Citation Nr: 1221373 Decision Date: 06/19/12 Archive Date: 06/29/12 DOCKET NO. 07-14 855 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Seattle, Washington THE ISSUE Entitlement to service connection for hidradenitis of the groin. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Veteran (Appellant) ATTORNEY FOR THE BOARD T. Sherrard, Associate Counsel INTRODUCTION The Veteran, who is the Appellant in this case, had active service from April 1968 to April 1971. This matter comes before the Board of Veterans' Appeals (BVA or Board) from a March 2006 rating decision by the above Department of Veterans Affairs (VA) Regional Office (RO). The Veteran provided testimony at a June 2009 Travel Board hearing in Seattle before a Veterans Law Judge who is no longer with the Board. A transcript is associated with the claims folder. In February 2012, the Veteran was offered a new hearing, and he sent correspondence received in March 2012 indicating he did not wish to have a new hearing and for his case to be considered on the evidence of record. The Board remanded the case in January 2010 for further development. As discussed below, additional development is necessary prior to appellate review. In a November 2011 statement, the Veteran indicated he wished to claim service connection for type II diabetes. The issue of entitlement to service connection for type II diabetes has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, D.C. REMAND The Veteran in this case contends that his hidradenitis was incurred during or caused by active service. He also avers that the skin disorder may have been caused by exposure to Agent Orange while serving in Vietnam. He states that in 1970, he sought treatment at a U.S. Public Health Service facility for a rash, and that, since then, he has experienced rashes, cysts, boils, and other lesions on his skin. His service enlistment examination report indicates that, prior to service, he had a sebaceous cyst removed from his back. Then, in October 1969, he sought treatment for a cyst on his thigh, for which he was given a heat pad. His March 1971 separation examination report is negative for any complaints or diagnoses of a skin disorder, and examination of the skin was marked as normal. In January 2010, the Board remanded the case for further development. Specifically, the Board directed the RO to attempt to obtain the records from the U.S. Public Health Service facility at which the Veteran said he sought treatment in the 1970s. In addition, the Board said that a VA examination was necessary to determine whether there was a relationship between the current hidradenitis and active service, including the documented cyst in service, or between the hidradenitis and Agent Orange exposure. Review of the claims file indicates that multiple attempts have been made to obtain the records of the U.S. Public Health Service facility in Portland, Oregon. Requests for those records were sent in July and October 2011. In October 2011, a response was received from the Health Department of Multnomah County, Oregon indicating that they had no record of the Veteran in their possession. The Veteran was afforded a VA examination in February 2010. After reviewing the claims file and examining and interviewing the Veteran, the examiner stated that he could not provide an opinion as to whether there was a relationship between the current skin disorder (diagnosed as perianal/scrotal hidradenitis) without resort to mere speculation. He then stated that "[i]t is possible that the probability of hidradenitis suppurativa occurring in the military population exposed to agent orange is just as likely as in the general population," and that a search of medical literature using the terms "hidradenitis" and "agent orange" did not produce any results. Moreover, the examiner cited to an article which stated that hidradenitis was quite common, and that one study found a genetic predisposition to hidradenitis suppurativa. The Board finds that clarification of the VA examiner's opinion is necessary to decide the claim. Specifically, the examiner's statement that the "probability of hidradenitis suppurativa occurring in the military population exposed to agent orange is just as likely as in the general population" suggests that it is possible that Agent Orange exposure caused the Veteran's hidradenitis, but appears to be speculative in nature without explanation of why an opinion cannot be reached without resort to speculation. The examiner should be asked to provide an opinion as to whether it is at least as likely as not that there is a relationship between the Veteran's hidradenitis and Agent Orange exposure, and, if an opinion cannot be reached without resort to speculation, should provide an explanation as to what additional information, if any, would be necessary to obtain in order to provide and opinion, or, explain that the limits of medical knowledge have been reached regarding the etiology of the Veteran's hidradenitis. In addition, the 2010 VA examiner did not address the question of whether the current hidradenitis is related to the documented thigh cyst found in service or otherwise to active service. The January 2010 Board remand stated that the VA examiner should address the question of whether the current skin disorder is related to any symptomatology documented in service. Therefore, the Board finds that the February 2010 VA examination report is inadequate, and that another VA medical opinion must be obtained before the claim can be decided on the merits. Accordingly, the case is REMANDED for the following action: 1. Request an addendum opinion from the same VA examiner who conducted the February 2010 VA skin examination or a suitable substitute to address the question of direct service connection and causation due to Agent Orange exposure. The claims file should be made available to the examiner for review of the history in conjunction with the examination, and the examination report should reflect that such review was accomplished. If the examiner determines that a new examination is required, one must be conducted. a. The examiner shoulder offer an opinion as to whether it is at least as likely as not (i.e., to at least a 50/50 degree of probability) that the Veteran's current perianal/scrotal hidradenitis was incurred during or caused by the Veteran's active service. The examiner should specifically comment on whether there is a relationship between the current skin disorder and the thigh cyst documented in October 1969, and should provide an explanation for the opinion reached. Note: The term "at least as likely as not" does not mean merely within the realm of medical possibility, but rather that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of causation as it is to find against it. b. Next, the examiner should offer an opinion as to whether it is at least as likely as not (i.e., to at least a 50/50 degree of probability) that the Veteran's current perianal/scrotal hidradenitis was caused or aggravated by exposure to Agent Orange during active service. The examiner should assume Agent Orange exposure in addressing this issue, and should provide an explanation for the opinion reached. If the opinion and/or supporting rationale cannot be provided without invoking processes relating to guesses or judgment based upon mere conjecture, the examiner should so specify in the report, and explain why any opinion could not be offered. In this regard, if the examiner concludes that there is insufficient information to provide an etiologic opinion without result to mere speculation, the examiner should state whether the inability to provide an opinion is due to a need for further information (with such needed information identified) or because the limits of medical knowledge have been exhausted regarding the etiology of the Veteran's hidradenitis. 2. When the development requested has been completed, the case should again be reviewed by the RO on the basis of the additional evidence. If the benefit sought is not granted, the Veteran and his representative should be furnished a Supplemental Statement of the Case and afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). The Veteran is advised to appear and participate in any scheduled VA examination(s), as failure to do so may result in denial of the claim(s). See 38 C.F.R. § 3.655 (2011). 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 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2011). _________________________________________________ K. J. ALIBRANDO Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2011).