Citation Nr: 1139163 Decision Date: 10/21/11 Archive Date: 10/25/11 DOCKET NO. 07-20 732 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for bilateral hearing loss. 2. Entitlement to service connection for tinnitus. 3. Entitlement to service connection for tremors. 4. Entitlement to service connection for a disability manifested by numbness in the hands and fingers. 5. Entitlement to service connection for lung polyps. 6. Entitlement to service connection for a disability manifested by dry skin. 7. Entitlement to service connection for a liver disability (to include cirrhosis, Hepatitis B, constant fatigue, night sweats, and fevers). 8. Entitlement to service connection for an enlarged spleen. 9. Entitlement to service connection for sleep apnea. 10. Entitlement to service connection for an acquired psychiatric disorder (other than PTSD). 11. Whether new and material evidence has been received to reopen a claim of service connection for a skin disability to include ring worm and basal cell carcinoma claimed as due to herbicide exposure. 12. Entitlement to a rating in excess of 10 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Vietnam Veterans of America WITNESSES AT HEARING ON APPEAL The Veteran and his wife ATTORNEY FOR THE BOARD S. Armstrong, Associate Counsel INTRODUCTION The appellant is a Veteran who served on active duty from November 1966 to April 1975. These matters are before the Board of Veterans' Appeals (Board) on appeal from September 2006, June 2007, October 2008, and June 2009 rating decisions of the Waco, Texas Department of Veterans Affairs (VA) Regional Office (RO). In January 2011, a Travel Board hearing was held before the undersigned; a transcript of the hearing is associated with the claims file. At the hearing, the Veteran sought, and was granted, a 60 day abeyance period for the submission of additional evidence and submitted additional evidence with a waiver of initial RO consideration. At the hearing and in writing the Veteran confirmed his intent to withdraw the issues of service connection for hypertension and non-Hodgkin's lymphoma. The Veteran and his representative also conceded that his constant fatigue, night sweats, and fever were symptoms of his hepatitis B and liver disability. Therefore the Board has recharacterized the issue to encompass all liver disability. The issues have been characterized accordingly. The matters of an increased rating for PTSD and service connection for an acquired psychiatric disorder (other than PTSD), tremors, and skin disability to include ringworm and basal cell carcinoma on de novo review are being REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the Veteran if further action on his part is required. FINDINGS OF FACT 1. It is reasonably shown that the Veteran has a bilateral hearing loss disability that is causally related to his exposure to noise trauma in service. 2. It is reasonably shown that the Veteran has tinnitus that is causally related to his exposure to noise trauma in service. 3. It is not shown that the Veteran has, or during the pendency of this claim has had, a diagnosis of a disability manifested by numbness in the hands and fingers to include neuropathy. 4. Lung polyps were not manifested in service and the preponderance of the evidence is against a finding that the Veteran's current lung polyps are related to an event, injury, or disease in service. 5. It is not shown that the Veteran has, or during the pendency of this claim has had, a diagnosis of a disability manifested by dry skin. 6. It is reasonably shown that the Veteran has a liver disability (to include cirrhosis, Hepatitis B, constant fatigue, night sweats, and fevers) that is related to his active service. 7. A disability manifested by an enlarged spleen not manifested in service and the preponderance of the evidence is against a finding that the Veteran's current enlarged spleen related to an event, injury, or disease in service. 8. It is not shown that the Veteran has, or during the pendency of this claim has had, a diagnosis of sleep apnea. 9. An unappealed January 2002 rating decision denied the Veteran's claim of service connection for a skin disability to include ring worm and basal cell carcinoma based on a finding that such disability was unrelated to his active service. 10. Evidence received since the January 2002 rating decision consists of the Veteran's lay testimony suggesting continuity of symptomatology; relates to the unestablished fact necessary to substantiate the claim of service connection for a skin disability; and raises a reasonable possibility of substantiating the claim. CONCLUSIONS OF LAW 1. Service connection for bilateral hearing loss disability is warranted. 38 U.S.C.A. §§ 1110, 1154(b), 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.385 (2011). 2. Service connection for tinnitus is warranted. 38 U.S.C.A. §§ 1110, 1154(b), 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2011). 3. Service connection for a disability manifested by numbness in the hands and fingers is not warranted. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2011). 4. Service connection for lung polyps is not warranted. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2011). 5. Service connection for a disability manifested by dry skin is not warranted. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2011). 6. Resolving all reasonable doubt in favor of the Veteran, service connection for a liver disability (to include cirrhosis, Hepatitis B, constant fatigue, night sweats, and fevers) is warranted. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2011). 7. Service connection for an enlarged spleen is not warranted. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2011). 8. Service connection for sleep apnea is not warranted. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2011). 9. New and material evidence has been received, and the claim of service connection for a skin disability may be reopened. 38 U.S.C.A. §§ 5108, 7105 (West 2002); 38 C.F.R. § 3.156 (2011). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS A. Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). The VCAA applies to these claims. Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative of any information, and any medical or lay evidence, not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). VCAA notice requirements apply to all five elements of a service connection claim: 1) veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484-86 (2006), aff'd, 483 F.3d 1311 (Fed. Cir. 2007). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Regarding service connection for bilateral hearing loss, tinnitus, and liver disability, inasmuch as the benefits sought are being granted, there is no reason to belabor the impact of the VCAA on these matters; any notice defect or duty to assist failure is harmless. The Veteran was advised of VA's duties to notify and assist in the development of his claims prior to their initial adjudication. May 2006, November 2006, June 2008, September 2008, February 2009, and April 2009, letters explained the evidence necessary to substantiate his claims, the evidence VA was responsible for providing, and the evidence he was responsible for providing. A March 2006 letter informed the Veteran of disability rating and effective date criteria. He has had ample opportunity to respond/supplement the record and has not alleged that notice in this case was less than adequate. Regarding disabilities manifested by dry skin and numbness in the hands and fingers and sleep apnea as there is no competent evidence that the Veteran has current disabilities or recurrent symptoms of disabilities that may be associated with his active service, the "low threshold" standard as to when an examination to secure a nexus opinion is required is not met, and development for such an examination is not necessary. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). Regarding serviced connection for lung polyps and an enlarged spleen, as there is no competent evidence that such disabilities may be related to the Veteran's service (to include presumed herbicide exposure therein), the "low threshold" standard as to when an examination to secure a nexus opinion is required is not met, and development for such an examination is not necessary. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Veteran's service treatment records (STRs) and pertinent postservice treatment records have been secured. He has not identified any pertinent evidence that remains outstanding. VA's duty to assist is met. Accordingly, the Board will address the merits of the claims. B. Legal Criteria, Factual Background, and Analysis Service connection may be established for disability due to disease or injury that was incurred in or aggravated by active service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Continuity of symptoms is required where a condition in service is noted but is not, in fact, chronic or where a diagnosis of chronicity may be legitimately questioned. 38 C.F.R. § 3.303(b). 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). In order to establish service connection for a claimed disability, there must be medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and an evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a). A disability may be service connected if shown to be chronic in service or if seen in service with continuity of symptomatology thereafter. 38 C.F.R. § 3.303(b). Continuity of symptomatology is an alternative method of demonstrating the second and/ or third elements discussed above. See Savage v. Gober, 10 Vet. App. 488, 495-96 (1997). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). The Board notes that it has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to these appeals. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence as appropriate and the analysis will focus specifically on what the evidence shows, or fails to show, as to the claims. Hearing loss and tinnitus Service incurrence or aggravation of organic disease of the nervous system (to include SNHL) may be presumed if such is manifested to a compensable degree within a year following a Veteran's discharge from service. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Hearing loss disability is defined by regulation. For the purpose of applying the laws administered by VA, impaired hearing is considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. The Veteran's DD Form 214 reflects that his military occupational specialty in service was aircraft ordinance technician and that he was awarded the Combat Action Ribbon (CAR) and a Purple Heart. The Veteran's STRs are silent for complaints, findings, treatment, or diagnosis relating to hearing loss and tinnitus. No service audiometry shows a hearing loss disability of either ear by VA standards. On June 2008 VA examination a bilateral hearing loss disability by VA standards was shown on audiometric testing. The Veteran reported noise exposure from aircraft during his tour in Vietnam and that he worked as a trucker for 33 years after service without recreational noise exposure. He reported that his tinnitus had its onset in 1968 during the Tet Offensive. The examiner opined that as the Veteran's hearing loss was within normal limits at separation with no significant threshold shifts apparent, his current hearing loss occurred subsequent to military separation and may be attributable to aging and noise exposure as a trucker. She noted that as there was no report of tinnitus in his service medical record, the Veteran's tinnitus was less likely as not the result of military noise exposure. A July 2009 VA outpatient treatment record notes that the Veteran had had tinnitus since Vietnam. At the January 2011 Travel Board hearing the Veteran testified that he was exposed to noise trauma in service 12 hours a day 7 days a week in his duties in aviation ordinance and that while ear protection was issued it got in the way most of the time. He noted that he first started to experience tinnitus after he was "blown through a wall" during a rocket attack and that he had experienced it ever since. He testified that he had lived with the hearing loss and tinnitus ever since Vietnam but did not seek treatment until 1998. It is not in dispute that the Veteran now has a bilateral hearing loss disability by VA standards, as such is diagnosed and was found on official VA audiometry. As tinnitus is a disability capable of lay observation (the diagnosis is essentially established on the basis of subjective complaints), and there is no reason to question the Veteran's credibility, it is reasonably shown that he has tinnitus. He received a CAR and Purple Heart (evidencing service in combat), and he is therefore entitled to the relaxed evidentiary standards afforded under 38 U.S.C.A. § 1154(b). The Board finds no reason to question his accounts of exposure to noise trauma in service (or the lay accounts supporting his claim). The remaining criterion for establishing service connection for the Veteran's hearing loss disability and tinnitus is whether such disabilities are related to the recognized noise trauma in service. The June 2008 VA examiner opined that his current hearing loss occurred subsequent to military separation and may be attributable to aging and noise exposure as a trucker and that without a report of tinnitus in his service treatment record, such was less likely as not the result of military noise exposure. She based her opinion on the Veteran's normal hearing at separation. Notably, in Hensley v. Brown, 5 Vet. App. 155 (1993), the Court noted that 38 C.F.R. § 3.385, "does not preclude service connection for a current hearing disability where hearing was within normal limits on audiometric testing at separation from service." Hensley, 5 Vet. App. at 159. As the Court noted in Hensley, a Veteran who displayed normal hearing acuity at service separation may nonetheless be awarded service connection for hearing loss at a later date if the medical evidence determines his/her hearing loss was the result of an in-service disease or injury. Id. Additionally, the opinion on etiology is speculative (i.e. may be attributable to post-service and non-service-connected causes). See Obert v. Brown, 5 Vet. App. 30, 33 (1993) (holding that medical evidence that is speculative, general, or inconclusive cannot be used to support a claim). While she acknowledged the Veteran's report of having tinnitus since 1968, the basis for the opinion was a lack of contemporaneous medical evidence in service (i.e. tinnitus was not noted in STRs). Notably, lay evidence concerning continuity of symptoms after service, if credible, is ultimately competent, regardless of the lack of contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). For these reasons the Board finds the examiner's opinion to be of diminished probative value. Considering the further pertinent evidence, the Board notes that most of it relates to continuity of symptomatology of the hearing loss disability and tinnitus. The Veteran stated that he experienced hearing loss and tinnitus at the time of a rocket attack when he was "blown through a wall" which has continued to the present. The lay accounts of postservice continuity of the Veteran's hearing difficulty complaints and tinnitus serve to corroborate his allegations. Laypersons are competent to provide evidence of symptoms capable of lay observation. See Davidson, 581 F.3d at 1316; Jandreau v. Nicholson, 492 F. 3d 1372, 1376 (2007). Hearing acuity impairment and ringing in the ears are readily lay observable. The Board finds the lay statements of record to be competent, credible, and probative evidence in the matter of continuity of symptomatology of the Veteran's hearing loss and tinnitus. When the medical evidence is