Citation Nr: 0504326 Decision Date: 02/16/05 Archive Date: 02/24/05 DOCKET NO. 00-15 428 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a skin disorder, to include actinic keratoses and/or squamous cell carcinoma, claimed as due to in-service herbicide exposure. 2. Entitlement to service connection for heart disease, claimed as due to in-service herbicide exposure. 3. Entitlement to service connection for post-traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESSES AT HEARINGS ON APPEAL The veteran and his brother ATTORNEY FOR THE BOARD L. Cryan, Counsel INTRODUCTION The veteran had active service from February 1969 to December 1971 including service in the Republic of Vietnam from January 2, 1971 to December 5, 1971. This case is before the Board of Veterans' Appeals (Board) on appeal from a November 1999 rating decision by the RO whereby the RO denied service connection for actinic keratoses/squamous cell carcinoma and denied service connection for heart disease. The veteran timely appealed that determination. The veteran testified at a personal hearing before a Decision Review Officer (DRO) at the RO in February 2000. Then, in June 2003, the veteran testified at a personal hearing before the undersigned Veterans Law Judge, sitting at the RO. Copies of the transcripts of each personal hearing have been associated with the claims file. In a July 2003 rating decision, service connection for PTSD was denied. The RO thereafter received the veteran's Notice of Disagreement (NOD) with that issue in September 2003. The case was remanded by the Board to the RO in December 2003 for additional development of the record, in particular, compliance with the VCAA's duties to notify and assist the veteran with the development of his claims. In January 2004, the veteran submitted a claim of service connection for Type II, diabetes mellitus, claimed as due to in-service herbicide exposure. In addition, the veteran submitted a claim of service connection for bilateral peripheral neuropathy, lower legs and feet, arms, fingers, and face, claimed as secondary to the Type II diabetes mellitus. The Board refers these matters to the RO for appropriate development and adjudication. This appeal, as to the issue of entitlement to service connection for PTSD, is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify you if further action is required on your part. FINDINGS OF FACT 1. The veteran served in Vietnam during the Vietnam Era and is presumed to have been exposed to agent orange while in service. 2. Heart disease was not present in service or for many years later, and it is not causally related to an incident in service, including exposure to in-service herbicides. 3. The competent medical evidence of record does not demonstrate that the veteran's current skin conditions, including actinic keratoses and/or squamous cell carcinoma, began during service or for many years after service, or that they were caused by any incident of service including herbicide exposure in Vietnam. CONCLUSIONS OF LAW 1. Heart disease was not incurred in or aggravated by active service; nor may heart disease be presumed to have been incurred in active service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116, 1131, 1137 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2004). 2. A skin disorder, to include actinic keratoses and squamous cell carcinoma, was not incurred in or aggravated by service, nor may a skin disorder be presumed to have been incurred in active service. 38 U.S.C.A. §§ 1110, 1116 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2004). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS At the outset, the Board notes that on November 9, 2000, the VCAA was enacted. See 38 U.S.C.A. §§ 5103, 5103A (West 2002). Among other things, the VCAA amended 38 U.S.C.A. § 5103 to clarify VA's duty to notify claimants and their representatives of any information that is necessary to substantiate the claim for benefits. The VCAA also created 38 U.S.C.A. § 5103A, which codifies VA's duty to assist, and essentially states that VA will make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate a claim. Implementing regulations for the VCAA were subsequently enacted, which were also made effective November 9, 2000, for the most part. See 66 Fed. Reg. 45,620 (Aug. 29, 2001) (codified at 38 C.F.R. §§ 3.102, 3.159). The intended effect of the implementing regulations was to establish clear guidelines consistent with the intent of Congress regarding the timing and scope of assistance VA will provide to claimants who file a claim for benefits. See 66 Fed. Reg. 45,620 (Aug. 29, 2001). Both the VCAA and the implementing regulations are applicable in the present case, and will be collectively referred