Citation Nr: 0002327 Decision Date: 01/28/00 Archive Date: 02/02/00 DOCKET NO. 94-14 048 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for post-traumatic stress disorder. 2. Entitlement to service connection for joint problems, to include service connection secondary to service-connected residuals of a right nephrectomy. 3. Entitlement to service connection for hypertension, to include service connection secondary to service-connected residuals of a right nephrectomy. 4. Entitlement to service connection for gout, to include service connection secondary to service-connected residuals of a right nephrectomy. 5. Entitlement to service connection for poor vision, to include service connection secondary to service-connected residuals of a right nephrectomy. 6. Entitlement to service connection for heart problems, to include service connection secondary to service-connected residuals of a right nephrectomy. 7. Entitlement to an increased evaluation for post operative residuals of a right nephrectomy for renal cell carcinoma, currently evaluated as 30 percent disabling. 8. Entitlement to an increased evaluation for an incisional hernia, currently evaluated as 20 percent disabling. 9. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities. REPRESENTATION Appellant represented by: Alabama Department of Veterans Affairs ATTORNEY FOR THE BOARD L. Jennifer Lane, Counsel INTRODUCTION The veteran had active service from May 1965 to May 1967 and August 1967 to July 1971. The appeal arises from a rating decision dated in June 1993 in which the Regional Office (RO) denied increased evaluations for post operative residuals of a right nephrectomy for renal cell carcinoma and incisional hernia and a total disability rating based on individual unemployability. The veteran subsequently perfected an appeal of that decision; and the Board of Veterans' Appeals (Board) remanded the case in January 1996 and April 1999. In a June 1999 rating decision, the RO denied service connection for post-traumatic stress disorder and joint problems, hypertension, gout, poor vision and heart problems secondary to the veteran's service-connected post operative residuals of a right nephrectomy. The veteran also appealed that decision. FINDINGS OF FACT 1. No competent medical evidence is of record that would establish that the veteran currently has a disability of the joints, hypertension, gout, a visual disability or heart disability which is causally related to service or to any incident or event therein, or which shows that such a disability is etiologically related to his service-connected post operative residuals of a right nephrectomy for renal cell carcinoma or has been aggravated by that service- connected disability. 2. Competent evidence has been received that shows that the veteran has post-traumatic stress disorder as a result of his service in Vietnam. 3. All relevant information necessary for an equitable disposition of the appeal of the claims for entitlement to increased evaluations for post operative residuals of a right nephrectomy for renal cell carcinoma and incisional hernia has been developed. 4. Prior to February 1994, the veteran's left kidney was functioning normally. 5. Since February 1994, the veteran has experienced urinary frequency about every 30 minutes and wakes up at least eight times a night to go to the bathroom. 6. The veteran's incisional hernia is moderate to large, easily reducible and does not require a belt. CONCLUSIONS OF LAW 1. The veteran's claims for entitlement to service connection for joint problems, hypertension, gout, poor vision and heart problems secondary to the veteran's service- connected post operative residuals of a right nephrectomy are not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 2. The claim for entitlement to service connection for post- traumatic stress disorder is well-grounded. 38 U.S.C.A. §§ 1110, 1154(b), 5107 (West 1991); 38 C.F.R. §§ 3.303, 3.304 (1999). 3. The criteria, in effect prior to February 1994, for an evaluation in excess of 30 percent for post operative residuals of a right nephrectomy for renal cell carcinoma were not met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.2, 4.7, 4.10, Part 4, Diagnostic Codes 7500, 7528 (1993). 4. The criteria for a 40 percent evaluation, effective since February 1994, for post operative residuals of a right nephrectomy for renal cell carcinoma are met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.2, 4.7, 4.10, 4.115a, Part 4, Diagnostic Codes 7500, 7528 (1999). 5. The criteria for an evaluation in excess of 20 percent for incisional hernia are not met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 4.2, 4.7, 4.10, Part 4, Diagnostic Code 7339 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Service Connection Initially, the Board notes that entitlement to service connection for a particular disability requires evidence of the existence of a current disability and evidence that the disability resulted from a disease or injury incurred in or aggravated during service. 38 U.S.C.A. § 1110. Additionally, where a veteran served continuously for ninety (90) days or more during a period of war or during peacetime service after December 31, 1946, and arthritis, hypertension or cardiovascular disease becomes manifest to a degree of 10 percent within one year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 1991); 38 C.F.R. §§ 3.307, 3.309 (1999). Service connection may also 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). Additionally, secondary service connection for a disability is warranted when that disability is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a) (1999). Secondary service connection is also warranted for a disability when that disability is aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). The Board also notes that the veteran must submit evidence that a claim for entitlement to service connection benefits is well-grounded. 38 U.S.C.A. § 5107(a). A well-grounded claim is one which is plausible; that is meritorious on its own and capable of substantiation. Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). Unlike civil actions, the Department of Veterans Affairs (VA) benefit system requires more than just an allegation. The veteran must submit supporting evidence that is sufficient to justify a belief by a fair and impartial individual that the claim is plausible. Tripak v. Derwinski, 2 Vet. App. 609, 611 (1992); Grivois v. Brown, 6 Vet. App. 136, 139 (1994). The three elements of a well grounded claim for service connection benefits are: (1) evidence of a current disability as provided by a medical diagnosis; (2) evidence of incurrence or aggravation of a disease or injury in service as provided by either lay or medical evidence, as the situation dictates; and, (3) a nexus, or link, between the inservice disease or injury and the current disability as provided by competent medical evidence. See Caluza v. Brown, 7 Vet. App. 498, 506 (1995); 38 C.F.R. § 3.303. This means that there must be evidence of disease or injury during service, a current disability, and a link between the two; and, with regard to a claim for service connection benefits on a secondary basis, there must be evidence of a current disability and evidence linking that disability to a service- connected disability. Further, the evidence must be competent. That is, the presence of a current disability requires a medical diagnosis; and, where an opinion is used to link the current disorder to a cause during service or a service-connected disability, a competent opinion of a medical professional is required. See Caluza at 504; Reiber v. Brown, 7 Vet. App. 513 (1995). There is competent evidence of record tending to show that the veteran has joint problems, hypertension, gout, poor vision and heart problems. At a VA examination in April 1974, mild hypertension was diagnosed. The veteran underwent a VA general medical examination in January 1993. The diagnoses included hypertensive cardiovascular disease, angina pectoris and gout. The veteran underwent another VA general medical examination in September 1998. That examination revealed some question as to visual acuity. The diagnoses included long standing diabetes mellitus, with ocular and foot complications. The diagnoses also included hypertension, coronary artery disease and recurrent gout with arthritis of the foot and knee. While the service medical records show that the veteran needed corrective lenses for near vision and had defective color vision, they include no findings pertaining to joint problems, hypertension, gout or heart problems. Moreover, the veteran primarily contends that he has joint problems, hypertension, gout, poor vision and heart problems secondary to his service-connected post operative residuals of a right nephrectomy. While the Board finds the veteran's contentions credible for the purpose of determining whether his service connection claims are well-grounded, he is not competent to link any current medical disability to service or to a service- connected disability. Nor is there any competent evidence tending to show that hypertension, cardiovascular disease or arthritis became manifest to a compensable degree within one year after service. Moreover, the veteran has submitted no competent evidence tending to show that any current disability of the joints, eyes or heart, hypertension or gout was caused by his service-connected right nephrectomy or underwent an increase in disability due to that service- connected disability. The Board notes that refractive error of the eye, which includes myopia, is not a disease or injury within the meaning of applicable legislation for disability compensation purposes. Dorland's Illustrated Medical Dictionary, 1092 (27th ed. 1988); 38 C.F.R. § 3.303(c) (1999). Under the circumstances discussed above, the Board finds that the claims for entitlement to service connection for joint problems, hypertension, gout, poor vision and heart problems secondary to the veteran's service-connected post operative residuals of a right nephrectomy are not well-grounded. Where the veteran has not met the burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that a claim for service connection benefits is well-grounded, the VA has no duty to assist him in developing facts pertinent to such claim, to include obtaining medical opinions. 38 U.S.C.A. § 5107. Further, if the veteran does not submit a well-grounded claim, the appeal of the claim must fail. 38 U.S.C.A. § 5107(a); Murphy, 1 Vet. App. at 81. The governing law, 38 U.S.C.A. § 5107(a), [R]eflects a policy that implausible claims should not consume the limited resources of the VA and force into even greater backlog and delay those claims which -- as well grounded -- require adjudication. . . . Attentiveness to this threshold issue is, by law, not only for the Board but for the initial adjudicators, for it is their duty to avoid adjudicating the implausible claims at the expense of delaying well grounded ones. Grivois v. Brown, 6 Vet. App. 136, 139 (1994). Additionally, the Board notes that the veteran has not reported that any competent evidence exists that if obtained would establish well-grounded claims for entitlement to service connection for joint problems, hypertension, gout, poor vision and heart problems secondary to the veteran's service-connected post operative residuals of a right nephrectomy. Under the circumstances, the VA has no further duty to assist the veteran in developing well-grounded claims for entitlement to service connection for those disorders, to include service connection on a secondary basis. Epps v. Brown, 9 Vet. App. 341 (1996); Robinette v. Brown, 8 Vet. App. 69 (1995). The Board notes that the RO's failure to find the claims for entitlement to service connection for joint problems, hypertension, gout, poor vision and heart problems secondary to the veteran's service-connected post operative residuals of a right nephrectomy not well-grounded constitutes harmless error. Edenfield v. Brown, 8 Vet. App. 384 (1995). Additionally, with regard to the reference to Dorland's Illustrated Medical Dictionary, the Board finds that, because the claim for entitlement to service connection for poor vision is not well-grounded, the veteran is not entitled to receive an adjudication of his claim on the merits and any violation of Thurber v. Brown, 5 Vet. App. 119 (1993), is not prejudicial to him. Dean v. Brown, 8 Vet. App. 449 (1995). With regard to the claim for entitlement to service connection for post-traumatic stress disorder, the Board notes that the RO denied service connection for an acquired psychiatric disorder, to include post-traumatic stress disorder, in a rating decision dated in May 1988. However, review of the claims file does not disclose that notice of that particular decision was sent to the veteran. Therefore, the May 1988 rating decision regarding post-traumatic stress disorder is not final. 38 U.S.C.A. § 7105 (West 1991). Under the provisions of 38 C.F.R. § 3.304(f), service connection for post-traumatic stress disorder requires medical evidence establishing a clear diagnosis of the condition, credible supporting evidence that the claimed inservice stressor actually occurred, and a link, established by medical evidence, between current symptomatology and the claimed inservice stressor. The medical evidence of record includes VA outpatient treatment records dated in December 1987 and March 1988 which include diagnoses of post-traumatic stress disorder. Also, according to the report of a VA psychiatric evaluation in January 1990, the veteran's diagnoses included chronic post- traumatic stress disorder secondary to Vietnam service. Thus, there is competent evidence of a clear diagnosis of post-traumatic stress disorder and a link between current symptomatology and the claimed inservice stressor. Additionally, review of the medical records and the veteran's statements show that he contends that he served three tours in Vietnam as a combat medic and an infantryman. Also, at a VA psychiatric examination in June 1990, the veteran related that he constantly thought about his friends who were killed or severely wounded in Vietnam. In January 1988 and January 1999, the RO requested specific information from the veteran regarding his alleged stressors. He also reported that he had served with the 1st Air Calvary Division, the 87th Airborne Division and the 101st Airborne Division while in Vietnam. While it does not appear that the veteran provided the requested information, it also does not appear that the RO attempted to verify the veteran's claimed exposure to combat through sources such as the U.S. Armed Services Center for Research of Unit Records (USASCRUR) or obtain the veteran's personnel records. The Board also notes that the U.S. Court of Appeals for Veterans Claims (Court) (known as the United States Court of Veterans Appeals prior to March 1, 1999) has held that while the sufficiency of a stressful event and its relationship to a post-service disorder are medical determinations, the existence of the precipitating event is a factual matter. Cohen v. Brown, 10 Vet. App. 128 (1997). Furthermore, the evidence required to determine the existence of a stressor is generally dependent upon whether the veteran "engaged in combat," in which case the provisions of 38 U.S.C.A. § 1154(b) apply, or not, in which case, corroboration is required to establish the existence of a stressor. Thus, development of the veteran's claimed stressors depends on whether it is determined that the veteran engaged in combat. If it is determined that he did not engage in combat, verification of the veteran's claimed stressors is warranted. Under the circumstances discussed above, the Board finds that the veteran's claim for entitlement to service connection for post-traumatic stress disorder is well-grounded. The Board also finds that additional action by the RO, which is discussed below, is warranted in accordance with the VA's duty to assist the veteran with the development of his well- grounded claim. II. Increased Ratings The Board finds that the claims for entitlement to increased evaluations for his service-connected disabilities are well- grounded within the meaning of 38 U.S.C.A. § 5107, that is, they are plausible, meritorious on their own or capable of substantiation. Proscelle v. Derwinski, 2 Vet. App. 629 (1992). The Board further finds that the VA has met its duty to assist in developing the facts pertinent to those claims. 38 U.S.C.A. § 5107. Disability ratings are based on schedular requirements which reflect the average impairment of earning capacity occasioned by the state of a disorder. 38 U.S.C.A. § 1155. Separate rating codes identify the various disabilities. 38 C.F.R. Part 4. In determining the level of impairment, the disability must be considered in the context of the whole recorded history, including service medical records. 38 C.F.R. § 4.2. An evaluation of the level of disability present must also include consideration of the functional impairment of the veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10. Also, where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In November 1972, the veteran underwent radical transabdominal nephrectomy of the right kidney. In a rating decision dated in April 1973, the RO granted service connection for renal cell carcinoma with right nephrectomy and assigned a 100 percent evaluation for that disability under the VA Schedule of Rating Disabilities, effective in November 1972. 38 C.F.R. Part 4. In a May 1974 rating decision, the RO reduced the rating assigned for right nephrectomy for renal cell carcinoma with no pathology in the left kidney to a 30 percent evaluation under Diagnostic Codes 7500-7528, effective in August 1974. Service connection was subsequently granted for incisional hernia, and a 20 percent evaluation was assigned for said disability under the provisions of Diagnostic Code 7339, effective in November 1974. Changes to the criteria for evaluating of disabilities of the genitourinary system became effective in February 1994. The Board notes that, where a law or regulation changes after a claim has been filed or reopened but before the administrative or judicial appeal process has been concluded, the version most favorable to an appellant applies. See Karnas v. Derwinski, 1 Vet. App. 308, 313 (1991). Therefore, the Board will consider both the new and old regulations in evaluating the veteran's post operative residuals of a right nephrectomy for renal cell carcinoma. Additionally, the Board notes that a grant of benefits based on revised rating criteria may not be effective prior to the date of the liberalizing legislation. Rhodan v. West, 12 Vet. App. 55 (1998); 38 U.S.C.A. § 5110(g) (West 1991). Under the previous provisions of Diagnostic Code 7528, malignant growths of any specified part of the genitourinary system were rated 100 percent. That rating would be continued for one year following the cessation of surgical, X-ray antineoplastic chemotherapy or other therapeutic procedures. At that point, if there had been no local recurrence or metastases, the rating would be made on residuals, with a minimum rating of 10 percent assigned. 38 C.F.R. Part 4 (1993). Under the old provisions of Diagnostic Code 7500, the absence of one kidney warranted a 30 percent evaluation when the other was functioning normally. A 60 percent evaluation required mild to moderate nephritis, infection or pathology of the remaining kidney; and a 100 percent evaluation required severe nephritis, infection or pathology of the remaining kidney. 38 C.F.R. Part 4 (1993). Under the current provisions of Diagnostic Code 7528, malignant neoplasms of the genitourinary system are rated 100 percent disabling. Following the cessation of surgical, X- ray, antineoplastic chemotherapy or other therapeutic procedure, the rating of 100 percent is continued in effect with a mandatory VA examination at the expiration of six months. If there has been no local reoccurrence or metastasis, the genitourinary disorder is rated on residuals as voiding dysfunction or renal dysfunction, whichever is predominant. 38 C.F.R. Part 4 (1999). Under the current provisions of Diagnostic Code 7500, removal of one kidney is rated at a minimal evaluation of 30 percent, as in this case. If there is nephritis, infection, or pathology of the other kidney, removal of one kidney is rated as renal dysfunction. 38 C.F.R. Part 4 (1999). As for renal dysfunction, a 30 percent evaluation is warranted when there is albumin constant or recurring with hyaline and granular casts or red blood cells; or transient or slight edema, or hypertension at least 10 percent disabling under Diagnostic Code 7101. A 60 percent evaluation is warranted when there is constant albuminuria with some edema; or definite decrease in kidney function; or, hypertension at least 40 percent disabling under Diagnostic Code 7101. 38 C.F.R. § 4.115a (1999). The Board notes that, under the provisions of Diagnostic Code 7101, a 40 percent evaluation is warranted when diastolic pressure is predominantly 120 or more with moderately severe symptoms. 38 C.F.R. Part 4 (1999). Voiding dysfunction is evaluated as urine leakage, frequency or obstructed voiding. If urine leakage, post surgical urinary diversion, urinary incontinence or stress incontinence requires the wearing of absorbent materials which must be changed two to four times per day, a 40 percent evaluation is warranted. If the use of an appliance or the wearing of absorbent materials, which must be changed more than four times per day, is required, a 60 percent rating is warranted. If urinary frequency is manifested by daytime voiding intervals less than one hour or awakening to void five or more times per night, a 40 percent evaluation, the highest rating available for urinary frequency, is warranted. 38 C.F.R. § 4.115a (1999). In September 1998, the veteran underwent a VA genitourinary examination. Initially, the examiner commented that the examination was extremely difficult because communication was almost nil, noting that it was very difficult for the veteran to understand the examiner's questions and that his mother knew very little more than the veteran. According to the veteran, his frequency of urination was about every 30 minutes and he had to get up at least eight times a night to go to the bathroom. He reported that he did not have hesitancy, diminution of stream or dysuria. While he did report having had incontinence at times, he did not have to wear a pad or appliance. According to the examination report, the veteran had a right nephrectomy well healed scar without any herniation, a larger upper midline scar which was about 20 cm. in length and a 1 1/2 to 2 cm. wide scar from retention sutures. The diagnosis was carcinoma of the kidney with nephrectomy and post-operative incisional hernia and impotence. The examiner added that the nephrectomy alone would not be reason that the veteran could not be gainfully employed. There is no probative evidence that the veteran has experienced any ascertainable nephritis, infection or pathology of the remaining left kidney. Additionally, there is no probative evidence that the veteran has constant albuminuria with some edema, definite decrease in kidney function, or experiences hypertension with a diastolic pressure predominantly 120 or more with moderately severe symptoms. His blood pressure at the January 1993 VA examination was 165/108. Also, while any incontinence the veteran experiences does not require him to wear a pad or an appliance, he has complained of urinary frequency about every 30 minutes and having to get up at least eight times a night to go to the bathroom. Thus, the criteria for a 40 percent evaluation for voiding dysfunction under the new provisions of 38 C.F.R. § 4.115a are met. However, as he does not require the use of an appliance and he does not have to wear pads, an evaluation in excess of 40 percent for urine leakage, post surgical urinary diversion, urinary incontinence or stress incontinence is not warranted. The veteran's incisional hernia has been evaluated under the provisions of Diagnostic Code 7339, for postoperative ventral hernia. Under that Diagnostic Code, a 20 percent evaluation is warranted when the hernia is small, not well supported by belt under ordinary conditions, or where there are healed ventral hernia or postoperative wounds with weakening of abdominal wall and indication for a supporting belt. A 40 percent evaluation is warranted when the hernia is large, not well supported by belt under ordinary conditions. The Board also notes that a noncompensable rating is warranted when there are healed, post-operative wounds with no disability and indicating no need for a belt. 38 C.F.R. Part 4. A VA outpatient treatment record dated in March 1992 shows that the veteran had a large incisional hernia, which was easily reducible with surrounding tenderness. According to another VA outpatient treatment record dated in April 1992, the examiner described the incisional hernia as moderate. It was noted that the hernia was easily reducible. According to the report of a January 1993 VA general medical examination, the veteran had a large, irreducible ventral hernia underlying the midline surgical scar. At that examination, the veteran complained that his hernia caused considerable discomfort. Additionally, the report of a VA general medical examination performed in September 1998 includes no findings pertaining to the incisional hernia. Thus, while the veteran's incisional hernia was described as large on one occasion in March 1992 and moderate in April 1992, the medical evidence pertinent to the current claim consistently shows that such hernia is easily reducible. Additionally, there is no probative evidence that there is weakening of the abdominal wall or a need for a supporting belt. Under the circumstances, the Board finds that the record supports finding that the criteria for a noncompensable percent evaluation more closely approximate the severity of the veteran's post operative residuals of a right nephrectomy for renal cell carcinoma than the criteria for a 40 percent rating. Additionally, the preponderance of the evidence is against finding that the criteria for an evaluation higher than 20 percent for incisional hernia are met. 38 C.F.R. § 4.7, Part 4, Diagnostic Code 7339. Preliminary review of the record reveals that the RO considered referral of the case to the Chief Benefits Director or the Director, Compensation and Pension Service for the assignment of an extra-schedular rating under 38 C.F.R. § 3.321(b)(1) (1999). This regulation provides that to accord justice in an exceptional case where the schedular standards are found to be inadequate, the field station is authorized to refer the case to the Chief Benefits Director or the Director, Compensation and Pension Service for assignment of an extra-schedular evaluation commensurate with the average earning capacity impairment. The governing criteria for such an award 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. The Court has held that the Board is precluded by regulation from assigning an extra-schedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance, however, the Board is not precluded from raising this question, and in fact is obligated to liberally read all documents and oral testimony of record and identify all potential theories of entitlement to a benefit under the law and regulations. Floyd v. Brown, 9 Vet. App. 88 (1996). The Court has further held that the Board must address referral under 38 C.F.R. § 3.321(b)(1) only where circumstances are presented which the Director of VA's Compensation and Pension Service might consider exceptional or unusual. Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Having reviewed the record with these mandates in mind, the Board finds no basis for further action on this question. VAOPGCPREC. 6-96 (1996). Finally, when after consideration of all evidence and material of record, 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 such matter shall be given to the claimant. 38 U.S.C.A. § 5107(b). However, for the reasons discussed above, the Board finds that the preponderance of the evidence is against the veteran's claims for entitlement to an increased evaluation for incisional hernia and an evaluation in excess of 40 percent for post operative residuals of a right nephrectomy for renal cell carcinoma. ORDER To the extent that the veteran is contending that his claim for entitlement to service connection for post-traumatic stress disorder is well-grounded, that appeal is granted. The appeal of the claims for entitlement to service connection for joint problems, hypertension, gout, poor vision and heart problems secondary to the veteran's service- connected post operative residuals of a right nephrectomy is denied. A 40 percent evaluation for post operative residuals of a right nephrectomy for renal cell carcinoma is granted, subject to the provisions of 38 U.S.C.A. § 5110(g). An increased evaluation for incisional hernia is denied. REMAND As the veteran has submitted a well-grounded claim for entitlement to service connection for post-traumatic stress disorder and in light of the evidence discussed above, the Board finds the additional development listed below is warranted. Additionally, a grant of additional service connection benefits could change the outcome of the appeal of the issue of entitlement to a total disability rating based on individual unemployability. Therefore, the Board will defer consideration of the claim regarding individual unemployability until the action described below is completed. While the Board regrets the delay involved in remanding this case, under the circumstances discussed above, it is felt that proceeding with a decision on the merits at this time would not withstand scrutiny by the Court. For that reason and to ensure that the VA has met its duty to assist the veteran in developing the facts pertinent to his appeal, the case is REMANDED to the RO for the following action: 1. The RO should notify the veteran that he may submit additional evidence and argument in support of the claims remaining on appeal. See Quarles v. Derwinski, 3 Vet. App. 129, 141 (1992). 2. The RO should obtain copies of all of the veteran's service personnel records, including a copy of his DD Form 214 for the period of service from May 1965 to May 1967. 3. The RO should seek verification of the veteran's claimed exposure to combat from the U.S. Armed Services Center for Research of Unit Records. Specifically, the USASCRUR should be asked to verify the veteran's claimed three tours in Vietnam; his service with the 1st Air Calvary Division, the 87th Airborne Division and the 101st Airborne Division while in Vietnam; and his exposure to combat as a medic and any service as an infantryman. If that organization requires more specific information, the veteran should be afforded another opportunity to provide the required information. If the veteran responds to the request for additional information, the RO should again request verification of his claimed exposure to combat from the USASCRUR or other sources of information. Regardless of whether or not the veteran responds to the request for additional information, the RO should provide the USASCRUR or other source of information with copies of the veteran's service personnel records, the DD Forms 214, a copy of this remand, and any additional information provided by the veteran regarding his claimed exposure to combat. 4. The RO should also ask the veteran to identify the names and complete addresses of any additional medical providers who have treated him for post-traumatic stress disorder. After securing any necessary release, the RO should obtain records of any treatment identified by the veteran, which has not already been obtained. 5. To ensure that all pertinent VA medical records have been obtained, the RO should also attempt to secure copies of all VA medical records pertaining to the veteran since his separation from service, including archived records, and records of a hospitalization in January 1999. 6. Upon completion of the above development, if it is verified that the veteran was exposed to combat while in Vietnam, the RO should afford the veteran another VA psychiatric examination. All psychiatric diagnoses should be in conformity with the DSM-IV criteria and all appropriate studies or tests should be accomplished. It is very important that the examiner review the veteran's claims file and a copy of this Remand. After reviewing the claims file or copies of the pertinent records, the examiner should provide an opinion as to whether the veteran meets the DSM-IV criteria for a diagnosis of post-traumatic stress disorder. If the examiner determines that such criteria are met, he or she should comment upon the link between the current symptomatology and an inservice stressor and provide complete rationales for all opinions expressed. (The examiner should be aware that, as of this writing, there is no evidence corroborating the veteran's allegations that he served as a combat medic or infantryman while in Vietnam.) 7. After the development requested above has been completed to the extent possible, the RO should again review the record in light of all of the additional evidence. If service connection is granted for post-traumatic stress disorder, the RO should again address the issue of entitlement to a total disability rating based on individual unemployability. If any benefit sought, for which an appeal has been perfected, remains denied, the veteran and his representative should be furnished a supplemental statement of the case and given the opportunity to respond thereto with additional argument and/or evidence. Thereafter, the case should be returned to the Board. The veteran need take no action until notified. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded to the regional office. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims 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. JEFF MARTIN Member, Board of Veterans' Appeals