weighed against the lay evidence and resolving all reasonable doubt in favor of the Veteran, the Board finds that the evidence reasonably supports the Veteran's claims. Accordingly, service connection for bilateral hearing loss disability and tinnitus are warranted. Lung polyps and enlarged spleen The Veteran's STRs are silent for complaints, findings, treatment, or diagnosis relating to the lungs or spleen. An August 2007 VA diagnostic study was interpreted as revealing splenomegaly. An August 2009 VA diagnostic study was interpreted as revealing a 6mm nodular density in the right upper lobe and a 3mm nodule in the right lower node. Lung polyps and an enlarged spleen were not noted in service or on service separation examination. Accordingly, service connection for such disabilities on the basis that they became manifest in service and persisted is not warranted. Hence, to establish service connection for the disabilities on a direct basis the Veteran must show by competent evidence that they are otherwise related to his active service. There is no competent evidence of record that relates the Veteran's current lung polyps and enlarged spleen to his service. None of the medical evidence of record suggests a relationship between the Veteran's current disabilities and his service (to include presumed exposure to herbicide therein). Whether current lung polyps and an enlarged spleen are related to the Veteran's serviced and presumed herbicide exposure therein is a medical question that is not capable of resolution through lay observation. See Jandreau v. Nicholson, 492 F. 3d 1372, 1377 (2007). Such a question requires medical expertise and training including: knowledge of the etiology of disease; review of current clinical findings; and correlation with past medical records and reported history. The Veteran's ability to provide an opinion on medical causation/etiology (requiring medical knowledge he is not shown to possess) is distinguished from observing symptoms of the disabilities. In the absence of competent evidence of a nexus between the current disabilities and the Veteran's service, service connection may not be established. In light of the foregoing, the Board finds that the preponderance of the evidence is against the Veteran's claims. Therefore, the benefit of the doubt rule does not apply; the claims must be denied. Numbness in the hands and fingers and dry skin Chronic disabilities manifested by dry skin and/or numbness in the hands and fingers were not noted in service or on service separation examination. Accordingly, service connection for such disabilities on the basis that they became manifest in service and persisted is not warranted. The threshold question here, as in any claim seeking service connection is whether the Veteran now has, or at any time since the filing of his claim of service connection has had, the disabilities he seeks to have service-connected, i.e., chronic disabilities manifested by dry skin and numbness in the hands and fingers. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (the requirement that there be a current disability is satisfied when the disability is shown at the time of the claim or during the pendency of the claim). The only competent (medical) evidence of record (showing treatment during the appeal period) is private and VA treatment records. Review of the records shows that the Veteran has been diagnosed with and treated for numerous skin disabilities but fails to show a chronic disability manifested by dry skin. A December 2008 letter from N.A., M.D. noted that the Veteran had "dry skin" and "numbness in his fingers" but did not attribute such symptoms to any underlying disabilities. At the hearing when asked about dry skin the Veteran stated that all of his skin disability was correlated and he primarily focused on ringworm and basal cell carcinoma (a claim which the Board has reopened and remanded for further development below). He testified that the numbness in his hands and fingers was neuropathy from Agent Orange. Whether or not there is underlying pathology/disability entity to account for the Veteran's reported/observed symptoms of dry skin and numbness of the hands and fingers is a medical question that is beyond lay observation, but requires medical expertise. See Jandreau v. Nicholson, 492 F. 3d 1372, 1377 (2007). Additionally, there is no competent evidence in the record to suggest that the Veteran has persistent or recurrent symptoms which may be related to his service. The Veteran has presented no medical evidence to support that he has had a chronic disabilities manifested by dry skin and/or numbness in the hands and fingers/neuropathy at any time since he filed his claim. The preponderance of the evidence is against a finding that at any time since he filed his claim of service connection for such disabilities the Veteran has been shown to have diagnosed disabilities manifested by dry skin, numbness in the hands a finger to include neuropathy. As noted above, the claim for basal cell carcinoma, a specific skin disability which the Veteran is shown to have a diagnosis of, is being developed further. Consequently, he has not satisfied the threshold requirement necessary to substantiate claims of service connection for chronic disabilities manifested by dry skin and numbness in the hands and fingers, and has not presented valid claims of service connection. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Hence, the claims must be denied. Liver disability The Veteran contends that he received vaccinations in service that were administered by a type of air injector and were not sanitized by Corpsman between injections. The Veteran's STRs show that he received various vaccinations and immunizations throughout his service and do not document any high risk activities prior to service. A July 2000 VA treatment record notes that the Veteran used alcohol rarely, had never used illicit drugs or had transfusions, and had no family history of liver disease. The assessment was mild hepatic injury, probably fatty liver. VA treatment records show that Hepatitis B was diagnosed in 2006. In January 2011, in support of his claim, the Veteran submitted various studies pertaining to Hepatitis C, Hepatitis B, and the use of multi-use jet injectors in service. One study noted that various types of air gun injectors contained enough residual blood to transmit Hepatitis B infection. Another noted that the risk for transmission of Hepatitis B would exist if it became contaminated with blood during an injection and was not properly cleaned and disinfected before subsequent injections. In one document, a June 2004 VBA fast letter, it was noted that the large majority of Hepatitis C virus infections can be accounted for by known modes of transmission, primarily transfusion of blood products before 1992 and injection drug use. See VBA Fast Letter 04-13 (June 29, 2004). The conclusion was that despite the lack of any scientific evidence to document transmission of the Hepatitis C virus with air gun injections, it was "biologically plausible." It also noted that the Hepatitis B virus was "heartier" and more readily transmitted than Hepatitis C and that there was one case report of Hepatitis B transmission by an air gun. Also in January 2011 the Veteran submitted a November 2005 Board decision which noted that: The VA physician indicated that a review of the medical literature, including a report from the CDC MMWR dated in June 1986, confirmed a high correlation between this method of immunization and Hepatitis C infection (the Board notes that this excerpt actually pertains to the Hepatitis B virus). The VA physician also noted that a review of a document from the Department of Defense - Epidemiology Board dated in January 1998 strongly recommended that multi-use jet gun injectors not be used because of the risk of transmission of blood borne diseases. At the January 2011 Travel Board hearing the Veteran testified that he received injections with jet guns in service and that Corpsman "never cleaned them off" and blood was "flying everywhere" as they proceeded down the line. He also noted that he did not drink. Review of the evidence of record fails to reveal the usual risk factors as the etiology of the Veteran's Hepatitis B. He has consistently denied any exposure to risk factors before or after service. Some of these statements were made in conjunction with treatment (which the Board finds to be highly probative as they were given for treatment purposes). The evidence submitted establishes that transmission of the Hepatitis B virus through jet gun injectors is possible (and has happened) and that there was a confirmed high correlation between air gun injector use and Hepatitis B infection. The Board also notes that there is no negative or contrary evidence of record disproving the Veteran's theory of entitlement. In light of the foregoing, the Board finds that the evidence is in equipoise and that service connection for a liver disability is warranted. Sleep Apnea The threshold matter that must be addressed here (as in any claim seeking service connection) is whether or not there is competent evidence that the Veteran actually has the disability for which service connection is sought (sleep apnea). In the absence of proof of such disability there is no valid claim for service connection. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The evidence of record does not show that the Veteran has, or during the appeal period has had, sleep apnea. In his January 2011 hearing the Veteran testified that he snored and had problems sleeping in service. He noted that he had not been diagnosed with sleep apnea as the sleep study waiting list was "5 years." There is no medical evidence establishing or even suggesting that the Veteran has sleep apnea. While the Veteran is competent to report sleep related symptoms such as snoring, the question of a specific diagnosis of a disability entity to account for the Veteran's reported/observed symptoms is a medical question that is beyond lay observation, but requires medical expertise. See Jandreau v. Nicholson, 492 F. 3d 1372, 1377 (2007). There has been no evidence since received that shows or suggests the presence of sleep apnea, and the Veteran has not identified any pertinent evidence in the matter that remains outstanding. Consequently, the threshold requirement necessary to substantiate the claim of service connection for sleep apnea is not met. Without a diagnosis of sleep apnea, there is no valid claim of service connection for such disability. See Brammer, 3 Vet. App. at 225. Hence, the claim must be denied. Skin disability - New and Material Evidence Generally, when a claim is disallowed, it may not be reopened and allowed, and a claim based on the same factual basis may not be considered. 