to as "the VCAA." Pertinent to the merits of the veteran's claims of entitlement to service connection for heart disease and for a skin disorder to include actinic keratoses and squamous cell carcinoma, claimed as due to in-service herbicide exposure, the Board finds that compliance with the VCAA has been satisfied. The Board notes that the case was remanded by the Board to the RO in December 2003 specifically to insure compliance with the VCAA. To comply with the aforementioned VCAA requirements, the RO must satisfy the following four requirements. First, the RO must inform the claimant of the information and evidence not of record that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103 (West 2002) and 38 C.F.R. § 3.159(b)(1) (2004). A letter sent to the veteran in February 2004 informed him that to establish entitlement to service connection, the evidence must show a current disability and a medical nexus between such and the veteran's military service. Second, the RO must inform the claimant of the information and evidence VA will seek to provide. See 38 U.S.C.A. § 5103 (West 2002) and 38 C.F.R. § 3.159(b)(1) (2004). The February 2004 letter advised the veteran that the RO would make reasonable efforts to obtain evidence such as medical records, employment records, or records from other Federal agencies. Third, the RO must inform the claimant of the information and evidence the claimant is expected to provide. See 38 U.S.C.A. § 5103 (West 2002) and 38 C.F.R. § 3.159(b)(1) (2004). The February 2004 letter requested that the veteran provide an Authorization and Consent to Release Information form (VA Form 21-4142) (release form) for each private physician who had treated him for his claimed conditions. He was also advised to provide the name of the person, agency, or company who has any relevant records and to provide a release form for each identified facility. In this regard, the Board notes that the veteran did provide the name of his private doctor who allegedly treated him in 1972 and 1973 for high blood pressure and skin lesions; however, the veteran also indicated that all records from that doctor had been destroyed long ago. The veteran indicated that a statement from that doctor would be forth coming, in support of his claims; however, the veteran never submitted any such statement. Finally, the RO must request that the claimant provide any evidence in the claimant's possession that pertains to the claim. See 38 U.S.C.A. § 5103 (West 2002) and 38 C.F.R. § 3.159(b)(1) (2004). Even though the RO never sent a letter prior to the unfavorable November 1999 rating decision, specifically requesting that the veteran provide any evidence in his possession that pertained to his claim (as required by 38 C.F.R. § 3.159 (b)), the Board finds that the veteran is not prejudiced by such failure. The RO has consistently requested the veteran to provide information about where and by whom he was treated for his claimed disabilities. In the February 2004 letter, he was specifically asked to tell VA about any additional information or evidence and send VA the evidence needed as soon as possible. Thus, he was, in effect, asked to submit all evidence in his possession. Therefore, for all of the aforementioned reasons, it is determined that the veteran was not prejudiced by the RO's not specifically requesting that the veteran provide any evidence in his possession that pertained to his claims prior to the November 1999 rating decision. See Bernard v. Brown, 4 Vet. App. 384 (1993). Moreover, the veteran submitted a statement in February 2004 indicating that he had no additional evidence to submit in support of his claims of service connection for heart disease and a skin disorder to include actinic keratoses and squamous cell carcinoma. In short, the RO has informed the appellant of the information and evidence not of record that is needed, the information and evidence that the VA will seek to provide, and the information and evidence the appellant must provide. See 38 U.S.C.A. § 5103 (West 2002) and 38 C.F.R. § 3.159(b)(1) (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In view of the procedures that have been undertaken in these claims, further development is not needed to comply with VCAA. The appellant has been informed of the information and evidence needed to substantiate his claims, and he has been made aware of how VA would assist him in obtaining evidence and information. He has not identified any additional, relevant evidence that has not been requested or obtained. For the aforementioned reasons, there is no reasonable possibility that further assistance would aid in the substantiation of the claims. Service connection may be granted for disability due to a disease or injury which was incurred in or aggravated by active service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2004). Where certain chronic diseases, including heart disease, become manifest to a degree of 10 percent within one year from date of termination of active service, it shall be presumed to have been incurred in active service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2004). The evidence shows that the veteran served in Vietnam during the Vietnam Era while in service. Under the circumstances, he is presumed to have been exposed to agent orange in service. 