Citation Nr: 0006825 Decision Date: 03/14/00 Archive Date: 03/17/00 DOCKET NO. 98-00 098A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Oakland, California THE ISSUES 1. Entitlement to a disability rating in excess of 30 percent for post-traumatic stress disorder (PTSD). 2. Entitlement to service connection for bilateral hearing loss. 3. Entitlement to service connection for a back disorder. 4. Entitlement to service connection for a bilateral eye disorder, claimed as secondary to creosote poisoning. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD John Kitlas, Associate Counsel INTRODUCTION The veteran served on active duty from May 1966 to August 1969. This matter is before the Board of Veterans' Appeals (Board) on appeal from rating decisions issued in May and September 1997 by the Department of Veterans Affairs (VA) Regional Office (RO) in Oakland, California. In the May 1997 rating decision, the RO denied service connection for hearing loss, a back disorder, an eye disorder, and PTSD. However, in the September 1997 rating decision, the RO granted service connection for PTSD and assigned a 10 percent disability rating, effective February 14, 1997. This rating was subsequently increased to 30 percent, effective February 14, 1997, by a December 1998 rating decision and concurrent Supplemental Statement of the Case. A claim placed in appellate status by disagreement with the original or initial rating award (service connection having been allowed) but not yet ultimately resolved, as is the case here with the PTSD issue, remains an "original claim" and is not a new claim for increase. Fenderson v. West, 12 Vet. App. 119 (1999). In such cases, separate compensable evaluations must be assigned for separate periods of time if such distinct periods are shown by the competent evidence of record during the pendency of the appeal, a practice known as "staged" ratings. Id. at 126. Where entitlement to compensation has already been established in a prior final rating action, an appellant's disagreement with a subsequent rating is a new claim for an increased evaluation based on the level of disability presently shown by the evidence. Suttman v. Brown, 5 Vet. App. 127, 136 (1993). In a February 2000 statement, the veteran's representative asserted that the RO misstated the veteran's PTSD claim as an "increased rating" claim and that the Board should consider remanding the case for the RO. With respect to this contention, the Board finds that a review of the evidence shows that rather than provide a staged rating for discrete intervals during the pendency of the appeal, the RO made the highest rating award it found was warranted retroactive to the earliest effective date assignable. It is evident that the RO's rating action contemplated all relevant evidence on file. Accordingly, although the RO characterized the issue as an "increased rating," the substantive adjudicative considerations in Fenderson, supra, have been fully satisfied by the RO's rating action and the Board does not find that the claimant will be prejudiced by appellate review on the current record. The Board also notes that at a February 1999 VA general medical examination, the veteran indicated that he had experienced tinnitus since his period of active duty. This examination also indicated that the veteran might have a seizure disorder as a result of a purported in-service head injury. As these matters have not been developed below, they are referred to the RO for appropriate action. FINDINGS OF FACT 1. The veteran's PTSD is not manifest by flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impaired judgment; or impaired abstract thinking 2. The medical evidence shows that the veteran has no more than mild memory loss and a slightly depressed mood due to his PTSD. 3. Overall, the evidence shows that the veteran's PTSD is manifest by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, but that the veteran is generally functioning satisfactorily, with routine behavior, self-care and conversation normal. 4. The medical evidence shows that the veteran has a current hearing loss disability pursuant to VA regulations. 5. A competent medical opinion is on file which relates the veteran's hearing loss disability to his account of noise exposure while stationed in the Republic of Vietnam. 6. The evidence on file tends to show that the veteran served in a "combat area" or "combat zone" while stationed in the Republic of Vietnam, where he was subjected to rocket and mortar attack, among other things. However, the evidence, including the veteran's own statements, do not show that he "participated in events constituting an actual fight or encounter with a military foe or hostile unit or instrumentality." 7. No competent medical evidence is on file which relates the veteran's back disorder to his period of active duty, to include his account of back pain therein. 8. The service medical records confirm that the veteran received treatment for creosote exposure to his eye. However, no competent medical evidence is on file which shows that the veteran has an acquired eye disorder due to his period of active duty, to include his creosote exposure. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 30 percent for the veteran's PTSD are not met. 38 U.S.C.A. §§ 1155, 5107 (West 1991 & Supp. 1999); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.2, 4.10, 4.130, Diagnostic Code 9411 (1999). 2. The veteran's bilateral hearing loss was incurred in or aggravated by his period of active duty. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 1991 & Supp. 1999); 38 C.F.R. §§ 3.102, 3.303 (1999). 3. The claim of entitlement to service connection for a back disorder is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991 & Supp. 1999). 4. The claim of entitlement to service connection for an eye disorder, as secondary to creosote poisoning, is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991 & Supp. 1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Increased Rating Background. The evidence on file, including the veteran's service records, show that his period of active duty included service in the Republic of Vietnam. His DD Form 214 indicates that the veteran's military occupational specialty was that of a Builder. His related civilian occupational specialty was that of a carpenter. The service records, including the DD Form 214, show that he was awarded the National Defense Service Medal, the Vietnam Service Medal with 3 Bronze Stars and the Fleet Marine Force Combat Operations Insignia on the suspension ribbon and ribbon bar of the Vietnam Service Medal, and the Vietnam Campaign Medal with Device. The service records reflect that he was awarded the Fleet Marine Combat Operations Insignia in March 1968 for support of U.S. Marine Units in the Republic of Vietnam. The veteran's service medical records show no diagnosis of or treatment for psychiatric problems during his period of active duty. In fact, his psychiatric condition was clinically evaluated as normal on both his January 1966 enlistment examination and his July 1969 release from active duty examination. The veteran's original claim of entitlement to service connection for PTSD was received by the RO in February 1997. Thereafter, a January 1997 private medical report from the Petaluma Valley Hospital, and a February 1997 VA outpatient treatment report were added to the file. Both of these records reflect that the veteran received emergency room treatment at the