38 U.S.C.A. § 7105. However, a claim on which there is a final decision may be reopened if new and material evidence is submitted. 38 U.S.C.A. § 5108. New evidence means existing evidence not previously submitted to agency decisionmakers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. See 38 C.F.R. § 3.156(a). When determining whether the claim should be reopened, the credibility of the newly submitted evidence is to be presumed. Fortuck v. Principi, 17 Vet. App. 173, 179-80 (2003); Justus v. Principi, 3 Vet. App. 510 (1992). The United States Court of Appeals for Veterans Claims (Court) has held that the requirement of new and material evidence raising a reasonable possibility of substantiating the claim is a low threshold. Specifically, the Court interpreted the language of 38 C.F.R. § 3.156(a) as creating a low threshold, and viewed the phrase "raises a reasonable possibility of substantiating the claim" as "enabling rather than precluding reopening." See Shade v. Shinseki, 24 Vet. App. 110 (2010). A January 2002 rating decision denied the Veteran's claim of service connection for a skin disability to include ring worm and basal cell carcinoma on the basis that such was unrelated to his active service. He did not appeal that decision, and it is final. 38 U.S.C.A. § 7105. Accordingly, for evidence since received to be new and material, it must relate to that unestablished fact (i.e. it must show, or tend to show, that the Veteran's skin disability is related to his active service). Pertinent (and new) evidence received since the January 2002 rating decision includes the Veteran's testimony that he had experienced a skin disability since his treatment for ringworm in service and that it later turned out to be basal cell carcinoma and a private treatment providers opinion that the Veteran's skin disability might be associated with exposure to herbicide. The evidence received since January 2002 is new (as it was not previously of record), and it is material as it consists of the Veteran's testimony regarding continuity of lay observable symptomatology and medical evidence suggestive of a nexus between his skin disability and his service (to include presumed herbicide exposure). The new evidence pertains to the unestablished fact necessary to substantiate the claim of service connection for a skin disability; raises (under the Court's guidelines in Shade supra) a reasonable possibility of substantiating the claim; and is material. Accordingly, the claim may be reopened. De novo consideration of the matter is addressed in the remand below. ORDER Service connection for bilateral hearing loss is granted. Service connection for tinnitus is granted. Service connection for a disability manifested by numbness in the hands and fingers is denied. Service connection for lung polyps is denied. Service connection for a disability manifested by dry skin is denied. Service connection for a liver disability (to include cirrhosis, Hepatitis B, constant fatigue, night sweats, and fevers) is granted. Service connection for an enlarged spleen is denied. Service connection for sleep apnea is denied. The appeal to reopen a claim of service connection for a skin disability (to include ringworm and basal cell carcinoma) is granted. REMAND Regarding an increased rating for PTSD and service connection for an acquired psychiatric disability (other than PTSD), tremors, and skin disability (to include ring worm and basal cell carcinoma) on de novo review, while the notice provisions of the VCAA appear to be satisfied the Board finds that further development of the record is necessary to comply with VA's duty to assist the Veteran in the development of facts pertinent to his claims. See 38 C.F.R. § 3.159 (2010). Psychiatric disabilities At the January 2011 Travel Board hearing in response to being asked whether his PTSD had increased in severity the Veteran replied, "I blow up as quick as ever, so" and his wife testified that the Veteran was "on a steady increase" and thought that his PTSD had increased in severity. As his most recent VA examination to assess service-connected PTSD was in February 2010 (and therefore is not contemporaneous), another VA examination to determine the current severity of his service-connected PTSD is necessary. Additionally, as the February 2007 VA examiner opined that the Veteran's bi-polar disorder was "comorbid" with his PTSD, the evidence of record suggests that the Veteran may have a psychiatric disability that is related to his service-connected PTSD and a VA nexus examination is necessary. Tremors The Veteran's most recent VA problem list shows a diagnosis of essential and other forms of specified tremor. An April 2007 VA outpatient treatment record notes that the Veteran had a diagnosis of tremors and PTSD and that there was a question of whether the tremors were related to anxiety. Hence, an examination to determine whether the Veteran has a separate disability entity manifested by tremors or whether such are symptoms of