Citation Nr: 1232167 Decision Date: 09/18/12 Archive Date: 09/24/12 DOCKET NO. 06-11 421 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to service connection for chronic acne, to include as secondary to service-connected eczema. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD M. Mills, Associate Counsel INTRODUCTION The Veteran had active service from November 1996 to November 2004. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2005 rating decision of the Department of Veterans Affairs (VA), Regional Office (RO), in San Juan, the Commonwealth of Puerto Rico. This matter was previously before the Board in January 2010, May 2011, and November 2011, at which time it was remanded for further development. It is now returned to the Board. The the issue of an increased disability rating for the Veteran's service-connected low back disability 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 again referred to the AOJ for appropriate action. In addition to the paper claims file, there is a Virtual VA paperless claims file associated with the Veteran's claim. A review of the documents in such file reveals that they are either duplicative of the evidence in the paper claims file or are irrelevant to the issue on appeal. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. REMAND After a careful review of this matter, the Board believes a remand is required. Although the Board sincerely regrets the additional delay, it is necessary to ensure that the Veteran is afforded a complete record in full compliance with the statutory duty to assist. The Veteran is claiming entitlement to service connection for chronic acne. Specifically, the Veteran contends that he had pre-existing acne that was aggravated during his active duty service. In May 2011, the Veteran's claim was remanded in order to schedule him for a VA examination. The Board observes the Veteran was provided a VA examination in April 2010, and the examiner did not provide a rationale to support her opinion or address aggravation of the Veteran's pre-existing acne disorder. As a result, the Board remanded the Veteran's claim in an effort to have the examiner provide an addendum to the opinion, or, in the event the April 2010 examiner was unavailable, schedule the Veteran for a new VA examination. Following the Board's May 2011 remand, the Veteran was scheduled for a VA examination to take place on June 6, 2011. The record indicates that the Veteran failed to report for the scheduled examination. In a September 2011 Appellate Brief, the Veteran's representative argued that the AMC did not substantially comply with the Board's May 2011 remand directives. It noted that no attempt was made to have the April 2010 VA examiner provide an addendum opinion to the prior examination report. In November 2011, the Veteran's claim was again remanded to have a VA examiner provide an addendum to the April 2010 examination report. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance). Specifically, the Board requested a VA opinion with supporting rationale that addressed whether the Veteran's current acne condition increased in severity during the Veteran's active service (beyond the natural progression of the disease) and whether his acne condition was caused or aggravated by the Veteran's active service. The Board finds that the December 2011 addendum opinion is inadequate to decide the matter, and it is deficient for two reasons. First, the examiner reasoned that that Veteran's acne was not aggravated by active service because it pre-existed service. She did not provide a reasoned medical explanation for her opinion specific to this Veteran, rather the provided rationale addressed acne vulgaris generally. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (neither a VA examination report nor a private medical opinion is entitled to any weight in a service-connection or rating context if it contains only data and conclusions; most of the probative value of a medical opinion comes from its reasoning). Furthermore, the examiner stated that she reviewed the claims file. However, there was no discussion of the service treatment records, the Veteran's in-service diagnosis of inflammatory or pustular acne, or his residual scaring. In addition the examination report did not address the Veteran's prescriptions for topical and oral antibiotic medication including Accutane, Doxycycline, and Amoxicillin which were prescribed during service. Although the examiner stated that there was no indication of worsening during service, the opinion failed to address the pertinent evidence of record. As such, the December 2011 opinion is not adequate for rating purposes. An opinion is required which takes all of the evidence of record into consideration when determining whether the Veteran's pre-existing acne condition was aggravated during his active service or beyond the natural progression of the disease. Accordingly, the case is REMANDED for the following action: 1. The RO/AMC shall request that the December 2011 VA examiner provide an addendum to her opinion, and provide a complete rationale as to her determination regarding whether the Veteran's acne was caused by or is aggravated by service, beyond the natural progress of the disorder. The requested opinion must include a detailed rationale that specifically addresses the Veteran's in-service treatment for acne. If the December 2011 examiner is not available, the RO/AMC shall arrange to have another qualified VA examiner review the claims file and provide an addendum opinion. The mere statement of the examiner's expertise and/or a bare summary conclusion is not alone sufficient under the law to accomplish VA's legal obligation to assist the Veteran. By law, the Board must evaluate multiple factors in determining whether medical opinions are sufficient to evaluate a claim. These factors include but are not limited to whether the examiner was aware of all facts of record; reviewed the claims file; conducted any necessary clinical testing or interview of the Veteran; and whether the examiner explained the factual and medical bases for any opinion. With respect to the review of the claims file, the examiner's attention is referenced to the following: (a) December 1997 service treatment records that reflect prescriptions for Doxycycline and Amoxicillin antibiotic treatments for acne. (b) June 1998 and May 1999 service treatment records that include adjustments to the Veteran's acne medication. (c) January 2000 records that assessed inflammatory acne and a referral to in-service dermatology treatment. (d) April 2004 treatment that diagnosed the Veteran with Acne vulgaris and probable eczema. (e) An October 2004 examination report which notes the Veteran stopped Accutane medication. (f) The Veteran's October 2004 report of medical examination at separation that noted he had been prescribed Accutane to treat acne. Thereafter, the examiner shall provide an addendum to the examination report which addresses the following: Whether the Veteran's pre-existing acne increased during his period of active service, and if so, whether it increased beyond the natural progression of the disease, and if possible to what extent it was aggravated beyond the natural progression of the disease. In all conclusions, the examiner must identify and explain the medical basis or bases, with identification of the evidence of record. The examiner is requested to provide a fully reasoned explanation for his or her opinions, based on his or her clinical experience, medical expertise, and established medical principles. 2. The RO/AMC will then review the Veteran's claims file and ensure that the foregoing development actions have been conducted and completed in full, and that no other notification or development action, in addition to those directed above, is required. If further action is required, it should be undertaken prior to further claim adjudication. 3. The RO/AMC will then readjudicate the Veteran's claim. If the benefits sought on appeal remain denied, the Veteran and his representative should be provided with a Supplemental Statement of the Case. An appropriate period of time should be allowed for response. Thereafter, if appropriate, the case is to be returned to the Board, following applicable appellate procedure. The Veteran need take no action until he is so informed. He 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). The purposes of this remand are to obtain additional information and comply with all due process considerations. No inference should be drawn regarding the final disposition of this claim as a result of this action. 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). _________________________________________________ DEMETRIOS G. ORFANOUDIS Acting 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).