Petaluma Valley Hospital following a seizure. No pertinent findings were made regarding the veteran's psychiatric condition. In the April 1997 rating decision, the RO denied service connection for, among other things, PTSD. The RO found, in part, that there was no evidence of individual award denoting combat participation, and that the post-service treatment records showed no confirmed diagnosis of PTSD. Thereafter, the veteran submitted a statement, dated in May 1997, in which he recounted his purported in-service stressors. On this pre-printed form, the veteran reported that the military experiences he believed were the most terrifying, life threatening, or stressful included being bombed or shelled or tripping a booby-trap, and treating or dealing with casualties. He did not check the box for armed combat or enemy action. Regarding his role during these events, the veteran reported that he was in charge of a construction crew, and that he also helped in the event of casualties. Also on file is a May 1997 private psychological examination report of the veteran conducted by a Dr. P. S. Otto, clinical psychologist. Dr. Otto noted that the veteran came reporting difficulty with stress and self-control, particularly around Orientals. Also, it was noted that he had recently had a seizure in which he injured his back. On his intake form he also indicated having difficulties with his anger, health problems, temper, and self-control. It was further noted that the veteran was living on a ranch which was previously owned by his grandmother. He was in the process of trying to buy the ranch, but was having difficulty with a sister of his grandmother whom he was in conflict with. Additionally, it was noted that a couple of other Vietnam veterans lived on the ranch and for whom the veteran was providing housing. Dr. Otto also noted that the veteran was self-employed. He had a scrap iron business, and was trying to start a dust control business. The veteran reportedly described himself as staying pretty much to himself. He associated some with the veterans who were staying with him. Also, he enjoyed hunting and fishing, and did that when he was able to. With respect to his daily routine, the veteran reported that it consisted primarily of getting up in the morning, having coffee, walking his dog, working in his scrap iron business until dark, and then he went to bed. On mental status examination, Dr. Otto noted that the veteran came to his appointments in work clothes, and that his hands were generally greasy from mechanical work. The veteran's manner was found to be generally cooperative, yet slightly defensive. He was found to be of average intelligence. His speech was found to be appropriate and goal directed. Nevertheless, his mood was found to be slightly depressed. However, he was found to be oriented times 3, and Dr. Otto stated that the veteran showed no sign of a formal thought disorder. The veteran's affect was found to be appropriate to the content of his speech. His motor activity was found to be slightly tense. Additionally, Dr. Otto stated that the veteran's judgment appeared to be fair. Dr. Otto also noted that the veteran reported a mild to moderate sleep disturbance having some problems with nightmares and dreams. Regarding the veteran's stressors, Dr. Otto stated that the veteran's PTSD was the result of his two tours of duty in Vietnam, particularly the second tour of duty. During this period, he was on a Marine base which received mortar and rocket fire on a near daily basis. He was also shot at with small arms and sniper fire. One incident that was particularly painful occurred when he and his crew were hit by a mortar, which took an arm and leg off one of the veteran's men, and wounded three others with shrapnel. The veteran was reportedly blown out of the ditch while trying to take cover. Also, the veteran lost others of his friends in combat while in Vietnam. With respect to current symptomatology, Dr. Otto noted that the veteran had intrusive thoughts about Vietnam. When he first got back, they occurred on a daily basis, but were now two to three times per month. He also reported dreams and nightmares about Vietnam that occurred, at the time of the evaluation, approximately twice per month. Dr. Otto further stated that the veteran had avoidance of trauma related situations in the form of continuing to avoid Oriental people. For example, in the past he had quit shopping at stores if they employed Orientals. The veteran also recounted that he had had difficulties with the law when at one time he threw an Oriental man off a wharf. Dr. Otto stated that the veteran had a feeling of detachment from others and stayed pretty socially isolated. He had increased arousal in the form of difficulty controlling his anger. In the past he had reportedly hurt one or two persons badly. It was stated that he worked very hard at not losing control. Dr. Otto stated that the veteran had hyper vigilance, which took the form of keeping an eye on the door when in a public place. Also, the veteran had conflict in work settings where people would startle or aggravate him. Based on the foregoing, Dr. Otto diagnosed chronic PTSD, and assigned a Global Assessment of Functioning (GAF) score of 55. It is noted that GAF scores of 51 to 60 indicate moderate symptoms (e.g., flat effect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). Dr. Otto also commented that the veteran had been able to be consistently employed, primarily through finding ways that he could work on his own. It was noted that after service, the veteran took courses at a Community College and a trade school, and became certified as a diesel mechanic. His first job was "Freightliner" which only lasted three months due to a conflict with his supervisor. He was next employed for a trucking firm for two years, and then he quit. In 1976, he started his own business and continued to be self-employed at the time of the examination in a scrap metal business. Dr. Otto also noted that the veteran was trying to start a dust control business. In regard to relational history, Dr. Otto noted that the veteran had one marriage that ended in divorce in 1988. Other than that, he stayed fairly socially isolated with a couple of friends who were Vietnam veterans. It was noted that his relational style had caused him problems in the past when employed by others. With respect to the veteran's employability, Dr. Otto opined that the veteran's ability to establish and maintain relationships with others had been definitely impaired. While continuing to be self- employed, Dr. Otto opined that the veteran's ability to produce on an employment level had been considerably impaired. In a September 1997 rating decision, the RO granted service connection for PTSD. Among other things, the RO noted that the veteran's personnel records showed that he was a member of the U.S. Naval Mobile Construction Battalion TEN (CBE) which was selected as the Best of Type Construction Battalion in the Pacific. This award was for unequaled performance as fighter-builders during the Fiscal Year 1967. The RO also noted that the veteran was in Vietnam during the TET Offensive during 1968. Therefore, the RO concluded that the veteran's statement of stressors was consistent with the events of the time and place of assignment; stressors were established. As noted above, an initial rating of 10 percent was assigned for the veteran's PTSD, effective February 14, 1997. The veteran appealed this decision contended that a higher rating was warranted. A 30 percent rating was subsequently assigned, effective February 14, 1997, by a December 1998 rating decision and concurrent Supplemental Statement of the Case. The veteran underwent a VA PTSD examination in June 1998. The examiner noted that the veteran's claims file had been provided, and summarized the medical records therein. Additionally, the examiner summarized the veteran's account of stressors during service, as well as his problems when he was first discharged from service. For example, the veteran reported that after discharge he returned to his hometown, got married and moved to Southern California. The veteran's marriage lasted 19 years, then he got divorced and returned to his hometown. He reported that the divorce was because he had become too much of a workaholic and he disliked his wife's attitude toward him. Otherwise, he reported that he had generally been able to keep some friendships. Also, he was still in touch with people he knew from childhood. However, he felt that when he first came back from service, it did delay his sense of feeling totally comfortable and close to people. Regarding current symptomatology, the veteran reported that he still enjoyed some activities that he had before service, such as hunting and fishing. He reported that his moods were generally positive, that he tried to think positive and that he had always been that way. However, he still had nightmares about his combat time. These nightmares came a few times per month, or even more often. Intrusive thoughts came at a similar frequency, often triggered by Orientals, occasionally by gunfire or something he might see of a violent nature on television. It was noted that the veteran's sleep was very light, and that he could wake up quickly to any disturbance around him. With respect to his work history, it was noted that the veteran had always been self-employed. For example, he had a dust-control business, but had a seizure which resulted in a fracture of a vertebrae. As a result of this, he had his commercial driver's license revoked, and it was only reinstated a week before the examination. From January 1997 until the time of the examination, he had had very limited income. He participated in a recycling business owned by a childhood friend, but that only paid about $400 per month. The veteran reported that no one would hire him, and that he thought he was unemployable because of his seizure history and fracture and his back problems. In regard to his social history, the veteran reported that he had a few friends; that he did some target and trap shooting; that he was in touch with his children, ages 25 and 19; that he quit smoking; and that he did not drink. On mental status examination, the examiner found the veteran to be a tall, well-developed, well-nourished, clean shaven, and appropriately dressed. The veteran's speech was found to be fluent and logically constructed. His mood was found to be generally open and cooperative, but the examiner noted that there was an underlying sense of anxiety and trepidation. The examiner stated that he found no psychotic thinking; no suicidal or homicidal ideation; and no panic, phobic, or obsessive thought. Further, the veteran was found to be alert and oriented in all spheres. It was noted that he did mental arithmetic, proverb abstraction, and judgment testing well. However, his recall memory was noted to be done quite slowly, but that he was able to get three of four items spontaneously recalled. It was noted that the fourth item was recalled with a clue. The veteran's insight was found to be good. Based on the foregoing, the examiner diagnosed PTSD, and assigned a GAF score of 52. Also on file are VA medical treatment records which cover a period from March 1997 to July 1998. These records contain no pertinent findings regarding the veteran's PTSD. Similarly, while a February 1999 VA general medical examination included a diagnosis of PTSD by history, no pertinent findings were made regarding the severity of this disability. In a December 1999 statement, the veteran reported that he had started working in June 1999. He also stated that he had received his first check that same month in the amount of $850. In a February 2000 statement, the veteran's representative contended that the veteran had been unemployed due to his PTSD and nonservice-connected disabilities. The representative also contended that the 30 percent rating did not adequately reflect the severity of the veteran's PTSD. Legal Criteria. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of use- fulness, and the effects of the disabilities upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Under the current schedular criteria, effective November 7, 1996, Diagnostic Code 9411 provides that PTSD is evaluated under the general rating formula used to rate psychiatric disabilities other than eating disorders. 38 C.F.R. § 4.130. When a mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication, a noncompensable (zero percent) evaluation is warranted. Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication warrants a 10 percent evaluation. A 30 percent disability rating is in order when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped, speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintain effective work and social relationships. A 70 percent rating is warranted where there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near- continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. A 100 percent rating is warranted where there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. In addition, other related regulations were amended in November 1996. According to the amended rating criteria, when evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a) (1999). The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. Id. However, when evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation on the basis of social impairment. 38 C.F.R. § 4.126(b) (1999). In general, the degree of impairment resulting from a disability is a factual determination and generally the Board's primary focus in such cases is upon the current severity of the disability. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994); Solomon v. Brown, 6 Vet. App. 396, 402 (1994). However, in Fenderson v. West, 12 Vet. App. 119 (1999), it was held that the rule from Francisco does not apply where the appellant has expressed dissatisfaction with the assignment of an initial rating following an initial award of service connection for that disability. Rather, at the time of an initial rating, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. With regard to the veteran's request for an increased schedular evaluation, the Board will only consider the factors as enumerated in the applicable rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); Pernorio v. Derwinski, 2 Vet. App. 625, 628 (1992). In exceptional cases where the schedular evaluations are found to be inadequate, an extraschedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities may be approved provided the case presents such an exceptional or unusual disability picture with related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1). Analysis. In general, when a claimant is awarded service connection for a disability and subsequently appeals the RO's initial assignment of a rating for that disability, the claim continues to be well grounded as long as the rating schedule provides for a higher rating and the claim remains open. Shipwash v. Brown, 8 Vet. App. 218, 224 (1995). Therefore, the Board finds that the veteran's claim for an increased evaluation for his PTSD is well-grounded. Because the claim is well grounded, VA has a duty to assist the veteran in developing facts pertinent to the claim. 38 U.S.C.A. § 5107(a). Here, VA has accorded the veteran an examination in relation to this claim, and obtained medical records pertaining to the treatment he has received. There does not appear to be any pertinent medical evidence that is not of record or requested by the RO. Thus, the Board finds that VA has fulfilled its duty to assist the veteran in developing the facts pertinent to this claim. No further assistance to the veteran is required to comply with the duty to assist. In the instant case, the Board finds that the veteran does not meet or nearly approximate the criteria necessary for a schedular rating in excess of 30 percent. There is no evidence of any distinctive periods where the veteran had flattened affect due to his PTSD. On the May 1997 private psychological evaluation, Dr. Otto found the veteran's affect to be appropriate to the content of his speech, which Dr. Otto found to be appropriate and goal directed. Dr. Otto also found that there was no evidence of a formal thought disorder. There is no evidence of any distinctive periods where the veteran had circumstantial, circumlocutory, or stereotyped speech due to his PTSD. On the May 1997 private psychological evaluation, Dr. Otto found the veteran's speech to be appropriate and goal directed. Similarly, the June 1998 VA examiner found the veteran's speech to be fluid and logically construed. None of the medical evidence on file indicates that the veteran has had any panic attacks due to his PTSD. Thus, there is clearly no evidence of panic attacks occurring more than once a week. The Board finds that the evidence does not support a finding that the veteran has difficulty understanding complex commands. On the May 1997 private psychological evaluation, Dr. Otto found the veteran to be of average intelligence. Further, the June 1998 VA examiner noted that the veteran did mental arithmetic, proverb abstraction, and judgment testing well. The veteran has been shown to have some memory impairment. The May 1997 private psychological statement from Dr. Otto made no pertinent findings regarding the veteran's memory. However, the June 1998 VA examiner noted that the veteran's recall memory was done quite slowly, but that he was able to get three of four items spontaneously recalled. It was further noted that the fourth item was recalled with a clue. This evidence indicates that the veteran has no more than mild memory loss. Further, there is no indication of impairment of long term memory (e.g., retention of only highly learned material; forgetting to complete tasks). Thus, the level of the veteran's memory loss corresponds to the criteria for the 30 percent rating currently in effect. 38 C.F.R. § 4.130. The Board finds that the evidence does not support a finding that the veteran has impaired judgment due to his PTSD. On the May 1997 private psychological evaluation, Dr. Otto found the veteran's judgment to be fair. Further, the June 1998 VA examiner found no psychotic thinking; no suicidal or homicidal ideation; and no panic, phobic, or obsessive thought. Moreover, the veteran was found to be alert and oriented in all spheres. The Board further finds that the evidence does not support a finding that the veteran has impaired abstract thinking due to his PTSD. On the May 1997 private psychological evaluation, Dr. Otto found the veteran to be oriented times 3, and that there was no evidence of a formal thought disorder. Additionally, the June 1998 VA examiner found the veteran to be alert and oriented in all spheres. It was also noted that the veteran did mental arithmetic, proverb abstraction, and judgment testing well. The Board acknowledges that the veteran does have some disturbances of motivation and mood. As noted above, Dr. Otto found the veteran's mood to be slightly depressed. However, depressed mood corresponds to the criteria for the 30 percent rating currently in effect. 38 C.F.R. § 4.130. Similarly, while the June 1998 VA examiner found that the veteran exhibited an underlying sense of anxiety and trepidation, his mood was generally open and cooperative. Moreover, the June 1998 examiner found no psychotic thinking; no suicidal or homicidal ideation; and no panic, phobic, or obsessive thought. Additionally, the veteran's insight was found to be good. The veteran has exhibited some evidence of difficulty in establishing and maintaining effective work and social relationships. This is shown by, among other things, Dr. Otto's opinions regarding the veteran's employability and relational history. It is also shown by the veteran's own statements regarding his difficulty being around Orientals at both the May 1997 private psychological evaluation and the June 1998 VA examination. Further, the veteran has recounted symptoms of nightmares and intrusive thoughts at both examinations. Nevertheless, the May 1997 private psychological evaluation noted that the veteran was living with some fellow Vietnam veterans. The June 1998 VA examination noted that the veteran did have a few friends, some of whom he had known since childhood. Also, the June 1998 VA examination noted that the veteran was in touch with both of his children. This examination also noted that he was married for 19 years until he was divorced. Both of these examinations noted that he had been successfully self- employed until his seizure problems began in January 1997. Thereafter, the veteran did work with a childhood friend's recycling business. More recently, the veteran reported in a December 1999 statement that he had been employed since June 1999. The Board also notes that both Dr. Otto and the June 1998 VA examiner assigned GAF scores to the veteran which indicate no more than moderate impairment and/or symptoms. Accordingly, the Board finds that the evidence on file shows that the veteran's PTSD is manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, but that the veteran is generally functioning satisfactorily, with routine behavior, self-care and conversation normal. Thus, the veteran is not entitled to a disability rating in excess of 30 percent under the VA rating schedule. See 38 C.F.R. § 4.130. For the reasons stated above, the Board finds that the evidence is not evenly balanced, and that the veteran does not meet or nearly approximate the criteria for a disability rating in excess of 30 percent for his PTSD. Consequently, the Board concludes that the preponderance of the evidence is against the claim, and that it must be denied. The Board notes that in making this determination it has taken into consideration the applicability of "staged ratings," pursuant to Fenderson, supra. However, the record does not contain any competent evidence showing any distinctive periods for which the severity of the veteran's PTSD met or nearly approximated the criteria necessary for a disability rating in excess of 30 percent. The Board also concurs with the RO's determination that the veteran's PTSD does not warrant consideration of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1). No evidence is on file that the veteran has been hospitalized because of his PTSD. Regarding his employability, the evidence, including the veteran's own statements, tend to show that he was successfully self-employed for many years following his discharge from service. Although he was unemployed beginning in 1997, the evidence, including the veteran's own statements, show that this was due to his seizures and back problems. Moreover, the veteran reported in his December 1999 statement that he had started working in June 1999, and had received his first check for that same month in the amount of $850. Thus, the Board finds that the veteran's level of occupational impairment due to his PTSD is adequately compensated by the regular schedular standards; the evidence does not show that the veteran has experienced marked interference with employment due to his PTSD as to render impractical the application of the regular schedular standards. II. Service Connection Legal Criteria. Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131 (West 1991); 38 C.F.R. § 3.303 (1999). Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b). 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 disability was incurred in service. 38 C.F.R. § 3.303(d) (1999). The threshold question that must be resolved is whether the veteran has presented evidence of a well-grounded claim. A well-grounded claim is a plausible claim, that is, a claim which is meritorious on its own or capable of substantiation. An allegation that a disorder is service connected is not sufficient; the veteran must submit evidence in support of a claim that would "justify a belief by a fair and impartial individual that the claim is plausible." See 38 U.S.C.A. § 5107(a) (West 1991); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992); Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). The quality and quantity of the evidence required to meet this statutory burden of necessity will depend upon the issue presented by the claim. Grottveit v. Brown, 5 Vet. App 91, 92-93 (1993). In order for a claim to be well grounded, there must be competent evidence of a current disability (a medical diagnosis); evidence of incurrence or aggravation of a disease or injury in service (lay or medical evidence); and evidence of a nexus between the in-service injury or disease and the current disability (medical evidence). Caluza v. Brown, 7 Vet. App. 498, 506 (1995). In addition to the general standard set forth in Caluza v. Brown, chronicity and continuity standards can also establish a well-grounded claim. Savage v. Gober, 10 Vet. App. 488 (1997). The chronicity standard is established by competent evidence of the existence of a chronic disease in service or during an applicable presumption period; and present manifestations of the same chronic disease. The continuity standard is established by medical evidence of a current disability; evidence that a condition was noted in service or during a presumption period; evidence of post- service continuity of symptomatology; and medical, or in some circumstances, lay evidence of a nexus between the present disability and the post- service symptomatology. This type of lay evidence, for purposes of well groundedness, will be presumed credible when it involves visible symptomatology that is not inherently incredible or beyond the competence of a lay person to observe. Savage, supra. Where the determinant issue involves a question of medical diagnosis or medical causation, competent medical evidence is necessary to establish a well-grounded claim. Lay assertions of medical causation or a medical diagnosis cannot constitute evidence to render a claim well grounded. Grottveit, 5 Vet. App. at 93. A. Hearing Loss Background. The veteran's ears were clinically evaluated as normal on his January 1966 enlistment examination. An audiological evaluation conducted as part of this examination revealed pure tone thresholds, in decibels, as converted from American Standards Association (ASA) to International Standard Organization (ISO) format, as follows: HERTZ 500 1000 2000 3000 4000 6000 RIGHT 20 5 5 5 5 25 LEFT 20 5 5 5 5 25 Further, at the time of his enlistment examination, the veteran reported that he had never experienced ear, nose, or throat trouble. The veteran's service medical records show no diagnosis of or treatment for hearing problems during his period of active duty. On his July 1969 release from active duty examination, the veteran's ears were clinically evaluated as normal. His hearing was found to be 15/15 bilaterally on voice testing. The veteran's claim of entitlement to service connection for hearing loss, among other things, was received by the RO in February 1997. Thereafter, a January 1997 private medical report from the Petaluma Valley Hospital, and a February 1997 VA outpatient treatment report were added to the file. Both of these records reflect that the veteran received emergency room treatment at the Petaluma Valley Hospital following a seizure. No pertinent findings were made regarding the veteran's hearing. VA medical treatment records are on file that cover the period from March 1997 to July 1998. Among other things, these records show that the veteran underwent an audiological evaluation in July 1998 which indicated pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 20 30 75 75 LEFT 10 10 25 70 70 Speech discrimination scores, unaided, were found to be 80 percent for the right ear, and 88 percent for the left ear. Overall assessment was that the veteran had normal hearing in both ears through 2,000 Hertz, dropping to severe sensorineural hearing loss centered at 4,000 Hertz for both ears. Speech discrimination scores were noted to be good for both ears. These records also show that the veteran was advised on the use of hearing aids. The veteran underwent a VA general medical examination in February 1999. Among other things, the veteran reported that while stationed in the Republic of Vietnam he was exposed to 105 mm Howitzers and had had ringing in his ears since that time. It was also noted that in July 1998 the veteran was diagnosed with sensorineural hearing loss with frequencies greater than 2,000 Hertz. Following examination of the veteran, the examiner diagnosed, in part, sensorineural high tone hearing loss secondary to noise exposure in the Republic of Vietnam. In commenting on this diagnosis, the examiner stated that the sensorineural high tone hearing loss was "most probably" related to noise exposure in the Republic of Vietnam. Also on file is the May 1997 private medical psychological examination report of the veteran from Dr. Otto. However, this report made no pertinent findings regarding the veteran's hearing loss claim. Legal Criteria. In addition to the rules of service connection cited above, service connection may also be established for certain diseases that were initially manifested, generally to a compensable degree of 10 percent or more, within a specified presumption period after separation from service. This presumption period is generally within the first post-service year. See 38 U.S.C.A. §§ 1110, 1112(a), 1116, 1131, 1133(a), 1137; 38 C.F.R. §§ 3.303(a), 3.306, 3.307. This presumption includes organic diseases of the nervous system such as sensorineural hearing loss. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. For the purpose of applying the laws administered by VA, impaired hearing is considered a disability when the auditory threshold in any of the frequencies 500, 1,000, 2,000, 3,000, or 4,000 Hertz is 40 decibels or greater; or when the auditory threshold for at least three of the frequencies 500, 1,000, 2,000, 3,000, or 4,000 Hertz is 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. Further, the United States Court of Appeals for Veterans Claims (Court) has indicated that the threshold for normal hearing is between 0 and 20 decibels and that higher thresholds show some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). When audiometric test results at a veteran's separation from service do not meet the regulatory requirements for establishing a "disability" at that time, he may nevertheless establish service connection for a current hearing disability by submitting evidence that the current disability is causally related to service. Hensley, 5 Vet. App. at 160. Analysis. In the instant case, the Board finds that the veteran's claim of entitlement to service connection for hearing loss is well grounded. The veteran's account of in- service noise exposure is presumed credible for the purpose of determining whether his claim is well-grounded. Meyer v. Brown, 9 Vet. App. 425, 429 (1996); King v. Brown, 5 Vet. App. 19, 21 (1993). The medical evidence shows that he has a current hearing loss disability as defined by 38 C.F.R. § 3.385, and the opinion of the February 1999 VA examiner provides the requisite medical nexus linking the disability to the veteran's period of active duty. Thus, the claim is well grounded. Caluza at 506. Adjudication of the veteran's claim of service connection for hearing loss does not end with the finding that the case is well-grounded. In determining that the veteran's claim is well-grounded, the credibility of evidence has been presumed and the probative value of the evidence has not been weighed. However, once the claim is found to be well-grounded, the presumption that it is credible and entitled to full weight no longer applies. In the adjudication that follows, the Board must determine, as a question of fact, both the weight and credibility of the evidence. Equal weight is not accorded to each piece of material contained in a record; every item of evidence does not have the same probative value. The Board notes that the evidence on file tends to show that the veteran served in a "combat area" or "combat zone" while stationed in the Republic of Vietnam, where he was subjected to rocket and mortar attack, among other things. As noted above, the RO found the veteran's account of rocket and mortar attacks during service to be credible when service connection was granted for PTSD in September 1997. Thus, the Board finds that the veteran's account of noise exposure during service, including the purported exposure to 105 mm Howitzers while in Vietnam, is consistent with his reported in-service stressors that have already been found to be credible by the RO. Additionally, the Board notes that the opinion of the February 1999 VA general medical examiner is the only competent medical opinion on file regarding the etiology of the veteran's hearing loss disability. No competent medical opinion is on file which refutes this opinion. The Board cannot substitute its own unsubstantiated opinion for that of a competent medical professional. Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). Accordingly, the Board must accept the examiner's opinion as correct. For the reasons stated above, the Board finds that the veteran is entitled to a grant of service connection for his hearing loss disability. Reasonable doubt has been resolved in the veteran's favor. 38 C.F.R. § 3.102. B. Back Disorder Background. The veteran's service medical records show no diagnosis of or treatment for a back disorder during his period of active duty. His spine was clinically evaluated as normal on both his January 1966 enlistment examination, and his July 1969 release from active duty examination. The veteran's claim of entitlement to service connection for a back disorder was received by the RO in February 1997. Thereafter, a January 1997 private medical report from the Petaluma Valley Hospital, and a February 1997 VA outpatient treatment report were added to the file. Both of these records reflect that the veteran received emergency room treatment at the Petaluma Valley Hospital following a seizure. Regarding the veteran's back, it was noted that the back was not injured although the veteran did complain of some tightness and aching to his lumbar back. In the April 1997 rating decision, the RO denied the claim of service connection for a back disorder, among other things, as not well grounded. There RO found, in part, that there was no record of treatment in service for a back disorder. Additionally, the RO informed the veteran that in order to establish a well-grounded claim, he needed to provide evidence which demonstrated that the claimed condition was incurred in or aggravated by military service. The veteran appealed his back disorder claim to the Board. In his May 1997 statement, Dr. Otto noted, in part, that the veteran had recently had a seizure in which he injured his back. The veteran underwent a VA general medical examination in February 1999. At this examination, the veteran reported, in part, that he sustained multiple back injuries that resulted in low back pain while in Vietnam, but that did not cause him to seek medical attention. Further, at the time of his seizure in January 1997, he fractured his thoracic spine. This fracture had reportedly healed with residual thoracic spine pain. Following examination of the veteran, the examiner diagnosed, among other things, degenerative joint disease, thoracic and lumbar spine, moderately disabling, permanent. However, the examiner opined that the degenerative joint disease of the veteran's back was "unrelated to military service." VA medical records are also on file which cover a period from March 1997 to July 1998. Among other things, these records show treatment for complaints of seizures and associated back pain in March and November 1997. Nothing in these records relates the veteran's back problems to his period of active duty. Analysis. In the instant case, the Board finds that the veteran's claim of entitlement to service connection for a back disorder is not well grounded. Initially, the Board notes that even though the service medical records show no diagnosis of or treatment for back problems during the veteran's period of active duty, his account of back problems during service is presumed credible for the purpose of determining whether the veteran's claim is well grounded. Meyer, supra; King, supra. Nevertheless, the Board finds that competent medical evidence is necessary in order to well ground the veteran's claim. There is no medical evidence that the veteran was diagnosed with a chronic back disorder during his period of active duty. Although the veteran has alleged continuity of symptomatology regarding back problems, the United States Court of Appeals for Veterans Claims (Court) stated in Voerth v. West, 13 Vet. App. 117 (1999), that the holding in Savage does not eliminate the requirement of medical nexus evidence when a claimant alleges continuity of symptomatology. Rather, a claimant diagnosed with a chronic condition must still provide a medical nexus between the current condition and the putative continuous symptomatology. Furthermore, in Clyburn v. West, 12 Vet. App. 296, 301 (1999), the Court held that even though a lay person is competent to testify to the pain he has experienced since his military service, he is not competent to testify to the fact that what he experienced in service and since service is the same condition. No competent medical evidence is on file which relates the veteran's current back disorder to his period of active duty, to include his account of back problems therein. Thus, the veteran's claim is not well grounded. Caluza at 506. In fact, the evidence tends to indicate that the veteran's current back problems were incurred as a result of his injuries following the January 1997 seizure. Moreover, the Board notes that the February 1999 VA examiner opined that the veteran's back disorder was "unrelated" to his military service. There is no competent medical evidence on file which refutes this opinion. As stated above, the Board cannot substitute its own unsubstantiated opinion for that of a competent medical professional. Colvin, supra. The only evidence on file to support the claim of service connection for a back disorder are the veteran's own contentions. Issues of medical diagnosis or medical causation require competent medical evidence in order to have probative value. See Grottveit at 93. Nothing on file shows that the veteran has the requisite knowledge, skill, experience, training, or education to render a medical opinion. See Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). Consequently, his contentions cannot well ground the claim. Grottveit at 93; Caluza at 504. For the reasons stated above, the Board finds that the veteran's claim is not well grounded, and must be denied. As the veteran has not submitted the evidence necessary for a well-grounded claim, a weighing of the merits of the claim is not warranted, and the reasonable doubt doctrine is not for application. See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990). C. Eye Disorder Background. The veteran's eyes were clinically evaluated as normal on his January 1966 enlistment examination. His uncorrected vision was found to be 20/20 for both eyes. At the time of this examination, the veteran reported that he had never experienced eye trouble. The service medical records reflect that the veteran was treated in March 1967 after he got saw dust in his right eye. In November 1968, he was treated after he got creosote in his right eye. Copious irrigation was performed. No permanent eye disability was diagnosed at that time, and no further treatment for eye problems is shown in the service medical records. On his July 1969 release from active duty examination, the veteran's eyes were clinically evaluated as normal. His uncorrected vision was again found to be 20/20 for both eyes. The veteran's claim of entitlement to service connection for an eye disorder, secondary to creosote poisoning, was received by the RO in February 1997. Thereafter, a January 1997 private medical report from the Petaluma Valley Hospital, and a February 1997 VA outpatient treatment report were added to the file. Both of these records reflect that the veteran received emergency room treatment at the Petaluma Valley Hospital following a seizure. His eye, pupils, and extraocular muscles were noted to be intact. In the April 1997 rating decision, the RO denied the claim of service connection for an eye disorder, among other things, as not well grounded. The RO found, in part, that while the service medical records showed treatment for a right eye condition secondary to creosote poisoning, this was shown to be a temporary condition which resolved with treatment, and no permanent residual disability was shown at the time of separation. The veteran appealed his eye disorder claim to the Board. Neither the May 1997 statement from Dr. Otto, nor the June 1998 VA PTSD examination made any pertinent findings regarding the veteran's eyes. As noted above, VA medical records are on file which cover a period from March 1997 to July 1998. Among other things, these records show that the veteran was treated in the eye clinic in November 1997 and February 1998. The records note that the veteran appeared for a general examination, in which he complained of decreased near vision. The veteran's visual acuity was apparently found to be 20/15 for both eyes, and the veteran was prescribed bifocals. However, the examiner noted that the veteran was told he had no service-connected disability, but the veteran insisted that he did. On the February 1999 VA general medical examination, the examiner noted that the veteran had creosote splashed into his eyes while on active duty. He was seen in sick call, where the creosote was washed out of his eyes. The examiner further noted that the veteran had not had difficulty with his vision since that time other than that which was associated with the aging process. On examination, the examiner found the veteran's pupils to be equal, round and react to light and accommodation. Extraocular movements were full and intact. No acquired eye disability was diagnosed by the February 1999 VA examiner. In a February 2000 statement, the veteran's representative contended, in part, that the veteran should be granted the benefits of 38 U.S.C.A. § 1154(b), based upon his service in Vietnam. Regarding both the veteran's back and eye claims, the representative stated that the RO denied the claims based upon the merits of both cases. Moreover, the representative contended that the RO did not inform the veteran of the types of evidence needed in order to obtain a favorable decision in accord with Robinette v. Brown, 8 Vet. App. 69 (1995). Analysis. In the instant case, the Board finds that the veteran's claim of entitlement to service connection for an eye disorder, claimed as secondary to creosote poisoning, is not well grounded. There is no dispute that the veteran was treated for creosote exposure to his right eye during service. However, it does not appear from the medical evidence on file that the veteran has an acquired eye disorder. While the February 1998 VA medical treatment records indicate that the veteran has decreased visual acuity, congenital or developmental defects and refractive error of the eye are not diseases or injuries within the meaning of service connection legislation. 38 C.F.R. §§ 3.303(c), 4.9. In the absence of proof of a present disability there can be no valid claim. Brammer v. Brown, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). As both the Caluza and Savage tests for well groundedness require medical evidence of a current disability, the Board finds that the veteran's claim is not well grounded and must be denied. Since the veteran has not submitted the evidence necessary for a well-grounded claim, a weighing of the merits of the claim is not warranted, and the reasonable doubt doctrine is not for application. See generally Gilbert, supra. Furthermore, the Board notes that even if the veteran did have an acquired eye disorder, he would still need competent medical nexus evidence in order to well ground his claim. No such evidence is on file. It has already been determined that the veteran is not qualified to render a medical opinion. Espiritu, supra. Consequently, the veteran's own contentions regarding a relationship between creosote exposure and a claimed eye disability cannot well ground the veteran's claim. The veteran's representative has contended that the veteran should be granted the benefits of 38 U.S.C.A. § 1154(b) based upon his service in Vietnam. Section 1154(b) provides: In the case of any veteran who engaged in combat with the enemy in active service with a military, naval, or air organization of the United States during a period of war, campaign, or expedition, the Secretary shall accept as sufficient proof of service- connection of any disease or injury alleged to have been incurred in or aggravated by such service satisfactory lay or other evidence of service incurrence or aggravation of such injury or disease, if consistent with the circumstances, conditions, or hardships of such service, notwithstanding the fact that there is no official record of such incurrence or aggravation in such service, and, to that end, shall resolve every reasonable doubt in favor of the veteran. Service-connection of such injury or disease may be rebutted by clear and convincing evidence to the contrary. The reasons for granting or denying service-connection in each case shall be recorded in full. The regulation implementing section 1154(b) is at 38 C.F.R. § 3.304(d). VA's General Counsel has recently held that the ordinary meaning of the phrase "engaged in combat with the enemy", as used in 38 U.S.C.A. § 1154(b), requires that a veteran "have participated in events constituting an actual fight or encounter with a military foe or hostile unit or instrumentality." VAOPGCPREC 12-99 (Oct. 18, 1999). Serving in a general "combat area" or "combat zone" does not qualify as engaging in combat with the enemy. Id. The Board is bound by this definition of combat. 38 C.F.R. § 19.5. The Board finds that the evidence on file does not support a finding that the veteran "engaged in combat with the enemy", as used in 38 U.S.C.A. § 1154(b). Granted, the evidence does show that the veteran served in a "combat area" or "combat zone" while serving in the Republic of Vietnam, during which he was subject to rocket and mortar fire. However, the veteran's own statements tend to show that he did not participate in events constituting an actual fight or encounter with a military foe or hostile unit or instrumentality. VAOPGCPREC 12-99. Such a finding would also be inconsistent with the veteran's military occupational specialty of a Builder. Even if the Board were to find that the veteran "engaged in combat with the enemy," it would make no difference to the decisions in the instant case regarding the back and eye claims. In determining that the veteran's claims were not well-grounded, the Board did not dispute the veteran's account of what occurred during service. As stated above, the veteran's account of his in-service back pain was presumed credible for the purpose of determining whether the claim was well grounded. Further, the service medical records confirmed that the veteran was treated for creosote exposure to his right eye during his period of active duty. Rather, the Board found that the claims were not well grounded due to the lack of a competent medical diagnosis of an acquired eye disorder, and lack of competent medical nexus evidence for both claims. In Kessel v. West, 13 Vet. App. 9 (1999) (en banc), it was held that 38 U.S.C.A. § 1154(b) only relaxes the evidentiary requirement regarding the service incurrence or aggravation element of a well grounded claim. For purposes of submitting a well grounded claim, a combat veteran's statements, standing alone, may be sufficient to establish service incurrence. However, where the determinative issue is nexus or the existence of current disability, 38 U.S.C.A. § 1154(b) is not controlling. See also Turpen v. Gober, 10 Vet. App. 536, 539 (1997) (holding that, absent medical-nexus evidence, there was "no reasonable possibility that consideration of § 1154(b) by the Board could change the outcome of the case on the merits"). Contrary to the representative's statements, the Board finds that the RO denied both the back and eye claims as not well grounded, and did not adjudicate the merits of the underlying claims. Even if the RO had adjudicated the merits of either or both of these claims, the Board finds that the veteran would not be prejudiced by the Board's denial of the claim as not well grounded due to the veteran's failure to meet the initial burden of the adjudication process. Meyer v. Brown, 9 Vet. App. 425, 432 (1996). VA has neither the duty nor the authority to assist a claimant in the absence of a well-grounded claim. Morton v. West, 12 Vet. App. 477 (1999); Epps v. Gober, 126 F.3d 1464 (Fed. Cir. 1997), cert. denied sub nom. Epps v. West, 118 S.Ct. 2348 (1998). However, VA may, dependent on the facts of the case, have a duty to notify the veteran of the evidence needed to support his claim. 38 U.S.C.A. § 5103; see also Robinette v. Brown, 8 Vet. App. 69, 79 (1995). Contrary to the contentions of the representative, this duty to inform does not require VA to specifically inform the veteran of the evidence necessary in order to obtain a favorable decision on his claims. Rather, the duty to inform obligation exists only in the limited circumstances where the appellant has referenced other known and existing evidence that would make his or her claim well grounded. Epps v. Brown, 9 Vet. App. 341, 344 (1996); see also generally Stuckey v. West, 13 Vet. App. 163, 175 (1999), (observing in part that when it is alleged that there is specific evidence that would manifestly well ground a claim, VA has a duty to inform the claimant of the importance of obtaining this evidence to "complete the application.") (Emphasis added). In accord with this obligation, the Board has examined all evidence of record with a view towards determining whether the veteran has notified VA of the possible existence of information which would render his claim plausible. However, the Board finds no such information. Moreover, the Board notes that the RO did inform the veteran of the elements necessary for a well grounded claim, and the February 2000 statement shows that the veteran's accredited representative is aware of these elements as well. As an additional matter, the Board notes that the record does not indicate that the RO actually considered the February 1999 VA general medical examination with respect to the service connection claims on appeal. The provisions of 38 C.F.R. § 20.1304(c) provide that any pertinent evidence submitted by the appellant or representative which has not been considered in a statement of the case or supplemental statement of the case must be referred to the RO for review and preparation of an Supplemental Statement of the Case unless this procedural right is waived, in writing, by the appellant or unless the Board determines that the benefit to which the evidence relates may be allowed on appeal without such referral. For the reasons stated above, the Board determined that the veteran was entitled to a grant of service connection for hearing loss based upon the medical nexus opinion proffered by the February 1999 VA examiner. With respect to back and eye claims, the Board finds that the information provided by this examination is redundant and not pertinent to the appeal, in that nothing in this examination report renders either claim well grounded. Accordingly, the Board concludes that additional RO consideration is not required, and that the veteran has not been prejudiced by the Board's decision on his claims. See Bernard v. Brown, 4 Vet. App. 384 (1993). ORDER Entitlement to a disability rating in excess of 30 percent for PTSD is denied. Entitlement to service connection for bilateral hearing loss is granted. Entitlement to service connection for a back disorder is denied. Entitlement to service connection for a bilateral eye disorder, claimed as secondary to creosote poisoning, is denied. Gary L. Gick Member, Board of Veterans' Appeals