his already service-connected PTSD is necessary. Skin disability The Veteran testified that all of his skin problems were correlated and that while in Vietnam he was sent to Subic Bay Philippines and treated for ringworm for three weeks sometime in 1968 or 1969. He noted that ringworm never really resolved and that after service it reoccurred every 3 to 4 months and that later ini 1994 a physician told him that what he thought was ring worm was actually cancer. He added that he thought that his skin cancers were related to exposure to Agent Orange. Development for records of the Veteran's hospitalization has not been sought. Furthermore, the evidence of record suggests that the Veteran's skin disability may be related to exposure to herbicides. Accordingly, the "low threshold" standard as to when development to secure a VA examination is necessary is met, and development for an examination to secure a nexus opinion is necessary. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Veteran reports that all of his treatment for the disabilities at issue was from VA. Any treatment records during the intervening period should be secured. Accordingly, the case is REMANDED for the following: 1. The RO/AMC should secure for the record copies of complete clinical records of all VA treatment the Veteran has received for the disabilities at issue from August 2010 to the present. 2. The RO/AMC should also ask the Veteran for more specific details (i.e. name and location of hospital, etc.) and an approximate date range for his hospitalization in Subic Bay, Philippines. Based on such information the RO should arrange for an exhaustive search for complete clinical records of the alleged treatment the Veteran received. If the records cannot be located, the scope of the search should be described for the record. If the Veteran provides insufficient identifying information, he must be advised of what further information is necessary. The RO should arrange for any further development suggested. 3. The RO/AMC should then arrange for a dermatological examination of the Veteran to determine the nature and likely etiology of any current skin disability. The Veteran's claims file must be reviewed by the examiner in conjunction with the examination. Based on review of the record and examination of the Veteran, the examiner should identify (by medical diagnosis) each of the Veteran's current chronic skin disabilities and, as to each, opine whether such is/are at least as likely as not (a 50 percent or greater probability) related to his service (to specifically include exposure to herbicides and the Veteran's treatment for skin condition). The examiner must explain the rationale for the opinion(s). If the examiner cannot respond without resorting to speculation, he/she should so indicate this and explain the reason why an opinion would be speculative. 4. The RO should then arrange for a psychiatric examination of the Veteran to determine the current severity of his PTSD, and to determine whether any other psychiatric disability is etiologically related either to his active service or to service-connected PTSD. The Veteran's claims file must be reviewed by the examiner in conjunction with the examination. The examiner should identify and describe the nature, frequency, and severity of all current PTSD symptoms. The examiner should also respond to the following: a. Please identify (by medical diagnosis) each psychiatric disability entity found (other than PTSD). b. As to each diagnosed psychiatric entity (other than PTSD), please indicate whether such is at least as likely as not (a 50% or better probability) related to the Veteran's service or was caused or aggravated by the Veteran's service-connected PTSD. The examiner should explain the rationale for all opinions. 5. The RO/AMC should arrange for an appropriate examination of the Veteran to determine the nature and the likely etiology of any current disability manifested by tremors. The Veteran's claims file must be reviewed by the examiner in conjunction with the examination. The examiner should also respond to the following: a. Please identify (by medical diagnosis) any current tremor disability found on examination, to include comment on whether the Veteran's tremors are a symptom of his service-connected PTSD or another psychiatric disability or are a separate disability entity. b. If a separate disability entity manifested by tremors is diagnosed, the examiner should opine whether it is at least as likely as not (a 50 percent or better probability) that such disability is related to the Veteran's active service or was caused or aggravated by service-connected PTSD. The examiner should explain the rationale for all opinions. 6. The RO should then re-adjudicate the claims. If any remains denied, the RO should issue an appropriate supplemental statement of the case and afford the Veteran and his representative the opportunity to respond. The case should then be returned to the Board, if in order, for further review. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board for additional development or other appropriate action must be handled in an expeditious manner. _____________________________________________ KRISTI L. GUNN Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs