged from service because he could not pass the educational portion of his examinations. His reported complaints and medical treatment, as well as the second work-related back injury sustained in 1990, were consistent with that discussed above. He reported incurring head trauma as a child when he was knocked unconscious after a swing hit him in the head. The report of a lumbar myelogram conducted in September 1991 indicated that there was a left-sided anterior extradural defect at L4-5, and a CT scan of the lumbar spine in September 1991 showed left paracentral posterior herniation of L4-5. The report of an examination conducted by Mohammed Nayeem, M.D., in April 1993 indicated that the veteran complained of headaches and stated that he was diagnosed with a benign tumor in the left side of the head. He also complained that he was "hard of hearing." He denied experiencing any chest pain, and examination of the chest wall was normal. There were no varicose veins. The RO obtained the veteran's VA records for treatment between January 1998 and January 1999. These records showed no complaints of or treatment for chest pain, headaches, varicose veins, hearing loss, or a scar above the eyebrow. The veteran continued to receive treatment for his back disorders, and he was essentially wheelchair-bound. A March 1998 progress note indicated that he denied having any headaches or chest pain. II. Legal Analysis A. Service connection claims Service connection means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated during service. 38 U.S.C.A. §§ 1110 and 1131 (West 1991); 38 C.F.R. § 3.303(a) (1999). It is the responsibility of a person seeking entitlement to service connection to present a well-grounded claim. 38 U.S.C.A. § 5107 (West 1991). Generally, a well-grounded claim is a "plausible claim, one which is meritorious on its own or capable of substantiation." Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). In order to be well grounded, a claim for service connection must be accompanied by supporting evidence that the particular disease, injury, or disability was incurred in or aggravated by active service; mere allegations are insufficient. Tirpak v. Derwinski, 2 Vet. App. 609, 610-611 (1992); Murphy, 1 Vet. App. at 81. In general, the veteran's evidentiary assertions are accepted as true for the purpose of determining whether a well-grounded claim has been submitted. King v. Brown, 5 Vet. App. 19, 21 (1993). However, an exception to this rule exists where the evidentiary assertion is inherently incredible. Id. (citing Espiritu v. Derwinski, 2 Vet. App. 492 (1992) and Tirpak, 2 Vet. App. 609). A claim for service connection requires three elements to be well grounded. It requires competent (medical) evidence of a current disability; competent (lay or medical) evidence of incurrence or aggravation of disease or injury in service; and competent (medical) evidence of a nexus between the in- service injury or disease and the current disability. Epps v. Gober, 126 F.3d 1464, 1468 (Fed. Cir. 1997); Caluza v. Brown, 7 Vet. App. 498, 506 (1995); aff'd 78 F.3d 604 (Fed.Cir. 1996) (table). This third element may be established by the use of statutory presumptions. Caluza, 7 Vet. App. at 506. Truthfulness of the evidence is presumed in determining whether a claim is well grounded. Id. at 504. 1. Migraine headaches and pain in chest Service connection is not warranted for a chronic headache disorder because the medical evidence does not show that the veteran currently has the claimed condition. A diagnosis of persistent headaches was rendered upon VA examination in March 1992, and the medical records from 1993 to 1996 showed occasional complaints of headaches, allegedly due to a brain tumor. However, upon VA examination in November 1996, the veteran reported that his headaches had resolved. A medical record from November 1997 showed that he had a one-time occurrence of a headache as a symptom of elevated blood glucose. In March 1998, the veteran denied experiencing any headaches. Medical diagnosis of a chronic headache disorder has not been rendered since 1992, and the veteran currently denies experiencing chronic headaches. The medical evidence does not warrant service connection for a disability manifested by pain in the chest. The evidence does not show that the veteran currently has an ascertainable disorder accounting for his complaints of chest pain and tenderness. His complaints are symptoms only and do not constitute a diagnosed medical disorder. The only "diagnoses" rendered have been chest wall pain and sternum tenderness, which are also symptoms only and not recognized medical disorders. See Sanchez-Benitez v. West, No. 97-1948 (U.S. Vet. App. December 29, 1999) (pain alone, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a disability for which service connection may be granted). There have been no findings of old chestbone fractures on any chest x-ray or CT scan. There have been no objective findings of pathology or abnormalities of the chest. Despite the fact that the veteran complained of headaches and chest pain during service, there must be an ascertainable chronic disability connected to those complaints in order to warrant service connection. The existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C.A. §§ 1110 and 1131 (West 1991); see Degmetich v. Brown, 104 F.3d 1328 (1997) (holding that Secretary's and Court's interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary and therefore the decision based on that interpretation must be affirmed); see also Caluza, 7 Vet. App. at 505; Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v Derwinski, 2 Vet. App. 141, 143 (1992). Therefore, since the medical evidence does not show a current disability due to a chronic headache disorder and a disability manifested by chest pain, the veteran's claims for service connection are not well grounded. 2. Right ear hearing loss Service connection may also be established for a current disability on the basis of a "presumption" under the law that certain chronic diseases manifesting themselves to a certain degree within a certain time after service must have had their onset in service. 38 U.S.C.A. §§ 1110, 1112, 1131 and 1137 (West 1991 & Supp. 1999); 38 C.F.R. §§ 3.303, 3.304, 3.307 and 3.309(a) (1999). Service connection for sensorineural hearing loss may be established based on a legal "presumption" by showing that it manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C.A. § 1112 (West 1991 & Supp. 1999); 38 C.F.R. §§ 3.307 and 3.309 (1999); see Under Secretary for Health letter (October 4, 1995) (It is appropriate for VA to consider sensorineural hearing loss as an organic disease of the nervous system and, therefore, a presumptive disability.) With respect to hearing loss, VA has specifically defined what is meant by a "disability" for the purposes of service connection. 38 C.F.R. § 3.385 (1999). ("[I]mpaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent."). The requirements for service connection for hearing loss as defined in 38 C.F.R. § 3.385 need not be shown by the results of audiometric testing during a claimant's period of active military service in order for service connection to be granted. The United States Court of Appeals for Veterans Claims (formerly the United States Court of Veterans Appeals) (Court) has held that 38 C.F.R. § 3.385 did not prevent a claimant from establishing service connection on the basis of post-service evidence of hearing loss related to service when there were no audiometric scores reported at separation from service. Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). The Court has also held that the regulation did not necessarily preclude service connection for hearing loss that first met the regulation's requirements after service. Hensley v. Brown, 5 Vet. App. 155, 159 (1993). Thus, a claimant who seeks to establish service connection for a current hearing disability must show, as is required in a claim for service connection for any disability, that a current hearing disability is the result of an injury or disease incurred in service, the determination of which depends on a review of all the evidence of record including that pertinent to service. 38 U.S.C.A. § 1110 (West 1991); C.F.R. §§ 3.303 and 3.304 (1999); Hensley, 5 Vet. App. at 159-60. The veteran is not entitled to direct or presumptive service connection for right ear hearing loss because the medical evidence does not show that he has a current disability. The audiograms conducted in 1992 and 1996, as detailed above, did not demonstrate that he has met the requirements for a hearing loss disability for the right ear. See 38 C.F.R. § 3.385 (1999). He does not have an auditory threshold of 26 decibels or higher for the right ear in any of the auditory frequencies 500, 1000, 2000, 3000, or 4000, and his hearing acuity has been classified as normal. His speech recognition scores on the Maryland CNC Test were 100 percent bilaterally. Therefore, despite the fact that examiners have diagnosed "bilateral hearing loss" based on the veteran's complaints of hearing difficulty, he does not have a current hearing loss disability according to VA regulations. Since there is no competent medical evidence of a current disability, the claim for service connection for right ear hearing loss is not well grounded. 3. Scar, right upper eyelid (claimed as residual of head injury) The veteran currently has a well-healed scar above the right eyebrow, which the VA examiner in 1996 concluded was the residual of a combat injury to the right eyelid in 1970. This opinion was based on the veteran's report of incurring such an injury. The examiner's opinion does not, however, well ground this claim. The veteran's report that the scar above his right eyebrow resulted from a shrapnel wound is fictitious. The service medical records clearly and unmistakably establish the existence of a scar above the veteran's right eyebrow upon his entrance into service in 1964. Although the veteran's account of the inservice shrapnel wound would generally be accepted as truthful, his account is incredible in light of the evidence showing that the claimed scar existed prior to service. The evidence does not show that he currently has two scars, so it is not plausible that he incurred an injury during service that resulted in a scar other than the one present upon entry into service. The Board is not required to accept his assertions as true in the circumstances of this case and is therefore also not required to accept the opinion linking the current scar to the reported inservice injury. See King, 5 Vet. App. at 21. The Board notes that the veteran does not contend that the preexisting scar above the right eyebrow was somehow aggravated by his military service. 4. Back disorder The medical evidence shows diagnoses of several back disorders that are separate, identifiable conditions. Due to the varied nature of these disorders, the Board will consider them as separate entities where appropriate. Also, since the veteran had two periods of service separated by almost three years, with complaints of back pain during both periods of service, his claim must be analyzed accordingly. There is some indication in the evidence that the veteran had problems with his back prior to service (i.e., veteran's statements in 1964 and 1965 as to having back pain "for years" and letter from Dr. Coleman indicating the veteran was treated for lumbar spine pain in 1960 following a football injury). However, a veteran who served during a period of war or during peacetime service after December 31, 1946, is presumed to be in sound condition when he entered into military service except for conditions noted on his entrance examination. 38 U.S.C.A. §§ 1111 and 1132 (West 1991); 38 C.F.R. § 3.304(b) (1999). The presumption of soundness can be rebutted by clear and unmistakable evidence that the disorder existed prior to entry into service. 38 U.S.C.A. §§ 1111 and 1132 (West 1991); 38 C.F.R. § 3.304(b) (1999). The existence of a back disorder was not noted upon the veteran's entry into service in 1964, and there is insufficient evidence from which the Board could conclude that he had a chronic back disorder prior to that period of service, as opposed to merely back pain. Therefore, he is entitled to the presumption of soundness. Spina bifida occulta with associated transitional vertebra was diagnosed during the veteran's first period of service. This was characterized as a congenital disorder by the VA examiner in 1974. Spina bifida occulta is an "embryologic failure of fusion of one or more vertebral arches," and spina bifida occulta is "where there is a spinal defect, but no protrusion of the cord or its membrane, although there is often some abnormality in their development." Stedman's Medical Dictionary at 1649 (26th ed. 1995); see also Godfrey v. Brown, 7 Vet. App. 398, 401 (1995) (defining spina bifida as "a congenital cleft of the vertebral column with hernial protrusion of the meninges;" meninges are more than one of the three membranes that envelop the brain and spinal cord) (citation omitted). A congenital or developmental defect is not a disease or injury within the meaning of applicable law. See 38 C.F.R. § 3.303(c) (1999). No disability resulting from a congenital or developmental defect may be service connected. Winn v. Brown, 8 Vet. App. 510, 516 (1996). The VA General Counsel has defined a "defect" as an imperfection or structural abnormality. VAOPGCPREC 82-90 (O.G.C. Prec. 82-90). The above definitions clearly establish that spina bifida is a congenital defect. Therefore, more than an increase in severity during service is required to warrant a grant of service connection. There is a lack of entitlement under the law to service connection for spina bifida unless the evidence shows that it was subject to a superimposed disease or injury during military service that resulted in disability apart from the developmental defect. See VAOPGCPREC 82-90 (O.G.C. Prec. 82-90). There is evidence that the veteran incurred a superimposed back injury during his first period of service, as shown by the service medical records and his testimony. Diagnoses other than spina bifida were shown by the service medical records (lumbosacral strain) and by the medical evidence shortly after his separation from service in 1966 (lumbosacral strain and lumbar myositis). Myositis is "muscular discomfort or pain from infection or an unknown cause." Godfrey, 7 Vet. App. at 401 (citation omitted). However, there is no evidence indicating that the veteran's back injuries during his first period of service resulted in chronic disability. There is no evidence showing treatment for back problems between 1966 and the veteran's reenlistment in service in 1969. Although he reported recurrent back pain upon his enlistment into service in 1969, it was only noted that he experienced back pain with heavy lifting. This is insufficient to establish the existence of a chronic back disorder at that time, as opposed to symptoms. Clinical evaluation of his spine was normal. Therefore, the veteran is entitled to the presumption of soundness for his second period of service. If he was in sound physical condition upon entry into service in 1969, it cannot be said that any injuries incurred during the first period of service resulted in chronic disability apart from the congenital spina bifida. Any back strain or myositis that the veteran had in 1966 was apparently of an acute and transitory nature, since such conditions had resolved by 1969. There is evidence that the veteran incurred a superimposed back injury during his second period of service, as shown by his testimony. However, the evidence does not establish that the alleged back injuries during his second period of service resulted in disability apart from the congenital spina bifida. The only diagnosis shown during the second period of service and upon VA examination shortly after separation from service in 1974 was the congenital spina bifida. Furthermore, any disability allegedly resulting from injury incurred during the veteran's second period of service was clearly minimal. There is no evidence showing treatment for back problems between 1974 and 1989, which was when the veteran first injured his back at work. After the 1989 work- related injury, the veteran sought extensive medical treatment. At no time did he report a longstanding history of back problems or of incurring back injuries during his military service, and he consistently dated his back problems to the 1989 injury. After incurring another work-related injury in 1990, the veteran again sought extensive medical treatment, and he again dated his back problems to the 1989 injury, with no report of prior back injury or back problems. In connection with his claim for Social Security disability benefits, he also reported onset of his back condition as the 1989 work-related injury. Since the evidence does not establish that the veteran incurred a superimposed disease or injury during either period of service that resulted in chronic disability apart from the congenital spina bifida occulta, any claim for service connection for this condition is not plausible. With respect to the veteran's degenerative disc disease and herniated discs, the medical evidence first showed these conditions in 1989, approximately 15 years after the veteran's separation from service. These conditions were not shown until after the veteran incurred two work-related back injuries. No medical professional has rendered an opinion that any of these disorders is related to an inservice disease or injury, including the veteran's complaints of back pain. No medical professional has rendered an opinion that any of these disorders have resulted from disease or injury incurred during the veteran's military service that was superimposed on the congenital spina bifida. The medical evidence does show a statement by a VA psychiatrist in 1997 that the veteran has debilitating pain and history of pinched nerve arthritis related to injury in service (prior to going to Vietnam). Pinched nerve arthritis is not a recognized medical disorder. Arthritis, by definition, affects only joints, not nerves. This "diagnosis" must have been based solely on the veteran's reported history, since the psychiatrist did not examine the veteran's back, and there is no indication that the psychiatrist reviewed any of the veteran's medical records. This "diagnosis" is directly contradicted by the rest of the evidence of record and therefore does not render this claim plausible. See Godfrey v. Brown, 8 Vet. App. 113, 121 (1995). 5. Conclusion for service connection claims As discussed above, the veteran does not contend that he currently has a chronic headache disorder and has, in fact, denied such. Any contentions that he currently has chest and/or back disorders and right ear hearing loss as a result of his military service are not competent evidence. He cannot meet his initial burden under 38 U.S.C.A. § 5107(a) by simply presenting his own unqualified opinion. There is no indication that the veteran possesses the requisite medical knowledge or education to render a probative opinion involving medical diagnosis or medical causation. See Edenfield v. Brown, 8 Vet. App. 384, 388 (1995); Robinette v. Brown, 8 Vet. App. 69, 74 (1995); Grottveit v. Brown, 5 Vet. App. 91, 93 (1993); Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). The veteran has the initial burden of establishing a well- grounded claim for service connection for a disorder. Until he does so, VA has no duty to assist him in developing facts pertinent to the claim, including providing him additional medical examinations at VA expense. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.326(a) (1999) (VA examination will be authorized where there is a well-grounded claim for compensation); see Morton v. West, 12 Vet. App. 477 (1999) (VA cannot assist a claimant in developing a claim that is not well grounded). When a claimant refers to a specific source of evidence that could make his claim plausible, VA has a duty to inform him of the necessity to submit that evidence to complete his application for benefits. See Epps v. Brown, 9 Vet. App. 341, 344-45 (1996), aff'd Epps v. Gober, 126 F.3d 1464 (Fed. Cir. 1997). The Board finds VA has no outstanding duty to inform the veteran of the necessity to submit certain evidence to complete his application for VA benefits, see 38 U.S.C.A. § 5103(a) (West 1991), as he has not referred to any specific piece of evidence that is missing. Nothing in the record suggests the existence of evidence that might well ground any of these claims. As indicated above, the presentation of a well-grounded claim is a threshold issue. Therefore, since the veteran has failed to present competent medical evidence that these claims are plausible, the claims for service connection must be denied as not well grounded. Dean v. Brown, 8 Vet. App. 449 (1995) and Boeck v. Brown, 6 Vet. App. 14, 17 (1993). There is no duty to assist further in the development of these claims, because such additional development would be futile. See Murphy, 1 Vet. App. 78. B. Claim to reopen (varicose veins) A decision of a duly-constituted rating agency or other agency of original jurisdiction is final and binding as to all field offices of the Department as to written conclusions based on evidence on file at the time the veteran is notified of the decision. 38 C.F.R. § 3.104(a) (1999). Such a decision is not subject to revision on the same factual basis except by a duly constituted appellate authority. Id. The veteran has one year from notification of a decision of the agency of original jurisdiction to file a notice of disagreement (NOD) with the decision, and the decision becomes final if a NOD is not filed within that time. 38 U.S.C.A. § 7105(b) and (c) (West 1991); 38 C.F.R. §§ 3.160(d) and 20.302(a) (1999). In a March 1988 rating decision, the RO denied entitlement to service connection for varicose veins on the merits. A letter from the RO, advising the veteran of that decision and of appellate rights and procedures, was issued in March 1988. The veteran did not disagree with that decision, and it is therefore final. 38 U.S.C.A. § 7105 (West 1991). In order to reopen a claim which has been previously denied and which is final, the claimant must present new and material evidence. 38 U.S.C.A. § 5108 (West 1991). New and material evidence means evidence not previously submitted to agency decisionmakers which bears directly and substantially upon the specific matter under consideration, which is neither cumulative nor redundant, and which by itself or in connection with evidence previously assembled is so significant that it must be considered in order to fairly decide the merits of the claim. 38 C.F.R. § 3.156(a) (1999); see also Hodge v. West, 155 F.3d 1356 (Fed. Cir. 1998). When presented with a claim to reopen a previously finally denied claim, VA must perform a three-step analysis. Elkins v. West, 12 Vet. App. 209 (1999). First, it must be determined whether the evidence submitted by the claimant is new and material. Second, if new and material evidence has been presented, it must be determined, immediately upon reopening the claim, whether the reopened claim is well grounded pursuant to 38 U.S.C. § 5107(a) based upon all the evidence and presuming its credibility. There is no duty to assist in the absence of a well-grounded claim. Epps v. Gober, 126 F.3d 1464, 1468 (Fed. Cir. 1997) cert. denied, sub nom. Epps v. West, 118 S.Ct. 2348 (1998). See also Winters v. West, 12 Vet. App. 203 (1999). Third, if the reopened claim is well grounded, VA may evaluate the merits of the claim after ensuring that the duty to assist under 38 U.S.C. § 5107(b) has been fulfilled. In the rating decision on appeal, the RO adjudicated this issue according to the definition of material evidence enunciated in Colvin v. Derwinski, 1 Vet. App. 171 (1991) ("a reasonable possibility that the new evidence, when viewed in the context of all the evidence, both new and old, would change the outcome" of the final decision). The Federal Circuit in Hodge declared this definition of material evidence invalid. Therefore, the determination as to whether the veteran has submitted new and material evidence to reopen this claim will be made pursuant to the definition of new and material evidence contained in 38 C.F.R. § 3.156(a), as discussed above. It is not necessary to remand this claim because no prejudice to the veteran results from the Board's consideration of this claim. He was provided notice of the applicable laws and regulations regarding new and material evidence, including 38 C.F.R. § 3.156. See Bernard v. Brown, 4 Vet. App. 384 (1993). Furthermore, the Board's review of this claim under the more flexible Hodge standard accords the veteran a less stringent "new and material" evidence threshold to overcome. Although the RO reopened this claim in the July 1993 rating decision after concluding that the veteran had submitted new and material evidence, the Board must also consider this issue. See Barnett v. Brown, 8 Vet. App. 1, 4 (1995) (Board has a legal duty to consider the requirement of whether new and material evidence has been submitted regardless of the RO's actions); Wakeford v. Brown, 8 Vet. App. 237 (1995) (VA failed to comply with its own regulations by ignoring issue of whether any new and material evidence had been submitted to reopen the veteran's previously and finally denied claims). The evidence received subsequent to March 1988 is presumed credible for the purposes of reopening the veteran's claim unless it is inherently false or untrue, or it is beyond the competence of the person making the assertion. Duran v. Brown, 7 Vet. App. 216, 220 (1995); Justus v. Principi, 3 Vet. App. 510, 513 (1992). See also Robinette v. Brown, 8 Vet. App. 69, 75-76 (1995). Since March 1988, the following evidence has been received: (1) the veteran's contentions, including those raised at a personal hearing in 1994; (2) VA treatment and hospitalization records dated from January 1993 to January 1999; (3) copies of service medical records; (4) reports of VA examinations conducted in 1992 and 1996; (5) private medical records submitted by the veteran, including records from Drs. White, Price, and Graf, Springhill Memorial Hospital, Mobile Infirmary Medical Center, ProHealth Fitness and Rehabilitation Center, Donna Kline, P.T., Fairview Park Hospital, and Industrial Medical Center; (6) a decision by the Social Security Administration and the private medical records supporting that decision; (7) a VA attending physician's statement received in 1994; and (8) the report of a VA aid and attendance examination conducted in 1997. The veteran continues to argue that he has varicose veins as a result of his military service. This evidence is not new. He has not submitted any new contentions regarding this claim; he has merely, at best, repeated his prior assertions. This evidence is cumulative of evidence associated with the claims file at the time of the March 1988 rating decision and is not new for purposes of reopening a claim. The service medical records submitted by the veteran in 1993 and obtained from the National Personnel Records Center in 1993 are also not new. Under pertinent regulations, where new and material evidence consists of a supplemental report from the service department received after the decision has become final, the decision will be reconsidered by the agency of original jurisdiction. 38 C.F.R. § 3.156(c) (1999). These records were copies of the service medical records previously associated with the claims file and are therefore not new for purposes of reopening a claim. The rest of the evidence received since March 1988 is new in that it was not previously of record. To serve to reopen the claim, it must also be material. Material evidence is that which bears directly and substantially on the merits of each essential element that was a basis for the prior denial. Because the veteran is seeking to establish service connection for varicose veins, material evidence would be significant evidence that bore substantially and directly on the current existence of the claimed disorder and a relationship between the current disorder and a disease or injury incurred during the veteran's military service. None of the new evidence is material. The new evidence does not show that the veteran currently has varicose veins. Although "mild" varicose veins were shown on VA examination in March 1992, every subsequent examination has failed to show that he has varicose veins. The new evidence is not so significant that it requires reopening of the veteran's claim, in that it fails to show that he currently has the claimed disorder. The veteran's contentions that he has varicose veins as a result of his military service are neither material nor competent evidence, as discussed above. Accordingly, the Board finds that the evidence received subsequent to March 1988 is not new and material and does not serve to reopen the veteran's claim for service connection for varicose veins. 38 U.S.C.A. §§ 5108 and 7105 (West 1991); 38 C.F.R. § 3.156(a) (1999). C. Higher rating for left ear hearing loss a. Schedular evaluation The first responsibility of a claimant is to present a well- grounded claim. 38 U.S.C.A. § 5107(a) (West 1991). The July 1993 rating decision erroneously denied this claim as entitlement to service connection, but the RO subsequently addressed this claim as the proper evaluation for left ear hearing loss. An October 1992 rating decision had granted service connection for left ear hearing loss. Resolving any reasonable doubt in the veteran's favor, the Board concludes that he intended to appeal the initial assignment of a zero percent disability rating for this condition. As discussed above, he submitted a statement in January 1993 indicating his desire to appeal his "claim." Since he did not specify which claim he was appealing, it is plausible that his left ear hearing loss claim was included in this possible notice of disagreement. Since the veteran arguably perfected his appeal as to the initial grant of service connection and original assignment of a disability rating for his left ear hearing loss, his claim continues to be well grounded as long as the rating schedule provides a higher rating for this condition. Shipwash v. Brown, 8 Vet. App. 218, 224 (1995). VA has a duty to assist the veteran in the development of facts pertinent to his claim. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.103 (1999). The duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the veteran. Green v. Derwinski, 1 Vet. App. 121 (1991). Where there is a well- grounded claim, including original claims and claims for an increase, but the medical evidence is not adequate for rating purposes, an examination will be authorized. 38 C.F.R. § 3.326(a) (1999). Reexamination will be requested whenever VA determines that there is a need to verify either the continued existence or the current severity of a disability. 38 C.F.R. § 3.327(a) (1999). Generally, reexaminations are required if it is likely that a disability has improved, if the evidence indicates that there has been a material change in a disability, or if the current rating may be incorrect. Id. The RO provided the veteran several VA audiological examinations, and he had a personal hearing in accordance with his request. There is no indication of additional medical records that the RO failed to obtain, and sufficient evidence is of record to rate the veteran's service-connected disability properly. Therefore, in these circumstances, no further assistance to the veteran is required to comply with the duty to assist mandated by 38 U.S.C.A. § 5107(a). Disability ratings are intended to compensate reductions in earning capacity as a result of the specific disorder. The ratings are intended, as far as practicably can be determined, to compensate the average impairment of earning capacity resulting from such disorder in civilian occupations. 38 U.S.C.A. § 1155 (West 1991). Evaluation of a service-connected disorder requires a review of the veteran's entire medical history regarding that disorder. 38 C.F.R. §§ 4.1 and 4.2 (1999). This appeal being from the initial rating assigned to a disability upon awarding service connection, the entire body of evidence is for equal consideration. Consistent with the facts found, the rating may be higher or lower for segments of the time under review on appeal, i.e., the rating may be "staged." Fenderson v. West, 12 Vet. App. 119 (1999); cf. Francisco v. Brown, 7 Vet. App. 55, 58 (1994) (where an increased rating is at issue, the present level of the disability is the primary concern). Such staged ratings are not subject to the provisions of 38 C.F.R. § 3.105(e), which generally requires notice and a delay in implementation when there is proposed a reduction in evaluation that would result in reduction of compensation benefits being paid. Fenderson, 12 Vet. App. at 126. The Board will consider all evidence, from service forward, in determining the appropriate evaluation for the veteran's service-connected disability. It is also necessary to evaluate the disability from the point of view of the veteran working or seeking work, 38 C.F.R. § 4.2 (1999), and to resolve any reasonable doubt regarding the extent of the disability in the veteran's favor. 38 C.F.R. § 4.3 (1999). If there is a question as to which evaluation to apply to the veteran's disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (1999). The veteran's left ear hearing loss is rated under Diagnostic Code 6100. During the pendency of this appeal, regulatory changes amended the VA Schedule for Rating Disabilities, 38 C.F.R. § Part 4 (1998), including the rating criteria for evaluating a hearing loss disorder. This amendment was effective June 10, 1999. See 64 Fed. Reg. 25202 through 25210 (May 11, 1999). When a law or regulation changes after a claim has been filed but before the administrative appeal process has been concluded, VA must apply the regulatory version that is more favorable to the veteran. Karnas v. Derwinski, 1 Vet. App. 308, 312-13 (1991). Therefore, the Board must evaluate the veteran's claim for a higher rating under both the old criteria in the VA Schedule for Rating Disabilities and the current regulations in order to ascertain which version is most favorable to his claim, if indeed one is more favorable than the other. The new regulations were not in effect when the rating decisions on appeal were made, and the RO has not considered the new regulations. Also, the veteran has not been given notice of the new regulations. However, it is not necessary to remand this claim since he is not prejudiced by the Board's consideration of the new regulations in the first instance. See Bernard v. Brown, 4 Vet. App. 384 (1993). The amended regulations did not result in any substantive changes. Essentially, the old and new regulations for evaluating a hearing loss disorder are identical. See 64 Fed. Reg. 25202 (May 11, 1999) (discussing the method of evaluating hearing loss based on the results of puretone audiometry results and the results of a controlled speech discrimination test and indicating that there was no proposed change in this method of evaluation). In this case, neither rating criteria can be more favorable to the veteran's claim since the criteria are identical. The amended regulations did incorporate some explanatory comments concerning VA's method of evaluating a hearing loss disorder, and these comments will be discussed where appropriate. The severity of a hearing loss disability is determined by applying the criteria set forth at 38 C.F.R. § 4.85 (1999). Under these criteria, evaluations of bilateral hearing loss range from noncompensable to 100 percent based on organic impairment of hearing acuity as measured by the results of controlled speech discrimination tests together with the average hearing threshold level as measured by pure tone audiometry tests in the frequencies 1,000, 2,000, 3,000 and 4,000 cycles per second. See 38 C.F.R. § 4.85(a) and (d) (1999). To evaluate the degree of disability from defective hearing, the rating schedule establishes eleven auditory acuity levels from level I for essentially normal acuity through level XI for profound deafness. 38 C.F.R. §§ 4.85 and 4.87, Diagnostic Code 6100; Table VI (1998 and 1999); 38 C.F.R. § 4.85(b) and (e) (1998 and 1999). Tables VI and VII are reproduced below. See Lendenmann v. Principi, 3 Vet. App. 345 (1992). The amended regulations changed the title of Table VI from "Numeric Designations of Hearing Impairment" to "Numeric Designations of Hearing Impairment Based on Puretone Threshold Average and Speech Discrimination." See 64 Fed. Reg. 25202 (May 11, 1999). Moreover, Table VII was amended in that hearing loss is now rated under a single code, that of Diagnostic Code 6100, regardless of the percentage of disability. See 64 Fed. Reg. 25204 (May 11, 1999). TABLE VI Numeric Designation of Hearing Impairment Based on Puretone Threshold Average and Speech Discrimination Percent of Discrimination Average Puretone Decibel Loss 0-41 42- 49 50- 57 58- 65 66- 73 74- 81 82- 89 90- 97 98+ 92- 100 I I I II II II III III IV 84- 90 II II II III III III IV IV IV 76- 82 III III IV IV IV V V V V 68- 74 IV IV V V VI VI VII VII VII 60- 66 V V VI VI VII VII VIII VIII VIII 52- 58 VI VI VII VII VIII VIII VIII VIII IX 44- 50 VII VII VIII VIII VIII IX IX IX X 36- 42 VIII VIII VIII IX IX IX X X X 0-34 IX X XI XI XI XI XI XI XI Table VII Percentage Evaluations for Hearing Impairment LEVEL OF HEARING IN BETTER EAR XI 100 * X 90 80 IX 80 70 60 VII I 70 60 50 50 VII 60 60 50 40 40 VI 50 50 40 40 30 30 V 40 40 40 30 30 20 20 IV 30 30 30 20 20 20 10 10 III 20 20 20 20 20 10 10 10 0 II 10 10 10 10 10 10 10 0 0 0 I 10 10 0 0 0 0 0 0 0 0 0 XI X IX VII I VII VI V IV III II I LEVEL OF HEARING IN POORER EAR The results of the 1992 and 1996 audiograms, as indicated above, showed that the veteran's left ear hearing loss is properly evaluated as zero percent disabling. Since only the veteran's left ear is service-connected and he is not totally deaf in his right ear, the hearing acuity of his right ear is considered normal. VAOPGCPREC 32-97; see also Boyer v. West, 11 Vet. App. 477, 479-80 (1998), aff'd upon motion for reconsideration, Boyer v. West, 12 Vet. App. 142 (1999). Therefore, a designation of Level "I" is assigned for his right ear. Based on 96-100 percent speech recognition scores and 15-28 decibel puretone threshold averages as shown between 1992 and 1996, Table VI indicates a designation of Level "I" for the left ear. When applied to Table VII, the numeric designations of "I" for both ears translated to a zero percent evaluation. Therefore, the veteran's service- connected left ear hearing loss is properly assigned a noncompensable disability rating. 38 C.F.R. § 4.85, Tables VI and VII (1998 and 1999). The amended regulations added two new provisions for evaluating veterans with certain patterns of hearing impairment that cannot always be accurately assessed under § 4.85 because the speech discrimination test may not reflect the severity of communicative functioning that these veterans experience. See 64 Fed. Reg. 25203 (May 11, 1999). The first new provision, that of 38 C.F.R. § 4.86(a), indicates that if puretone thresholds in any four of the five frequencies of 500, 1000, 2000, 3000, and 4000 Hertz are 55 decibels or more, an evaluation can be based either on Table VI or Table VIa, whichever results in a higher evaluation. See 64 Fed. Reg. 25209 (May 11, 1999). This provision corrects for the fact that with a 55-decibel threshold level (the level at which speech becomes essentially inaudible) the high level of amplification needed to attempt to conduct a speech discrimination test would be painful to most people, and speech discrimination tests may therefore not be possible or reliable. Id. The second new provision, that of 38 C.F.R. § 4.86(b), indicates that when the puretone threshold is 30 decibels or less at 1000 Hertz and 70 decibels or more at 2000 Hertz, the Roman numeral designation for hearing impairment will be chosen from either Table VI or Table VIa, whichever results in the higher numeral, and that numeral will then be elevated to the next higher Roman numeral. Id. This provision compensates for a pattern of hearing impairment that is an extreme handicap in the presence of any environmental noise, and a speech discrimination test conducted in a quiet room with amplification of sound does not always reflect the extent of impairment experienced in the ordinary environment. Id. Table VIa is reproduced below. The amended regulations changed the title of Table VIa from "Average Puretone Decibel Loss" to "Numeric Designation of Hearing Impairment Based Only on Puretone Threshold Average." See 64 Fed. Reg. 25202 (May 11, 1999). TABLE VIa Numeric Designation of Hearing Impairment Based Only on Puretone Threshold Average Average Puretone Decibel Loss 0- 41 42- 48 49- 55 56- 62 63- 69 70- 76 77- 83 84- 90 91- 97 98- 104 105 + I II III IV V VI VII VIII IX X XI Neither of these new provisions applies to the veteran's situation. None of the puretone thresholds shown on the 1992 or 1996 VA examinations were 55 decibels or greater. Furthermore, neither of these audiometric evaluations showed puretone thresholds of 70 decibels or more at 2000 Hertz. In determining whether a higher rating is warranted for a disease or disability, VA must determine whether the evidence supports the veteran's claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107(a) (West 1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Although the Board sympathizes with the veteran's difficulties due to his left ear hearing loss, the Board is constrained to abide by VA regulations. In light of the above, the Board finds that the preponderance of the evidence is against his claim for a compensable disability rating for left ear hearing loss. b. Extraschedular evaluation The issue of entitlement to an extraschedular disability rating pursuant to 38 C.F.R. § 3.321(b) for the veteran's left ear hearing loss has been raised by his representative. In exceptional cases where schedular evaluations are found to be inadequate, the RO may refer a claim to the Under Secretary for Benefits or the Director, Compensation and Pension Service, for consideration of "an extraschedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities." 38 C.F.R. § 3.321(b)(1) (1999). "The governing norm in these exceptional cases is: A finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards." Id. In this case, the RO has not considered whether an extraschedular rating is appropriate for the veteran's left ear hearing loss. When the Board addresses an issue that was not addressed by the RO, consideration must be given to whether the veteran will be prejudiced by the Board's consideration of the issue in the first instance. See 38 U.S.C.A. §§ 5104, 5107(a), 7104(a), and 7105(d)(1) (West 1991); 38 C.F.R. §§ 3.103(a), 3.103(c)(1), 3.103(c)(2), 3.103(d), 19.9, 19.25, 19.29, and 19.31 (1999); see also VAOPGCPREC 16-92 (1992). Therefore, the Board must decide whether the veteran will be prejudiced by its consideration of this issue. Although the relevant statutes and regulations regarding extraschedular ratings were not included in the statement of the case or supplemental statements of the case, the veteran's due process rights are not violated by this Board decision. The Court has held that the question of an extraschedular rating is a component of the veteran's claim for an increased rating. See Bagwell v. Brown, 9 Vet. App. 337 (1996). While the Board does not have the authority to grant an extraschedular evaluation in the first instance, it is not precluded from reviewing an RO determination that referral is not warranted and confirming that decision. See Floyd v. Brown, 9 Vet. App. 88, 95 (1996) (Board may consider whether referral to "appropriate first-line officials" for extraschedular rating is required). The Board is also not precluded from concluding, on its own, that referral for extraschedular consideration is not warranted. See Bagwell, 9 Vet. App. at 339 (BVA may affirm an RO conclusion that a claim does not meet the criteria for submission pursuant to 38 C.F.R. § 3.321(b)(1) or reach such a conclusion on its own) (emphasis added). According to Bagwell, it is proper for the Board, in the first instance, to determine whether referral for an extraschedular evaluation is warranted. Since the veteran's representative has specifically raised this issue and had an opportunity to present argument on it, there is no prejudice if the Board considers it. See VAOPGCPREC 16-92 at 7-8. The veteran has had a full opportunity to present evidence and argument on his claim for a higher rating, and the Board can fairly consider this claim. See also VAOPGCPREC 6-96 at 12- 13. The schedular evaluations for hearing loss are not inadequate. As fully detailed above, higher disability ratings are available for hearing loss where specific objective criteria are met as shown by audiometric evaluations and speech discrimination tests. The veteran does not meet the schedular criteria for a compensable disability rating. It does not appear that the veteran has an "exceptional or unusual" disability; he merely disagrees with the rating schedule's assignment of a zero percent evaluation for his level of hearing impairment. The veteran has not required any periods of hospitalization, nor has he required any extensive outpatient treatment for this condition. There is no evidence in the claims file to suggest marked interference with employment as a result of this condition that is in any way unusual or exceptional, such that the schedular criteria do not address it. The Board therefore concludes that referral for extraschedular consideration is not warranted in this case. In the absence of any evidence that reflects that this disability is exceptional or unusual such that the regular schedular criteria are inadequate to rate it, referral for consideration of an extraschedular rating is not in order. D. Timeliness and Adequacy of Appeal A January 1998 rating decision granted service connection for PTSD, with assignment of a 30 percent disability rating, and the veteran's notice of disagreement in January 1999 was with that rating decision, rather than a February 1998 rating decision that confirmed and continued the 30 percent disability rating. The veteran was provided a statement of the case on January 11, 1999, and a supplemental statement of the case on February 23, 1999. A VA Form 9 is of record that was submitted by facsimile on June 10, 1999, and bears a hand-written notation that it was received on June 25, 1999, although it is unclear who the recipient was. It was dated March 15, 1999. It was signed by the veteran and by another individual. A Report of Contact dated June 28, 1999, indicated that the other individual who signed the VA Form 9 was the veteran's daughter, and that the veteran was in the hospital and unable to send in his VA Form 9 prior to June 10, 1999. The report does not indicate that the daughter said when the veteran was hospitalized, or where, or for what conditions. The RO certified this claim as on appeal to the Board, indicating that the VA Form 9 was accepted as late based on the veteran being unable to file earlier due to hospitalization. By letter dated November 4, 1999, the veteran was advised that the Board intended to consider the issue of timeliness and adequacy of the substantive appeal of this issue, pursuant to 38 U.S.C.A. § 7105(d) and VAOPGCPREC 9-99. The veteran was advised of the appropriate law and regulations and was given a period of 60 days to present further argument or request a hearing. His reply, dated December 6, 1999, indicated that he did not wish to request a hearing or present further argument. His representative, however, submitted argument dated February 1, 2000, in which remand was requested for the RO to determine where the veteran was hospitalized and whether he was in a coma that prevented him from filing a timely request for extension or substantive appeal. The Board declines to remand this issue for further development, finding that the issue has not been properly appealed to the Board, for the reasons set forth below. Under pertinent statutory provisions, a claimant must file a substantive appeal to perfect an appeal. 38 U.S.C.A. § 7105(a) (West 1991); 38 C.F.R. § 20.200 (1999); see Roy v. Brown, 5 Vet. App. 554 (1993). A substantive appeal consists of a properly completed VA Form 9 or correspondence containing the necessary information. 38 C.F.R. § 20.202 (1999). The substantive appeal should set out specific arguments relating to errors of fact or law made by the RO in reaching the determination being appealed. 38 U.S.C.A. § 7105(d)(3) (West 1991); 38 C.F.R. § 20.202 (1999). A substantive appeal must be filed within 60 days from the date that an agency of original jurisdiction mails the statement of the case to the appellant, or within the remainder of the one-year period from the date of the mailing of the notice of the determination appealed, whichever period ends later. 38 C.F.R. § 20.302(b). Where a supplemental statement of the case is provided, a period of 60 days is permitted for response. 38 C.F.R. § 20.302(c). In this case, since the statement of the case (SOC) was provided after expiration of the one-year period, the time limit that governed filing of a substantive appeal was within 60 days from the date of mailing of the SOC. That 60-day period expired on March 12, 1999. See 38 C.F.R. § 20.305(b) (1999). However, evidence was received and considered by the RO after the SOC was mailed and prior to expiration of the appeal period, and a supplemental statement of the case was sent to him on February 23, 1999. Even if the 60-day appeal period were to run from the latter date, the substantive appeal would have had to have been filed by April 26, 1999. An extension of the time for filing a substantive appeal may be granted for good cause, but the request for extension of time must be in writing and must be made prior to expiration of the time limit for filing the substantive appeal. 38 C.F.R. § 20.303 (1999). The veteran's representative has suggested that the veteran may have been unable to file a timely request for extension of time to file his appeal because he may have been in a coma when the appeal period expired, and that consideration should therefore be given to accepting the document filed in June 1999. There is no medical evidence that the veteran was in a coma or otherwise under an inability to request an extension of time to file on or prior to March 12, 1999, or on or prior to April 26, 1999, and neither the representative nor the veteran has offered such evidence. Notwithstanding the representative's implication that he may have been and the request for development to determine whether he was, the Board has no jurisdiction to require such development of the RO. The regulations are clear that a request for extension of time to file an appeal must be filed before the appeal period expires. Even taking the latest possible date of April 26 as the delimiting period for perfecting an appeal of this issue, it is clear that the June 10 transmittal of the Form 9 is not timely as an appeal. Although the form bears a date of March 15, there is no indication that it was mailed to the RO or received by the RO any time prior to June 10, 1999, nor has the veteran alleged that it was. The appeal period expired, at the latest, on April 26, 1999, and no request for extension of time with showing of good cause, was received before that date. The Form 9 received in June 1999 was not timely, and it did not serve to perfect an appeal. The Board has no jurisdiction over this appeal for another reason. The November 1999 letter also informed the veteran that the Board intended to consider, pursuant to 38 C.F.R. § 20.203, whether the Form 9 was adequate to perfect an appeal. A substantive appeal should set out specific arguments relating to errors of fact or law made by the agency of original jurisdiction in reaching the determination or determinations being appealed, and the Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. Proper completion and filing of a substantive appeal are the last actions the appellant needs to take to perfect an appeal. 38 C.F.R. § 20.202. In the VA Form 9 submitted in June 1999, the veteran did indicate an intention to appeal all issues on the statement of the case or supplemental statement of the case, by checking the appropriate box on the form. However, the form was entirely blank in the space in which the appellant is asked to specify why the case was decided incorrectly. He identified no error of fact or law in the statement or supplemental statement of the case. Having failed to allege any error, the purported appeal is not adequate to perfect an appeal to the Board. The Board shall not entertain an application for review on appeal unless it is in conformity with Chapter 71, Title 38, United States Code. 38 U.S.C.A. § 7108 (West 1991). The veteran's Form 9 was not timely; he did not file a timely request for extension; and it was inadequate to raise issues of error of fact or law. Accordingly, the Board must dismiss the issue of entitlement to a higher evaluation for PTSD from the initial grant of service connection. ORDER Entitlement to service connection for migraine headaches, right ear hearing loss, pain in the chest (claimed as residual of fracture of the chest bone), scar, right upper eyelid (claimed as residual of head injury), and a back disorder, including pain and numbness of the legs, is denied. As new and material evidence has not been received to reopen the veteran's claim for service connection for varicose veins, the claim is not reopened, and the appeal is denied. Entitlement to a compensable disability rating for left ear hearing loss, including consideration of an extraschedular rating, is denied. The appellant having failed to perfect an appeal through filing a timely or adequate substantive appeal from the issue of entitlement to a higher evaluation for PTSD from the initial grant of service connection, the appeal is dismissed. J. SHERMAN ROBERTS Member, Board of Veterans' Appeals