Citation Nr: 0006884 Decision Date: 03/14/00 Archive Date: 03/17/00 DOCKET NO. 95-37 634 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Whether new and material evidence has been submitted to reopen a claim for service connection for an anxiety neurosis. 2. Entitlement to service connection for PTSD. 3. Entitlement to service connection for hypotesticularosteopenia or loss of bone mass, a chronic acquired mid and upper back disorder, hypotesticularosteopenia or loss of bone mass, brain stem stroke, vertebrobasiliar insufficiency, human adjuvant disease, peripheral neuropathy, bleeding ulcers, chronic fatigue syndrome, dry eyes syndrome, hiatal hernia, chronic gastritis, esophagitis, and hypothyroidism as secondary to service-connected removal of the right testicle with testicular silicone implant. 4. Entitlement to service connection for chronic lung disease including as secondary to Agent Orange (AO) exposure. 5. Entitlement to an evaluation in excess of 10 percent for low back syndrome. REPRESENTATION Appellant represented by: R. Edward Bates, Attorney at Law ATTORNEY FOR THE BOARD Christopher B. Moran, Counsel INTRODUCTION The veteran served on active duty from August 1962 to June 1966 and from March 1970 to August 1976. This case was previously remanded by the Board in September 1999 in order for the Department of Veterans Affairs (VA) Regional Office (RO) to schedule the veteran for a personal hearing before a Member of the Board at the RO per the veteran's request in October 1995. However, the veteran subsequently submitted a statement dated in September 1999 withdrawing his request for a hearing before the Board or local hearing officer. The case has been returned to the Board for appellate consideration. The issues on appeal stem from rating decisions of the RO in Houston, Texas. The claim of entitlement to an evaluation in excess of 10 percent for low back syndrome is addressed in the remand portion of this decision. FINDINGS OF FACT 1. In April 1977 the RO denied entitlement to service connection for anxiety neurosis when it issued an unappealed rating decision in April 1977. 2. The evidence submitted since the April 1977 RO rating decision does not bear directly and substantially on the specific matter under consideration, is either cumulative or redundant, and is not by itself or in combination with the other evidence, so significant that it must be considered in order to fairly decide the merits of the claim. 3. The claims for service connection for hypotesticularosteopenia or loss of bone mass, a chronic acquired mid and upper back disorder, and human adjuvant disease with peripheral neuropathy as secondary to service- connected removal of the right testicle with testicular silicone implant; ulcers as secondary to medications prescribed for service-connected disability; and PTSD are supported by cognizable evidence showing that the claims are plausible or capable of substantiation. 4. The claims for service connection for chronic fatigue syndrome, vertebrobasiliar insufficiency, brainstem stroke, dry eyes syndrome, hiatal hernia, chronic gastritis, esophagitis and hypothyroidism as secondary to service- connected removal of the right testicle with testicular silicone implant are not supported by cognizable evidence showing that the claims are plausible or capable of substantiation. CONCLUSIONS OF LAW 1. Evidence submitted since the final April 1997 rating decision wherein the RO denied entitlement to service connection for anxiety neurosis is not new and material, and the veteran's claim for that benefit is not reopened. 38 U.S.C.A. §§ 5104, 5108, 7105(c); 38 C.F.R. §§ 3.104, 3.156(a), 20.1103 (1999). 2. The claims for service connection for chronic lung disease as secondary to AO exposure, chronic fatigue syndrome, vertebrobasiliar insufficiency, brainstem stroke, dry eye syndrome, hiatal hernia, chronic gastritis, esophagitis and hypothyroidism as secondary to service- connected removal of the right testicle with testicular silicone implant are not well grounded. 38 U.S.C.A. § 5107 (West 1991). 3. The claims for service connection for hypotesticularosteopenia or loss of bone mass, a chronic acquired mid and upper back disorder, and human adjuvant disease with peripheral neuropathy as secondary to service- connected removal of the right testicle with testicular silicone implant; ulcers as secondary to medications prescribed for service-connected disability; and PTSD are supported by cognizable evidence showing that the claims are plausible and capable of substantiation. 38 U.S.C.A. § 5107 (West 1991). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Factual Background Service-connection has been established for removal of the right testicle with atrophy of the left testicle evaluated as 20 percent disabling; low back syndrome, prostatitis with prostatism and bladder neck contractures, and dermatitis, each evaluated as 10 percent disabling; and bilateral inguinal hernia, postoperative, bilateral hearing loss, and fracture of the left metatarsal, each evaluated as noncompensable. The veteran served on active duty in the United States Navy from August 1962 to June 1966 and from March 1970 to August 1976. His military occupational specialty was that of cook/chef. Service Department records show recognized periods of service aboard ship while in the Vietnam combat zone. A review of the service medical records reflects episodes of respiratory symptoms variously diagnosed including upper respiratory infections and bronchitis between September 1962 and December 1975. The subsequently dated service medical records are silent for any residual respiratory symptomatology. In March 1964 the veteran was seen for stomach cramps and diarrhea for one day. Objective examination revealed epigastric pain but no nausea or vomiting. No gastrointestinal disorder was noted. He was given Phenobarbital. The remaining service medical records are silent for pertinent chronic gastrointestinal or digestive disabilities. The service medical records show that between approximately November 1975 and June 1976 the veteran was seen for complaints and symptoms associated with unstable anxiety depressive emotional personality and situational anxiety. In June 1976 his situational anxiety was noted as resolving. The service medical records show that between approximately February and April 1976 the veteran was seen for low back complaints diagnosed as lumbosacral strain and low back sprain. In early February 1976 he initially complained of low back pain for one day. He heard something pop while bending over to pick up a pan. Initial impressions were possible slipped disc or sprain. X-rays were negative for pathology. Impression was changed to lumbosacral strain in April 1976. There was indication that his complaints were in between acute and chronic. Aside form visual acuity findings associated with refractive error the service medical records with interim reports of physical examinations are silent for ocular pathology. Corrected vision was 20/20 bilaterally in service. The service medical records are silent for chronic fatigue syndrome, vertebrobasiliar insufficiency, brainstem stroke, dry eye syndrome, hiatal hernia, chronic gastritis, esophagitis, hypotesticularosteopenia or loss of bone mass, a mid or upper back disorder, or human adjuvant disease, peripheral neuropathy, or hypothyroidism. A November 1976 VA outpatient clinical record shows the veteran complained of a backache due to an injury sustained the previous week when he was working with a chain saw. A January 1977 VA special orthopedic examination report shows a pertinent diagnosis of chronic lower back syndrome. An X- ray of the lumbosacral spine was normal. A January 1977 VA psychiatric examination conclude din a diagnosis of anxiety neurosis, moderate. A January 1977 VA general medical examination report shows that a clinical evaluation of the eyes was normal. Clinical evaluations of the gastrointestinal and respiratory systems with chest X-ray were normal. The examination was silent for chronic fatigue syndrome, vertebrobasiliar insufficiency, brainstem stroke, dry eyes syndrome, human adjuvant disease, hiatal hernia, chronic gastritis and esophagitis, hypothyroidism, peripheral neuropathy, hypotesticularosteopenia or loss of bone mass and a mid and upper back disorder. A January 1977 VA genitourinary examination report shows it was noted as history that in service, the veteran's right testis was excised in 1976 with implant placed in the right scrotum. The left testicle was atrophied. In April 1977 the RO denied service connection for a psychiatric disorder essentially because there was no competent medical evidence of a link between the post service reported as moderate anxiety and the acute situational anxiety noted in service. VA outpatient treatment records in September 1978 showed treatment for thoracic and lumbar spine complaints. An X-ray of the thoracic spine revealed no significant abnormality. Tests for rheumatoid arthritis were negative. In October 1978 the veteran had an acute flare-up of low back pain with muscle spasm. In February 1979 the RO denied entitlement to direct service connection for a mid or upper back (thoracic spine) disorder as there was no underlying pathology demonstrated that was associated with thoracic back pain with onset in active service. A private medical record in August 1980 revealed treatment for middle back complaints following an injury whereby the veteran experienced pain after bending over to get something from a drawer and was unable to straighten-up. A history of previous back injuries in 1965, 1972 and 1976 was recorded. In a private medical statement dated in February 1981, RB, D.C., noted treating the veteran for a traumatically induced lower spinal condition previously aggravated by strenuous manual labor (i.e. heavy lifting). It was noted that the veteran's spine exhibited evidence of primary and compensatory scoliosis that was reflective of an inherent weakness continually aggravated by physical stress. Diagnoses were chronic traumatically induced unstable left sacroiliac and lumbosacral articulations with subsequent lumbosacral radiculitis, myositis, tenderness and spasm. An April 1981 VA orthopedic examination report shows a diagnosis of a history of chronic lumbosacral strain with minimal limitation of motion, symptomatic. An X-ray of the lumbosacral spine revealed no significant abnormality. A VA clinical record in June 1986 noted acquired spinal stenosis at L4-5 secondary to plugging anulus and hypertrophic facet disease. In September 1989 a VA orthopedic clinical record referred to treatment for complaints associated with a crush injury to the left foot in 1974. The veteran had continued pain and was on Motrin or Naprosyn for several years. X-rays were negative. Mild tenderness was noted over the 2nd metatarsal phalangeal joint. All non-steroidal anti-inflammatory (NSAID) drugs were discontinued. Subsequently dated records through the 1990's reveal low and mid back disabilities variously diagnosed including degenerative joint disease (DJD) of the thoracic spine, lumbar myofascial strain, L4-S1 nerve root irritation. Private medical records in the early 1990's refer to acute vertebrobasiliar insufficiency, and mild ventilatory defect noted on pulmonary function study, A VA medical record in June 1993 noted a diagnosis of possible gastritis secondary to NSAID's. Clinical symptoms of hypothyroidism were noted in private medical records in late 1993. A private hospital record in December 1993 shows a small old cortical infarct without hemorrhages noted on a computerized axial tomography (CAT) of the head. Discharge diagnoses on a private hospital report in January 1994 included human adjuvant disease, and autoimmune neuromuscular disease including neuropathy due to testicular silicone implant. Also noted were reflux esophagitis, hiatal hernia and dry eyes. It was noted as history that the veteran was given a right side testicular silicone implant in 1976 while in service. The implant was never removed. In 1988 he began developing pertinent symptoms including leg pain, fatigue, muscle weakness, joint pain, joint swelling, stiffness, backaches, numbness, burning, vomiting and gastrointestinal symptoms. It was noted that he presented with signs and symptoms of human adjuvant disease. It was noted that his symptoms were similar to the ladies with silicone breast implants and he appeared to have the same disease though his implant was testicular. Private medical records dated in 1994 noted the presence of hiatal hernia, prepyloric lesions and gastritis. Multiple lay statements dated in 1994 including two service comrades and other individuals generally described the veteran as nervous due to combat related experiences in Vietnam. A July 1994 VA psychiatric examination report shows diagnoses were major depression, anxiety disorder, not otherwise specified and organic mental disorder not otherwise specified. Subsequently dated private medical records show PTSD based upon the veteran's reported stressors in Vietnam. In a July 1994 statement, ANP, D.O., noted that the veteran's medical records revealed a long history of back problems starting in 1965 when he was injured by a shell falling on him in the Vietnam war. His back pain had progressively worsened over the past 29 years. It was noted as fairly obvious that the medical records demonstrated progressive disease with initial insult being the lumbar spine injury in 1965. It was also noted that the veteran currently had degenerative disc disease (DDD) in the entire spine as demonstrated by X-ray. Special testing revealed L4-L5 radiculopathy. In mid 1994 bone densitometry revealed that the bone density in the lumbar spine was below the normal level for age and placed the veteran at risk for fracture. In a September 1994 medical statement, JPT, M.D., Pain Relief, Center for Arthritis and Sports injuries, noted that the veteran's loss of bone density in the lumbar spine may be attributed to decreased testosterone associated with loss of testicular tissue in 1965 and 1966. He noted that these findings take on more significance in view of bone scans of the spine in 1993 showing degenerative changes. It was noted that the possibility of hypotesticularosteopenia was certainly evident. He noted that the veteran was initially seen by him in 1980 for acute and chronic pains and was intermittently treated for general problems and specifically the back and low testosterone for the past 14 years. It was noted that the veteran developed an active gastrointestinal ulcer due to Motrin as an attempt to control his back pain. Of record is a copy of a favorable Social Security Administration decision dated in early 1995. Also added to the record were additional lay statements in late 1994 pertaining to PTSD. VA treatment records dated in the late 1990's refer to chronic obstructive pulmonary disease (COPD), acute and chronic bronchitis, hypothyroid, multiple cerebral vascular accidents, PTSD, bipolar disorder and chronic fatigue syndrome. Also received was a copy of the ship's log records during active duty and duplicate service medical records. Criteria If no notice of disagreement is filed within the prescribed period, the action or determination shall become final and the claim will not thereafter be reopened or allowed, except as otherwise provided by regulation. 38 U.S.C.A. § 7105(c); 38 C.F.R. § 20.1103. When an issue has been previously denied by an unappealed RO rating decision, such claim may not be reopened and allowed in the absence of new and material evidence. 38 U.S.C.A. §§ 5108, 7105 (West 1991); 38 C.F.R. § 3.156(a) (1999). A decision of a duly constituted rating agency or other agency of original jurisdiction shall be final and binding on all field offices of the Department of Veterans Affairs as to conclusions based on the evidence on file at the time VA issues written notification in accordance with 38 U.S.C.A. § 5104 (West 1991). A final and binding agency decision shall not be subject to revision on the same factual basis except by duly constituted appellate authorities or except as provided in § 3.105 of this part. 38 C.F.R. § 3.104(a). The United States Court of Appeals for Veterans Claims (Court) has held that when "new and material evidence" is presented or secured with respect to a previously and finally disallowed claim, VA must reopen the claim. Manio v. Derwinski, 1 Vet. App. 140, 145 (1991). If new and material evidence is presented or secured with respect to a claim, which has been disallowed, the claim will be reopened and the former disposition of the claim reviewed. 38 U.S.C.A. § 5108 (West 1991); 38 C.F.R. § 3.156(a) (1999); Manio v. Derwinski, 1 Vet. App. 140 (1991); Colvin v. Derwinski, 1 Vet. App. 171 (1991). Evidence is considered new when it is not merely cumulative of other evidence in the record and is considered material when it is relevant and probative of the issue at hand. To justify a reopening of the claim on the basis of new and material evidence, there must be a reasonable possibility that the new evidence, when viewed in context of all the evidence, both new and old, would change the outcome. Colvin v. Derwinski, 1 Vet. App. 171 (1991). The evidence is "new" when it is not cumulative of evidence already of record and is not "material" when it could not possibly change the outcome of the case. Godwin v. Derwinski, 1 Vet. App. 419 (1991). "Material" evidence is evidence which is relevant to and probative of the issue at hand and, which, furthermore, when reviewed in context of all the evidence of record, both old and new, would change the outcome of the case. Smith v. Derwinski, 1 Vet. App. 171 (1992). When determining whether the veteran has submitted new and material evidence to reopen a claim, consideration must be given to all the evidence since the last final denial of the claim. Evans v. Brown, 9 Vet. App. 273 (1996). In the Evans case, the Court expounded upon the "two-step analysis" which must be conducted under 38 U.S.C.A. § 5108. First, it must be determined whether the evidence presented or secured since the prior final disallowance of the claim is new and material when "the credibility of the [new] evidence" is presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). Second, if the evidence is new and material the Board must reopen the claim and review all of the evidence of record to determine the outcome of the claim on the merits. The first step involves three questions: (1) Is the newly presented evidence "new" (not of record at the time of the last final disallowance of the claim and not merely cumulative of other evidence that was then of record)? (2) Is it "probative" of the issue at hand? (3) If it is new and probative, then, in light of all the evidence of record, is there a reasonable possibility that the outcome of the claim on the merits would be changed? However, in Hodge v. West, 155 F.3d 1356 (Fed. Cir. 1998), the Federal Circuit held that the United States Court of Appeals for Veterans Claims (Court) impermissibly ignored the definition of "material evidence" adopted by the Department in 38 C.F.R. § 3.156 and without sufficient justification or explanation, rewrote the regulation to require, with respect to newly submitted evidence, that "there must be a reasonable possibility that new evidence, when viewed in the context of all the evidence, both old and new, would change the outcome. See, Colvin v. Derwinski, 1 Vet. App. 171 (1991). The Federal Circuit held invalid the Colvin test for materiality as it was more restrictive than 38 C.F.R. § 3.156(a). New and material evidence means evidence not previously submitted to agency decision makers which bears directly and substantially upon the specific matter under consideration, which is neither cumulative nor redundant, and which by itself or in connection with evidence previously assembled is so significant that it must be considered in order to fairly decide the merits of the claim. 38 C.F.R. § 3.156(a). In Elkins v. West, 12 Vet. App. 209 (1999), the Court essentially held that the recent decision of the Federal Circuit in Hodge required the replacement of the two- step test in Manio with a three step test. Under the Elkins test, the Secretary must first determine whether new and material evidence has been presented under 38 C.F.R. § 3.156(a); second, if new and material evidence has been presented, immediately upon reopening, the Secretary must determine whether, based upon all the evidence and presuming its credibility, the claim as reopened is well grounded pursuant to 38 U.S.C. § 5107(a); and third, if the claim is well grounded, the Secretary may evaluate the merits after ensuring the duty to assist under 38 U.S.C. § 5107(b) has been fulfilled. Service connection may be established for a disability resulting from personal injury suffered or disease contracted in the line of duty or for aggravation of preexisting injury suffered or disease contracted in the line of duty. 38 U.S.C.A. §§ 1110, 1131 (West 1991). Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (1999). For the showing of chronic disease in service, there are required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Continuity of symptomatology is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (1999). If the disability is arthritis, organic disease of the nervous system, psychosis, gastric or duodenal ulcer, and cerebrovascular disease including brain hemorrhage and manifested to a compensable degree within one year following separation from active duty, service connection may be granted. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 1991 & Supp. 1999); 38 C.F.R. §§ 3.307, 3.309 (1999). Adjudication of a well grounded claim of service connection for PTSD requires the evaluation of the evidence in light of the places, types, and circumstances of service, as evidenced by service records, the official history of each organization in which the veteran served, the veteran's military records, and all pertinent medical and lay evidence. 38 U.S.C.A. § 1154(a). Under the provisions for direct service connection for PTSD, 60 Fed. Reg. 32807-32808 (1999) (codified at 38 C.F.R. § 3.304(f), service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125 (diagnosis of mental disorder); a link, established by medical evidence, between current symptoms and an in service stressor; and credible supporting evidence that the claimed in service stressor occurred. If the evidence establishes that the veteran engaged in combat with the enemy and the claimed stressor is related to this combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran's service, his lay testimony alone may establish the occurrence of the claimed in service stressor. Moreau v. Brown, 9 Vet. App. 389, 394 (1996). The VA regulation was changed in June 1999 to conform to the Court's determination in Cohen v. Brown, 10 Vet. App. 128 (1997). As the Cohen determination was in effect when the RO reviewed this case, the Board finds no prejudice to the veteran in proceeding with the case at this time. Bernard v. Brown, 4 Vet. App. 384 (1993). In determining whether an injury or disease was incurred in or aggravated in service, the evidence in support of the claim is evaluated based on the places, types and circumstances of service as shown by the service records, the official history of each organization in which the veteran served, the veteran's medical records, and all pertinent medical and lay evidence. 38 U.S.C.A. § 1154(b) (West 1991); 38 C.F.R. §§ 3.303(a), 3.304 (1999). Even where there is a lack of official records to corroborate that an injury or disease was incurred or aggravated during service (including a period of combat), VA is required to accept as sufficient proof of service connection satisfactory lay or other evidence that an injury or disease was incurred or aggravated during such period of service, if the evidence is consistent with the circumstances, conditions, or hardships of such service. 38 U.S.C.A. § 1154(b) (West 1991); 38 C.F.R. §§ 3.303(a), 3.304 (1998); Collette v. Brown, 82nd F.3d, 389 (Fed. Cir. 1996). The threshold question that must be resolved with regard to each claim is whether the claimant has presented evidence that the claim is well grounded; that is, that the claim is plausible. If he/she has not, his/her appeal fails as to that claim, and VA is under no duty to assist him/her in any further development of that claim. 38 U.S.C.A. § 5107(a) (West 1991); Murphy v. Derwinski, 1 Vet. App. 78 (1990). Case law provides that, although a claim need not be conclusive to be well grounded, it must be accompanied by evidence. A claimant must submit some supporting evidence that justifies a belief by a fair and impartial individual that the claim is plausible. Dixon v. Derwinski, 3 Vet. App. 261, 262 (1992); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992). In order for service connection to be warranted, there must be evidence of present disability which is attributable to a disease or injury incurred in or aggravated by service. Brammer v. Derwinski, 2 Vet. App. 23 (1992); Rabideau v. Derwinski, 2 Vet. App 141, 143 (1992). In determining whether a claim is well grounded, the claimant's evidentiary assertions are presumed true unless inherently incredible or when the fact asserted is beyond the competence of the person making the assertion. King v. Brown, 5 Vet. App. 19, 21 (1993). The Court has found that while a disorder need not have been present or diagnosed in service, there must be a nexus between a current disorder and military service, even if first diagnosed after service on the basis of all of the evidence of record. Godfrey v. Derwinski, 2 Vet. App. 352, 356 (1992). In order for a claim to be well grounded, there must be competent evidence of a current disability (a medical diagnosis), of an incurrence or aggravation of a disease or injury in service (lay or medical evidence), and a nexus between the in-service injury or disease and the current disability (medical evidence). Caluza v. Brown, 7 Vet. App. 498 (1995). A disability is impairment of earning capacity. See Allen v. Brown, 7 Vet. App. 439 (1995). The claim may also be found to be well grounded if there is competent evidence of incurrence or aggravation of a disease or injury in service and of continuing symptomatology since service, and medical evidence of a nexus between the current disability and the reported symptomatology. Savage v. Gober, 10 Vet. App. 488 (1997). It was held in Voerth v. West, 13 Vet. App. 117, 120 (1999) that the holding in Savage does not eliminate the requirement of medical nexus evidence when a claimant alleges continuity of symptomatology. Where the determinative issue involves the question of a medical diagnosis or causation, only individuals possessing specialized training and knowledge are competent to render a medical opinion. Espiritu v. Derwinski, 2 Vet. App. 192 (1992). A veteran who had active service in the Republic of Vietnam during the Vietnam Era shall be presumed to have been exposed during such service to a herbicide agent containing dioxin, including Agent Orange, unless there is affirmative evidence to establish that the veteran was not so exposed during that service. 38 C.F.R. § 3.307(a)(6). Regulations provide a list of diseases that are considered to be associated with herbicide exposure for purposes of presumptive service connection. The specified diseases that are considered to be associated with herbicide exposure and which may be presumptively service connected even though there is no record of such disease during service are: chloracne or other acneiform disease consistent with chloracne, Hodgkin's disease, multiple myeloma, non-Hodgkin's lymphoma, acute and subacute peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers of the lung, bronchus, larynx or trachea and certain specified soft tissue sarcomas (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). 38 C.F.R. §§ 3.307(a)(6), 3.309(e) (1999). The Secretary has also determined that there is no positive association between exposure to herbicides and any other condition for which he has not specifically determined a presumption of service connection is warranted. See Diseases Not Associated With Exposure to Certain Herbicide Agents, 59 Fed. Reg. 341-46 (Jan. 4, 1994). Notwithstanding the foregoing, the U.S. Court of Appeals for the Federal Circuit (Federal Circuit) has essentially determined that the Veteran's Dioxin and Radiation Exposure Compensation Standards (Radiation Compensation) Act, Pub. L. No. 98-542, § 5, 98 Stat. 2725, 2727-29 (1984) does not preclude a veteran from establishing service connection with proof of actual direct causation. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). Neither the statutory nor the regulatory presumption of exposure to Agent Orange will satisfy the incurrence element of the Caluza well-grounded claim test where the veteran has not developed a condition enumerated at either 38 U.S.C.A. § 1116(a) or 38 C.F.R. § 3.309(e). McCartt v. West, 12 Vet. App. 164 (1999). Disability which is proximately due to, the result of, or aggravated by a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a) (1999); Allen v. Brown, 7 Vet. App. 439 (1995). A claim for secondary service connection for a diagnosis clearly separate from the service-connected disorder, the veteran must present evidence of a medical nature to support the alleged causal relationship between the service-connected disorder and the disorder for which service connection is sought, in order for the claim to be well grounded. See Jones (Wayne L.) v. Brown, 7 Vet. App. 134 (1994). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When, after consideration of all of the evidence and material of record in an appropriate case before VA, there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b) (West 1991); 38 C.F.R. §§ 3.102, 4.3 (1999). Analysis Whether new and material evidence has been submitted to reopen a claim for service connection for an anxiety neurosis. When a claim is finally denied by the RO, the claim may not thereafter be reopened and allowed, unless new and material evidence has been presented. 38 U.S.C.A. § 7105; 38 C.F.R. § 3.104. When an appellant seeks to reopen a finally denied claim, the Board must review all of the evidence submitted since that action to determine whether the claim should be reopened and readjudicated on a de novo basis. Glynn v. Brown, 6 Vet. App. 523, 529 (1994). In order to reopen a finally denied claim there must be new and material evidence presented since the claim was last finally disallowed on any basis, not only since the claim was last denied on the merits. Evans v. Brown, 9 Vet. App. 273 (1996). Under Evans, evidence is new if not only previously of record and is not merely cumulative of evidence previously of record. In April 1977 the RO denied entitlement to service connection for a psychiatric disorder finding that the psychiatric symptoms in service were not more than transient in nature and there was no competent medical nexus between the psychiatric findings noted on the postservice VA examination in January 1977, and the acute situational anxiety noted in service. Following a comprehensive review of the record including the added evidence since April 1977, the Board notes that the additional evidence is totally absent any competent medical opinion and/or authority linking anxiety neurosis with any incident of active duty. With respect to the veteran's recorded history of a psychiatric disorder in active service, the Board notes that medical records with bare transcriptions of lay history of pertinent disability or evidence which is simply information recorded by a medical examiner, unenhanced by any additional medical comment by the examiner, are not transformed into "competent medical evidence" merely because the transcriber happens to be a medical professional. LeShore v. Brown, 8 Vet. App. 406 (1995). Such evidence cannot enjoy the presumption of truthfulness recorded by Justus v. Principi, 3 Vet. App. 510, 512 (1992) as to determination of whether there is new and material evidence for purposes of reopening a claim. Id. The Board notes that the lay statements submitted in support of the veteran's claim appear to relate to the veteran's claim of service connection for PTSD which is addressed below. With respect to the current issue such lay statements submitted without supporting competent medical evidence do not constitute new and material evidence. Additionally, the veteran's current arguments without supporting competent medical evidence do not constitute new and material evidence. Moreover, the copies of cumulative service medical records were previously considered by the RO, and are neither new nor material. For the foregoing reasons the Board notes that the added evidence does not bear directly and substantially on the specific matters under consideration and is cumulative or redundant, and by itself or in combination with the other evidence, is not so significant that it must be considered in order to fairly decide the merits of the veteran's claims. Accordingly, the veteran is not prejudiced by the Board's decision in this case without first referring it to the RO for initial consideration of the recent holding in Hodge as his claim would not be reopened under any standard. Bernard v. Brown, 4 Vet. App. 384, 392-94 (1993). As the Board noted earlier, the Court announced a three step test with respect to new and material cases. Under the Elkins test, VA must first determine whether the veteran has submitted new and material evidence under 38 C.F.R. § 3.156 to reopen the claim, and if so, VA must determine whether the claim is well grounded based on a review of all the evidence of record and lastly, if the claim is well grounded, VA must proceed to evaluate the merits of the claim, but only after ensuring that the duty to assist has been fulfilled. Winters v. West, 12 Vet. App. 203 (1999); Elkins v. West, 12 Vet. App. 209 (1999). Accordingly, in view of the fact that new and material evidence has not been submitted to reopen the veteran's claim of entitlement to service connection for anxiety neurosis, the first element has not been met. No further analysis of the application to reopen the claim is appropriate. Butler v. Brown, 9 Vet. App. at 171 (1996). Entitlement to service connection for chronic lung disease including as secondary to AO exposure. Following a comprehensive review of the record, the Board notes that the respiratory symptoms in the veteran's remote service including bronchitis were not shown to have been more than transient in nature and to have resolved with no residual disability. There was no evidence of chronic lung disease noted on an initial postservice VA examination in January 1977. The respiratory symptoms associated with COPD and chronic bronchitis as first noted many years post service are without competent medical evidence of a nexus with the acute respiratory symptoms in active service. Moreover, the veteran has not presented competent medical evidence of a nexus between the chronic lung disease first noted many years post service with any exposure to AO during active duty. The Board points out that none of the veteran's lung disorders are mentioned in the AO regulations. The respiratory symptoms in service were not shown to be part of an underlying chronic pulmonary disease process and no chronic pulmonary disorder was shown until years post service. There is no competent medical evidence of chronic lung disease which is linked to active duty including exposure to AO. See Caluza v. Brown, 7 Vet. App. 498 (1995); Savage v. Gober, 10 Vet. App. 488 (1997); Voerth v. West, 13 Vet. App. 117, 120 (1999). The veteran presently maintains that he has chronic lung disease which began in service or developed as a consequence of exposure to AO. The Board notes the Court has held that while a lay person is competent to testify as to facts within his own observation and recollection, such as visible symptoms, a lay party is not competent to provide probative evidence as to matters requiring expertise derived from specialized medical education, training or experience, such as matters relating to a diagnosis or medical causation. Espiritu v. Derwinski, 2 Vet. App. 492 (1992). As competent medical evidence of chronic lung disease with a nexus to the veteran's recognized active service on any basis has not been presented, the veteran's claim is not well grounded. If the claim is not well grounded, the Board does not have jurisdiction to adjudicate the claim. Boeck v. Brown, 6 Vet. App. 14, 17 (1993). Accordingly, the claim of entitlement to service connection for chronic lung disease including as secondary to exposure to AO is denied. Edenfield v. Brown, 6 Vet. App. 432 (1994). Although the Board considered and denied the veteran's appeal on a ground different from that of the RO, which denied the claim on the merits, he has not been prejudiced by the decision. This is because in assuming that the claim was well grounded, the RO accorded the veteran greater consideration than his claim in fact warranted under the circumstances. Bernard v. Brown, 4 Vet. App. 384 (1993). In light of the implausibility of the veteran's claim and the failure to meet his initial burden in the adjudication process, the Board concludes that he has not been prejudiced by the decision to deny his appeal for service connection for chronic lung disease including as secondary to exposure to AO. The Board further finds that the RO has advised the veteran of the evidence necessary to establish a well grounded claim, and the veteran has not indicated the existence of any post service medical evidence that has not already been requested and/or obtained that would well ground his claim. 38 U.S.C.A. § 5103(a) (West 1991); McKnight v. Gober, 131 F.3d 1483 (Fed. Cir. 1997); Epps v. Brown, 9 Vet. App. 341, 344 (1996), aff'd sub nom. Epps v. Gober, 126 F. 3d 1464 (Fed. Cir. 1997). Service connection for chronic fatigue syndrome, vertebrobasiliar insufficiency, brainstem stroke, dry eyes syndrome, hiatal hernia, chronic gastritis esophagitis and hypothyroidism as secondary to service-connected removal of the right testicle with testicular silicone implant. The Board notes that service-connection has been granted for removal of the right testicle with testicular implant. The contention presented on appeal is that the multiple disorders at issue are secondary to this service-connected genitourinary disability. None of the disorders are shown in the service medical records and the veteran does not contend otherwise. The Board recognizes that the voluminous medical records on file are without competent medical evidence of an etiologic link or nexus between the disorder at issue and the service- connected removal of the right testicle with testicular silicone implant. The veteran presently maintains that he developed the disorders at issue as secondary to his service-connected genitourinary disability of the right testicle with testicular silicone implant. The Board notes that the Court has held that while a lay person is competent to testify as to facts within his own observation and recollection, such as visible symptoms, a lay party is not competent to provide probative evidence as to matters requiring expertise derived from specialized medical education, training or experience, such as matters relating to a diagnosis or medical causation. Espiritu v. Derwinski, 2 Vet. App. 492 (1992). As there is no competent medical evidence of record linking the disorders at issue with the veteran's service-connected genitourinary disability, his claims are not well grounded. If the claim is not well grounded, the Board does not have jurisdiction to adjudicate the claim. Boeck v. Brown, 6 Vet. App. 14, 17 (1993). Accordingly, the claim of entitlement to service connection for the multiple disorders at issue as secondary to the service-connected genitourinary disability must be denied. Edenfield v. Brown, 6 Vet. App. 432 (1994). Although the Board considered and denied the veteran's appeal on a ground different from that of the RO, which denied the claim on the merits, he has not been prejudiced by the decision. This is because in assuming that the claim was well grounded, the RO accorded the veteran greater consideration than his claim in fact warranted under the circumstances. Bernard v. Brown, 4 Vet. App. 384 (1993). In light of the implausibility of the veteran's claim and the failure to meet his initial burden in the adjudication process, the Board concludes that he has not been prejudiced by the decision to deny his appeal for service connection for chronic fatigue syndrome, vertebrobasiliar insufficiency, brainstem stroke, dry eye syndrome, hiatal hernia, chronic gastritis, esophagitis and hypothyroidism as secondary to service-connected removal of the right testicle with testicular silicone implant. The Board further finds that the RO has advised the veteran of the evidence necessary to establish a well grounded claim, and the veteran has not indicated the existence of any post service medical evidence that has not already been requested and/or obtained that would well ground his claim. 38 U.S.C.A. § 5103(a) (West 1991); McKnight v. Gober, 131 F.3d 1483 (Fed. Cir. 1997); Epps v. Brown, 9 Vet. App. 341, 344 (1996), aff'd sub nom. Epps v. Gober, 126 F. 3d 1464 (Fed. Cir. 1997). Service connection for PTSD. The record shows that the veteran served in a combat area in Vietnam and there are private medical records reflecting a diagnosis of PTSD based upon alleged stressors inservice. While the 1994 VA psychiatric examination failed to show a diagnosis of PTSD, the Board notes that subsequently dated private medical records reflect a diagnosis of PTSD based upon reported stressors in service. The Board notes that the criteria for PTSD subsequently changed since the 1994 VA psychiatric examination. For the sole purpose of well grounding the claim, the Board notes that competent medical professionals have diagnosed the veteran with PTSD based upon stressors which have been related to service. The Board notes that there is need for verification of stressors and further additional special VA psychiatric examination, if needed, to comply with the duty to assist the veteran as mandated by 38 U.S.C.A. § 5107(a). These matters are addressed in the remand portion of the decision. Entitlement to service connection for hypotesticularosteopenia or loss of bone mass, mid and upper back disabilities, human adjuvant disease, and peripheral neuropathy as secondary to service- connected removal of the right testicle with testicular silicone implant, and for ulcers as secondary to medications prescribed for service-connected disability. At the outset, the Board notes that in determining whether a veteran's claim is well grounded, supporting evidence, both in the form of records in control of the government and the veteran's evidentiary assertions are presumed true except evidentiary assertions that ere inherently incredible or when the fact asserted is beyond the competence of the person making the assertion. Neither exception is found in this case. A comprehensive review of the voluminous medical evidence clearly shows that the record contains competent medical evidence suggestive of a nexus between the veteran's hypotesticularosteopenia or loss of bone mass, human adjuvant disease, and peripheral neuropathy as secondary to service- connected removal of the right testicle with testicular silicone implant. Moreover there is competent medical evidence suggesting the presence of an ongoing degenerative disability of the back related to either the initial onset of the veteran's service- connected low back syndrome or as secondary to loss of spinal bone mass associated with testosterone imbalance due to the service-connected removal of the right testicle. Additionally, the Board may not overlook the fact that competent medical evidence of record suggests the onset of a gastric ulcer due to treatment of a back disorder encompassing the service-connected low back syndrome. As the veteran has submitted competent medical evidence showing he has the multiple disorders at issue, and competent medical authority suggesting a link between those disorders and his service-connected disabilities to include medication therefore, the Board finds that the record is favorable solely for the purpose of well grounding his multiple claims. ORDER The veteran not having submitted new and material evidence to reopen a claim of entitlement to service connection for anxiety neurosis, the claim appeal is denied. The veteran not having submitted a well-grounded claim of entitlement to service connection for chronic lung disease including as secondary to AO exposure, the appeal is denied. The veteran not having submitted well grounded claims of entitlement to service connection for chronic fatigue syndrome, vertebrobasiliar insufficiency, brainstem stroke, dry eyes syndrome, hiatal hernia, chronic gastritis, esophagitis and hypothyroidism as secondary to service- connected removal of the right testicle with testicular silicone implant, the appeal is denied. The veteran having submitted well-grounded claims of entitlement to service connection for hypotesticularosteopenia or loss of bone mass, a chronic acquired mid and upper back disorder, human adjuvant disease, and peripheral neuropathy as secondary to service-connected removal of the right testicle with testicular silicone implant, the appeal is granted to this extent. The veteran having submitted a well grounded claim of entitlement to service connection for ulcers as secondary to medications prescribed for service-connected disability, the appeal is granted to this extent. The veteran having submitted a well ground claim of entitlement to service connection for PTSD, the appeal is granted to this extent. REMAND This claim must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board or by the Court for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 1999) (Historical and Statutory Notes). In addition, VBA's Adjudication Procedure Manual, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44-8.45 and 38.02-38.03. The Board finds