38 C.F.R. § 3.307(a)(6)(iii) (2004). These provisions were amended by the Veterans Education and Benefits Expansion Act of 2001 (P.L. 107-103) to include all Vietnam veterans as well as the requirement that respiratory cancer become manifest within 30 years of the veteran's departure from Vietnam to qualify for the presumption of service connection based on exposure to herbicides. Service connection may be granted for a disease based on exposure to agent orange when there is medical evidence linking it to such incident. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). If a veteran was exposed to an herbicide agent during active military, naval or air service, the following diseases shall be service-connected if the requirements of 38 U.S.C.A. § 1116 and 38 C.F.R. § 3.307(a)(6) are met, even though there is no record of such disease during service, provided further that the rebuttable presumption of 38 C.F.R. § 3.307(d) are also satisfied: Chloracne or other acneform disease consistent with chloracne; Hodgkin's disease; Non-Hodgkin's lymphoma; acute and subacute peripheral neuropathy; porphyria cutanea tarda; prostate cancer; multiple myeloma; respiratory cancers (cancers of the lung, bronchus, larynx or trachea); soft- tissue sarcoma, type 2 diabetes (also known as Type II diabetes mellitus or adult-onset diabetes), and chronic lymphocytic leukemia. 38 C.F.R. § 3.309(e) (2004). The diseases listed at 38 C.F.R. § 3.309(e) shall have become manifest to a degree of 10 percent or more at any time after service, except that chloracne, PCT, and acute and subacute peripheral neuropathy shall have become manifest to a degree of 10 percent or more within one year after the last date on which the veteran was exposed to an herbicide agent during active military, naval or air service. 38 U.S.C.A. §§ 1113, 1116 (West 2002); 38 C.F.R. § 3.307(a)(6)(ii) (2004); 68 Fed. Reg. 59540 (Oct. 16, 2003). The term "soft-tissue sarcoma" above includes adult fibrosarcoma; dermatofibrosarcoma protuberans; malignant fibrous histiocytoma; liposarcoma; leiomyosarcoma; epithelioid leiomyosarcoma (malignant leiomyoblastoma); rhabdomyosarcoma; ectomesenchymoma; angiosarcoma (hemangiosarcoma and lymphangiosarcoma); proliferating (systemic) angioendotheliomatosis; malignant glomus tumor; malignant hemangiopericytoma; synovial sarcoma (malignant synovioma); malignant giant cell tumor of tendon sheath; malignant schwannoma, including malignant schwannoma with rhabdomyoblastic differentiation (malignant Triton tumor), glandular and epithelioid malignant schwannomas; malignant mesenchymoma; malignant granular cell tumor; alveolar soft part sarcoma; epithelioid sarcoma; clear cell sarcoma of tendons and aponeuroses; extraskeletal Ewing's sarcoma; congenital and infantile fibrosarcoma; and malignant ganglioneuroma. See Note 1 following 38 C.F.R. § 3.309(e) (2004). A. Heart Disease At the outset, while the record reveals that the veteran served in Vietnam during the Vietnam Era while in service and it is presumed that he was exposed to agent orange, the evidence does not show that he has a heart disease for which service connection may be granted on a presumptive basis due to presumed exposure to Agent Orange. The service medical records are negative for any complaints, findings or diagnosis of a heart disorder. Moreover, the veteran's blood pressure reading on his entrance examination was 138/78 and the blood pressure reading on his separation examination was 130/70. The post-service evidence in this case does not show that the veteran had a heart disability until 1994. Prior to that time, there is no indication that the veteran had symptoms of heart disease. For example, a November 1987 private operative report dealing with the excision of a lip lesion, noted under the "cardiovascular" heading, "No history of a heart diagnosis." Furthermore, in conjunction with the surgical procedure to remove the lip lesion, the veteran was required to fill out a patient questionnaire. Part of the questionnaire asked for the veteran to check any box next to a disease/problem that applied to him currently, or in the past. The veteran checked boxes corresponding to sinus problems, ringing in the ears, frequency of urination, and anxiety. The veteran did not check the boxes corresponding to high blood pressure, stroke, heart disease, angina, heart attack, chest pain, or shortness of breath. The veteran also indicated that he smoked 1.5 packs of cigarettes per day, and that he had smoked for 15 years. Private treatment records from June 1994 show that the veteran underwent a cardiac catheterization with coronary angiogram, and an angioplasty of the distal left circumflex obtuse marginal. The procedure was suggested after the veteran had complained of chest pains. The impression was that of single vessel coronary artery disease involving the distal left circumflex which was successfully angioplasted with the 2.5 free hand balloon. Private treatment records from September 1994 note that the veteran had a recent history of tinnitus, vertigo and headaches. The impression was that of Meniere's syndrome. Meniere's syndrome was noted again, with symptoms, in a September 1995 private treatment record. Then, private medical records from March 1996 and May 1996 noted impressions including atherosclerotic heart disease, coronary artery disease, and hypercholesterolemia. The veteran complained of chest pain in July 1998. An August 1999 VA chest x-ray noted prior median sternotomy and cardiac surgery. There was no evidence of congestive heart failure. Abnormal retrosternal soft tissue opacity was noted, which was of indeterminate etiology. In conjunction with his claims of service connection, the veteran was afforded VA examinations in August 1999. At the general medical examination, the veteran complained of significant fatigue, which worsened after his coronary artery bypass graft. On physical examination, the veteran was without shortness of breath. Cardiovascular exam had a regular rate and rhythm without S3. A February 2000 treatment record/memorandum from a private cardiologist notes that the veteran had his first episode of angina in 1994 while working as a police officer. At that time, he underwent angiography and he was found to have a severe lesion of the circumflex marginal coronary artery. The report notes that the veteran went on to have a successful angioplasty of that vessel and was able to go back to work. The report further notes that in 1996, the veteran was admitted to the emergency room with more chest pain. He thereafter underwent a semi-emergency coronary artery bypass graft operation with a left internal mammary artery graft of the left anterior descending coronary artery and saphenous vein grafts to the right coronary artery and the circumflex coronary artery. At the time of discharge, he had considerable ventricular irritability and was discharged with bigeminy and trigeminy. He was able to go back to work after a 6-week convalescent period. He had to be readmitted 6 months later in 1996 with tiredness, easy fatigability and exertion related palpitations due to premature ventricular contractions. He was tried on different medications for the arrhythmias including atenolol. He was able to return to work in September 1998. The report further notes that the veteran evidently had a myocardial infarction. He underwent a cardiac catheterization and was told the grafts were patent. In 1998 and 1999 had several hospitalizations for arrhythmia. He underwent electrophysiological studies and attempt at ablating an arrhythmia focus on the right was done with partial improvement, but no cure. In October 1999 he had another attempt at ablation without success. At the time of this February 2000 report, the veteran continued to complain of angina, even at rest. The veteran's medications included Betapace for the ventricular irritability, Norvasc and nitrostat as needed for recurrent angina, Lasix, K-Dur, and Coumadin. The report further noted that cardiac catheterization determined occlusion of 2 of his 3 grafts and the only graft that was patent was the left anterior descending vessel with the left internal mammary artery graft. Attempts at angioplasty of 1 of the 2 occluded vein grafts was evidently unsuccessful. The veteran underwent evaluation for a possible second heart surgery, but his surgeon indicated that he was not operable. The report also noted that the veteran's father and mother, and one brother all died of heart disease. In summary, the private cardiologist opined that the cause of the veteran's severe heart condition was coronary atherosclerosis which dated back to 1994, when he had his first episode of angina requiring angioplasty. At his DRO hearing in February 2000, the veteran testified that he began feeling lightheaded and dizzy in 1972 or 1973 so he went to the doctor and the doctor diagnosed him with high blood