that the veteran's claim of entitlement to an increased evaluation for low back syndrome is well grounded within the meaning of 38 U.S.C.A. § 5107(a); and Proscelle v. Derwinski, 2 Vet. App. 629 (1992). As the Board noted earlier, additional development of the record is needed in order for the Board address the remaining issues for appellate review. Specifically, the RO should afford the veteran comprehensive examinations by appropriate specialists in order to determine the nature, extent of severity and etiology of the remaining disabilities at issue. Also, it appears to the Board that the regulatory amendments to 38 C.F.R. 4.125 & 4.126 (1999), and the incorporation of DSM-IV, will have a potentially liberalizing effect in adjudicating claims for service connection for PTSD, particularly when an individual is not a combat veteran or who is not shown to have "engaged in combat with the enemy." Where the law or regulations change while a case is pending, the version more favorable to the claimant applies, absent congressional intent to the contrary. Karnas v. Derwinski, 1 Vet. App. 308, 312-313 (1991). The Board believes that further development is necessary as the RO is not shown to have considered these changes. Moreover, the Board notes the Court has held that diagnostic codes predicated on limitation of motion do not prohibit consideration of a higher rating based on functional loss of use do to pain on use or due to flare-ups under 38 C.F.R. §§ 4.40, 4.45, 4.59 (1999), and that examinations upon which the rating decisions are based must adequately portray the extent of functional loss due to pain on use or due to flare-ups. DeLuca v. Brown, 8 Vet. App. 202, 206 (1995); Johnson v. Brown, 9 Vet. App. 7 (1997). The Board notes that the veteran has not had an adequate orthopedic examination in order to determine the extent and degree of severity of limitation of motion of the service- connected low back syndrome or fully address functional loss due to pain on use or flare-ups. Therefore, pursuant to VA's duty to assist the veteran in the development of facts pertinent to his claims under 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.103(a) (1999), and to ensure full compliance with due process requirements, the Board is deferring adjudication of the remaining issues prepared and certified for appellate review pending a remand of the case to the RO for further development as follows: 1. The veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded to the RO. Kutscherousky v. West, 12 Vet. App. 369 (1999). In this regard, the RO should contact the veteran and request that he identify the names, addresses, and approximate dates of treatment for medical care providers, VA and non-VA, inpatient and outpatient, who may possess aditional records of his treatment for the disabilities at issue. After obtaining any necessary authorization or medical releases, the RO should request and associate with the claims file legible copies of the veteran's complete treatment reports from all sources identified whose records have not previously been secured. Regardless of the veteran's response, the RO should secure all outstanding VA treatment reports. 2. The RO should request from the veteran a comprehensive statement containing as much detail as possible regarding the stressors to which he alleged he was exposed in active service including dates, assignments and the names of any friends he saw killed. The veteran is advised that this evidence is vitally necessary in order to obtain supportive evidence of the stressful events and that he must be as specific as possible, because without such detail, an adequate search for verifying information cannot be conducted. 3. With the additional information obtained, the RO should review the file and prepare a summary of all the claimed stressors. The summary, and all associated documents to include a copy of the veteran's record of service (DD-214), should be sent to the United States Armed Services Center For Research Of Unit Records (USASCRUR) formerly (Army and Joint Services Environmental Support Group (ESG)), 7798 Cissna Road, Suite 101, Springfield, Virginia 22150-3197. They should be requested to provide any information which might corroborate the veteran's alleged stressors. 4. Following the above, the RO must make a specific determination, based upon the complete record, with respect to whether the veteran was exposed to a stressor or stressors in service, and if so, the nature of the specific stressors. In any event, the RO must specifically render a finding as to whether the appellant "engaged in combat with the enemy." If the RO determines that the record establishes the existence of a stressor or stressors, the RO must specify what stressor or stressors in service it has determined is or are established by the record. In reaching this determination, the RO should address any credibility questions raised by the record. 5. If and only if the RO determines that the record establishes the existence of a stressor or stressors, the RO should arrange for the veteran to be accorded an examination by a board of two VA psychiatrists who have not previously examined him to determine the nature and etiology of any psychiatric disorder(s) which may be present. The RO is to stress to the veteran the seriousness of the scheduled examination, the importance of a definite diagnosis, and the obligation of reporting to the examination at the proper place and time. The claims file and a separate copy of this remand must be made available to and reviewed by each examiner prior and pursuant to conduction and completion of the examinations and the examination reports must be annotated by the examiners in this regard. The RO must specify for the examiners the stressor or stressors that it has determined are established by the record and the examiners must be instructed that only those events may be considered for the purpose of determining whether exposure to a stressor in service has resulted in current psychiatric symptoms and in determining whether the nature of the alleged event is of the quality required to produce PTSD. The examination report should reflect review of the pertinent material in the claims folder. The examiners should integrate the previous psychiatric findings and diagnoses with the current findings to obtain an accurate picture of the nature of the veteran's psychiatric status. If a diagnosis of PTSD is deemed appropriate, the examiners should specify: (1) whether each alleged stressor found to be established by the record by the RO was sufficient to produce PTSD; (2) whether the remaining diagnostic criteria to support the diagnosis of PTSD have been satisfied; and (3) whether there is a link between the current symptomatology and one or more of the in-service stressors found to be established by the record by the RO and found to be sufficient to produce PTSD by the examiners. Any necessary special studies including PTSD sub scales should be conducted. The examiners must be requested to assign a Global Assessment of Functioning Score (GAF) consistent with the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, and explain what the assigned score means. Any opinions expressed by the examiners must be accompanied by a complete rationale. 6. The RO should schedule the veteran for an examination by an appropriate specialist(s) for the purpose of ascertaining the nature, extent of severity, and etiology of hypotesticularosteopenia or loss of bone mass, a chronic acquired mid and upper back disorder, and human adjuvant disease with peripheral neuropathy, to include whether it is least as likely as not that any present cited disability is(are) causally related to service-connected removal of the right testicle with testicular silicone implant. Any indicated special studies or additional special examinations should be undertaken. The claims file and a separate copy of this remand must be made available to the and reviewed by the examiner(s) prior and pursuant to conduction and completion of the examination(s) and the examination report(s) must be annotated by the examiner(s) in this regard. If the examiner(s) determine that there is in fact a direct causal relationship between the disorders at issue and the service-connected genitourinary disability, after a complete rationale has been provided, no further analysis is required. If the examiner(s) discount any direct causal relationship, the examiner(s) must be requested to express an opinion as to whether the service- connected removal of the right testicle with testicular silicone implant has aggravated the hypotesticularosteopenia or loss of bone mass, a chronic acquired mid and upper back disorder, and human adjuvant disease with peripheral neuropathy. If such aggravation is determined to be present. The examiner(s) must address the following medical issues: (1) The baseline manifestations which are due to the nonservice-connected disorders at issue; (2( The increased manifestations which, in the opinion of the examiner(s), are due to the service- connected genitourinary disability; (3) The medical considerations supporting an opinion that increased manifestations of the nonservice-connected disabilities at issue are proximately due to the service- connected genitourinary disability. Any opinions expressed by the examiner(s) must be accompanied by a complete rationale. 7. The RO should arrange for a VA orthopedic examination by an orthopedic surgeon or other appropriate specialist for the purpose of ascertaining the nature, extent of severity service- connected low back syndrome. The claims file, copies of the criteria under 38 C.F.R. §§ 4.40, 4.45, 4.59, and a separate copy of this remand must be made available to and reviewed by the examiner prior and pursuant to conduction and completion of the examination and the examination report must be annotated in this regard. Any further indicated special studies should be conducted. The examiner should then determine the extent and degree of severity of the service-connected low back syndrome manifested by limitation of motion as opposed to any impairment associated with intercurrent and unrelated back disorder, if distinguishable. The examiner should be requested to report range of motion and degrees of arc in all planes with an explanation as to what is normal range of motion of the service-connected low back syndrome. All findings and diagnoses should be reported in detail. The examiner must identify all orthopedic manifestations of service-connected low back syndrome as opposed to intercurrent back disability, if distinguishable. The examiner should be requested to specifically comment upon the extent, if any, to which pain, supported by adequate pathology and evidenced by visible behavior of the veteran, results in functional loss. The examiner should carefully elicit all of the veteran's subjective complaints and then offer an opinion as to whether there is adequate pathology present to support the level of each of the veteran's subjective complaints. It is requested that the examiner also provide explicit responses to the following questions: Does the service-connected low back syndrome cause weakened movement, excess fatigability, and incoordination, and if so, the examiner should comment on the severity of these manifestations on the ability of the veteran to perform average employment in the civil occupation. The examiner is requested to specifically comment on whether pain is visibly manifested on movement of the right shoulder or left wrist and, if so, to what extent, and the presence and degree of, or absence of, any objective manifestation that would demonstrate disuse or functional impairment due to pain attributable to the service- connected disability. If any symptoms and manifestations associated with coexisting intercurrent and unrelated back disability found on examination may not be distinguishable from service- connected low back syndrome, the examiner should so state such opinion for the record. Otherwise, the examiner should distinguish the symptoms related to service-connected low disability from symptoms related to coexisting back disorders. The examiner should also comment on whether there are objective indications of the extent of the veteran's pain, such as medication he is taking or the type of any treatment he is receiving. The examiner should address the criteria in 38 C.F.R. §§ 4.40, 4.45, 4.59 in his/her descriptive evaluation of the severity of the service-connected low back syndrome. Any opinions expressed by the examiner as to the severity of the service-connected low back syndrome must be accompanied by a complete rationale. 8. The RO should afford the veteran an examination by a specialist in gastroenterology in order to determine the nature, extent of severity, and etiology of any present peptic ulcer disease, and for an opinion as to whether it is secondary to medication for treatment of the service-connected low back syndrome and/or left metatarsal fracture. Any indicated special studies should be undertaken. The claims file and a separate copy of this remand must be made available to and reviewed by the examiner prior and pursuant to conduction and completion of the examination and the examination reports must be annotated by the examiner in this regard. Any opinions expressed by the examiner must be accompanied by a complete rationale. 9. Thereafter, the RO should review the claims file to ensure that all of the foregoing requested development has been completed. In particular, the RO should review the requested examination reports and required opinions to ensure that they are responsive to and in complete compliance with the directives of this remand and if they are not, the RO should implement corrective procedures. Stegall v. West, 11 Vet. App. 268 (1998). 10. After undertaking any development deemed appropriate in addition to that specified above, the RO should re- adjudicate the issues of entitlement to service-connection for hypotesticularosteopenia or loss of bone mass, a chronic acquired mid and upper back disorder, human adjuvant disease, and peripheral neuropathy as secondary to service-connected removal of the right testicle with testicular silicone implant, service connection for ulcers as secondary to medications prescribed for service-connected disability, and service connection for PTSD. The RO should consider the provisions of 38 U.S.C.A. 1154 (b); Collette v. Brown, 82 F.3d 389 (1996); Zarycki v. Brown, 6 Vet. App. 91 (1993); Cohen v. Brown, 10 Vet. App. 128 (1997) Gaines v. West, 11 Vet. App. 353 (1998) and Allen v. Brown, where applicable. Thereafter, the RO should readjudicate the issue of entitlement to an increased evaluation for low back syndrome in light of the Court's holding in DeLuca and the provisions of 38 C.F.R. §§ 4.40, 4.45 and 4.59, and document its consideration of the applicability of 38 C.F.R. § 3.321(b)(1) (1999). If the benefits sought on appeal are not granted to the veteran's satisfaction, the RO should issue a supplemental statement of the case. A reasonable period of time for a response should be afforded. Thereafter, the case should be returned to the Board for final appellate review, if otherwise in order. By this remand, the Board intimates no opinion as to any final outcome warranted. No action is required of the veteran until he is notified by the RO. RONALD R. BOSCH Member, Board of Veterans' Appeals