pressure. The veteran also testified that he was unable to pass agility tests after service and was placed on blood pressure medication for about a year until his blood pressure was under control. Then, he was placed on medication again in 1994. The veteran testified that all records confirming this treatment in the early 1970's had been destroyed. At his personal hearing before the undersigned Veterans Law Judge in June 2003, the veteran testified that he was placed on blood pressure medication in 1972 or 1973, and that he remained on medication continuously since that time. The veteran also testified that he was referred by Dr. D.M. to a dermatologist in the early 1970's, but he could not recall that doctor's name. The veteran testified that he had obtained all records that he could locate regarding medical treatment. In this case, the record does not reflect that the veteran had any symptoms of heart disease until 1994, over twenty years after discharge from service. Although the veteran maintains that he was treated for high blood pressure in the early 1970's, he has not produced any competent medical evidence to support his contention. The veteran attributes his symptoms of light-headedness and dizziness in the 1970's to high blood pressure, but this is not shown by the medical evidence of record. In contrast to the veteran's contentions, the medical evidence of record shows that the veteran suffered from Meniere's syndrome, which could have accounted for his light-headedness and dizziness. In addition, the veteran did not report any heart symptoms or high blood pressure symptoms on a pre-operative report from 1987. Moreover, the private cardiologist in February 2000 opined that the veteran's heart disease was first manifest in 1994 when the veteran presented with symptoms of angina. In sum, there is no evidence of record, other than the appellant's contentions, that his current heart disease is related to any disease or injury incurred in or aggravated by service or that it may be presumed to be of service onset. As the appellant is not a medical expert, he is not competent to express an authoritative opinion on this issue. Espiritu v. Derwinski, 2 Vet. App. 492 (1992); Grottveit v. Brown, 5 Vet. App. 91 (1993). In the absence of competent evidence demonstrating a link between the current heart disease and service, including exposure to Agent Orange, service connection is not warranted for such a disease on any basis. In sum, the service medical records do not show the presence of hypertension or heart disease. The post-service medical records do not demonstrate symptoms of heart disease until around 1994 and there is no competent evidence linking this condition, found many years after service, to an incident of service, including exposure to Agent Orange. After consideration of all the evidence, the Board finds that the preponderance of the evidence is against the claim for service connection for heart disease. Hence, the claim is denied. B. Skin Disorder to include Actinic Keratoses and Squamous Cell Carcinoma The veteran contends that he has current skin disorder to include actinic keratoses and squamous cell carcinoma due to in-service herbicide exposure. As noted herein above, the veteran is presumed to have been exposed to Agent Orange during his service in Vietnam in 1971. In the case of such a veteran, service connection based on herbicide exposure will be presumed for certain specified diseases, including chloracne (or other acneform disease consistent with chloracne) and porphyria cutanea tarda that become manifest to a compensable degree within a year after the last date of Vietnam service. 38 U.S.C.A. § 1116 (2002); 38 C.F.R. §§ 3.307(a)(6), 3.309(e) (2004). Although it is presumed that the veteran was exposed to Agent Orange during service in Vietnam, he has not been diagnosed with a skin disorder for which service connection may be granted on a presumptive basis. Although the veteran is not entitled to service connection on a presumptive basis, the Board must also determine if service connection is warranted on a direct basis. As noted herein below, the evidence in this case does not tend to show that the veteran's skin disorders were incurred in or aggravated by service, despite presumed exposure to Agent Orange. In this case, the veteran's service medical records are negative for any complaints, findings or diagnosis of a skin condition or skin cancer during service. The veteran asserts that he began to notice skin lesions in 1972 or 1973, and has sought periodic treatment for them from his private physician, Dr. D.M since that time. The veteran attempted to obtain the medical records from the early 1970's, from Dr. D.M., but they have evidently been destroyed. The veteran reported that his skin lesions were continuous and grow back even after being frozen off. Some lesions grew to one inch in diameter and then fell off. The first evidence of record showing treatment for a skin disorder consists of private treatment records from 1987 indicating a microscopic diagnosis of: 1. Actinic cheilitis with focus of actinic atypia bordering on squamous cell carcinoma in situ, lower lip; 2. Features consistent with digitated solar keratosis (cornu cutaneum), skin segments, mid forehead. The veteran had a lesion removed from his lip in November 1987. The pathology report of the lower lip lesion noted a diagnosis of actinic keratosis with one focus of microinvasive squamous cell carcinoma. Other private treatment records from 1991 and 1995 note diagnoses of seborrheic keratosis, probably seborrheic dermatitis. The 1991 record notes that the veteran presented with a several month history of recurrent rash on his face which was described as a rash that blistered up, and kind of leaked for a while, and then resolved. It came and went in the same areas of the front of the face and below and behind his ears. It was itchy. The veteran then began to have similar eruptions on his chest area, below the neck. He also reported lesions on his feet. A treatment record from February 1996 noted multiple seborrheic keratoses. In November 1998, a private treatment record noted that the veteran underwent a procedure whereby five actinic keratoses were frozen, one on the nose and four on the hands. Private treatment records from May 1999 note that the veteran underwent an excision of squamous cell carcinoma in situ right dorsal hand. The pathology report noted that the skin biopsy of the right dorsal hand revealed a diagnosis of squamous cell carcinoma in situ, hypertrophic solar keratosis type. The same diagnoses were noted with regard to the skin biopsies of the left middle finger, left 4th finger, left dorsal 1st knuckle and left hand. At his VA examinations in August 1999, the veteran reported that he had been treated for actinic keratoses, squamous cell carcinomas of the skin since 1972 by a private physician. He reported his first skin cancer was of the lower lip and was a squamous cell carcinoma. The veteran also noted excisions for squamous cell carcinoma in May 1999 on the medial canthus and of the right dorsal hand. He was treated with Efudex for the multiple keratoses on his face and bilateral upper extremities. He reported experiencing sunburns as a child and denied the use of daily sunscreen as a child or during the time he was in the military. He did report that he currently used sunscreen. On physical examination of the face and bilateral upper extremities, there were multiple erythematous, hyperkeratotic papules with scale. He had a very ruddy complexion. He had well-healed scars on the right dorsal hand, lower lip, left forehead which were all skin cancer surgery excision sites. On the chest and back, there were a few brown waxy varicose papules present. There were multiple ephelides on the face, extremities, chest, back and bilateral lower extremities. The diagnoses were that of history of squamous cell carcinoma; history of actinic keratoses with residual activity on examination; onychomycosis; and chronic solar dermatitis. On the other August 1999 VA examination, the general medical examiner noted that the veteran was of very fair complexion with pale skin with numerous freckles. He had widely distributed hyperkeratotic lesions consistent with multiple actinic keratoses on the face, extremities, chest and back. The impression was that of possible Agent Orange exposure while in the military but without documentation. The examiner noted that the veteran did not suffer from any debilitating myopathy, arthralgias or neurological deficits post possible [Agent Orange] exposure. The impression also included that of actinic keratoses/squamous cell carcinoma of the skin, status post surgical repair. A September 1999 private dermatological follow-up visit noted that the veteran presented to the clinic with new lesions and extremely dry skin. The assessment was that of severe xerosis; multiple actinic keratoses; possible neoplasms on the left posterior shoulder, left ear, and left upper chest, all questionable squamous cell carcinoma versus inflamed seborrheic keratosis; and history of squamous cell carcinoma, multiple treatment sites, with no evidence of recurrence. Later that month, biopsies indicated that the lesions on the shoulder, left ear and left upper chest were squamous cell carcinoma in situ. At his personal hearing before the undersigned Veterans Law Judge in June 2003, the veteran submitted lay statements from his step-daughter, wife, and brother who all reported that the veteran was treated for high blood pressure and for skin lesions beginning in the early 1970's. The veteran once again testified that he began to notice the skin lesions after service and that he has had numerous lesions removed from all over his body since that time. The veteran also testified that he saw barrels of chemicals around his work site while in service in Vietnam. At his personal hearing before a DRO at the RO in February 2000, the veteran testified that no one in his immediate family or his numerous aunts, uncles and cousins ever had a skin disorder like his. The veteran continued to maintain that his skin problems began about three or four months after service with growths on his forehead and hands. Then, growths appeared on his legs, arms, chest, and scalp. The veteran testified that he had been having the growths removed ever since that time, but they just keep growing back. Some were burned off, and others had to be surgically removed. The veteran testified that he lived in Florida all his life and spend a lot of time outdoors. He testified that he never had chronic sunburn or problems with his skin until after his return from Vietnam. In this case, the record does not reflect that the veteran had any symptoms of a skin disorder until 1987, many years after discharge from service. Although the veteran and his family members maintain that he was treated for skin lesions in the early 1970's, he has not produced any competent medical evidence to support his contention. The veteran attributes his symptoms to exposure to Agent Orange exposure, but this is not shown by the medical evidence of record. The Board acknowledges that the veteran is sincere in his belief that his skin disorder (and heart disease) were incurred as a result of in-service herbicide exposure. However, there is no competent medical evidence to support that assertion and there is no competent evidence of record to show that the veteran suffered from a skin disorder until 1987. In sum, there is no evidence of record, other than the contentions of the veteran and his family, that his current skin disease is related to any disease or injury incurred in or aggravated by service. As neither the appellant nor the aforementioned family members are medical experts, they are not competent to express an authoritative opinion on this issue. Espiritu v. Derwinski, 2 Vet. App. 492 (1992); Grottveit v. Brown, 5 Vet. App. 91 (1993). In the absence of competent evidence demonstrating a link between the current actinic keratoses and squamous cell carcinoma, and service, including exposure to Agent Orange, service connection is not warranted for such a disease on any basis. After consideration of all the evidence, the Board finds that the preponderance of the evidence is against the claim for service connection for actinic keratoses and squamous cell carcinoma. Hence, the claim is denied. ORDER Service connection for heart disease is denied. Service connection for a skin disorder to include actinic keratoses and squamous cell carcinoma is denied. REMAND In a July 2003 rating decision, the veteran's claim of service connection for PTSD was denied. The veteran submitted a timely NOD with that decision in September 2003. The veteran has not yet been afforded a Statement of the Case on the issue of service connection for PTSD. As such, the RO is now required to send the veteran a Statement of the Case as to this issue in accordance with 38 U.S.C.A. § 7105 (West 2002) and 38 C.F.R. §§ 19.29, 19.30 (2004). In this regard, the United States Court of Appeals for Veterans Claims has held that where a Notice of Disagreement has been submitted, the veteran is entitled to a Statement of the Case. The failure to issue a Statement of the Case is a procedural defect requiring a remand. Manlincon v. West 12 Vet. App. 238 (1999); Godfrey v. Brown, 7 Vet. App. 398 (1995). Accordingly, the case is REMANDED to the AMC for the following action: The AMC should take appropriate steps in order to provide the veteran with a Statement of the Case as to the issue of service connection for PTSD in accordance with 38 U.S.C.A. § 7105 (West 2002) and 38 C.F.R. §§ 19.29, 19.30 (2004). If, and only if, the veteran perfects his appeal by submitting a timely and adequate substantive appeal, then the RO should return the claim to the Board for the purpose of appellate disposition. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. 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 Act of 2003, Pub. L. No. 108-183, § 707(a), (b), 117 Stat. 2651 (2003) (to be codified at 38 U.S.C. §§ 5109B, 7112). _________________________________________________ BARBARA B. COPELAND Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs