Citation Nr: 1300910 Decision Date: 01/09/13 Archive Date: 01/16/13 DOCKET NO. 09-21 772 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Newark, New Jersey THE ISSUES 1. Entitlement to service connection for a skin disorder, claimed as secondary to herbicide exposure. 2. Entitlement to service connection for a lumbar disorder. 3. Entitlement to service connection for a left knee disorder. 4. What evaluation is warranted for posttraumatic stress disorder (PTSD) since April 29, 2008? REPRESENTATION Appellant represented by: National Association of County Veterans Service Officers ATTORNEY FOR THE BOARD J. Smith, Counsel INTRODUCTION The Veteran served on active duty from June 1968 to June 1970. The Veteran's claim comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision of the Department of Veterans Affairs' (VA) Regional Office (RO) in Newark, New Jersey. In March 2011 and January 2012 the Board remanded the matter for additional development. The claims have been returned to the Board and the appeal is now partially ready for appellate disposition. The issue of entitlement to service connection for a skin disorder claimed as secondary to herbicide exposure is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The preponderance of the evidence is against a finding that the Veteran's lumbar disorder is related to active military service, and lumbar arthritis was not compensably disabling within one year from the date of his separation from active duty. 2. The preponderance of the evidence is against a finding that the Veteran's left knee disorder is related to active military service and left knee arthritis was not compensably disabling within one year from the date of his separation from active duty. 3. Since April 29, 2008, the Veteran's PTSD has not been manifested by occupational and social impairment with reduced reliability and productivity. CONCLUSIONS OF LAW 1. A lumbar disorder was not incurred or aggravated during the Veteran's active duty service, and lumbar arthritis may not be presumed to have been so incurred. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2012). 2. A left knee disorder was not incurred or aggravated during the Veteran's active duty service, and left knee arthritis may not be presumed to have been so incurred. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309. 3. Since April 29, 2008, the criteria for an initial evaluation greater than 30 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.7, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Notice and Assistance As regards the claims for service connection, the requirements of 38 U.S.C.A. §§ 5103 and 5103A have been met. There is no issue as to providing an appropriate application form or completeness of the application. VA notified the Veteran in May and July 2008 of the information and evidence needed to substantiate and complete a claim, to include notice of what part of that evidence is to be provided by the claimant, what part VA will attempt to obtain, and how disability ratings and effective dates are determined. The claim was most recently readjudicated in October 2012. As regards the increased rating claim on appeal, because service connection for PTSD has been granted and an initial rating and an effective date have been assigned, the notice requirements of 38 U.S.C.A. § 5103(a), have been met. Hartman v. Nicholson, 483 F. 3d 1311 (Fed Cir. 2007). VA fulfilled its duty to assist the Veteran in obtaining identified and available evidence needed to substantiate a claim, and as warranted by law, affording VA examinations. The Veteran was offered the opportunity for a personal hearing, but withdrew his request in September 2011. There is no evidence that additional records have yet to be requested, or that additional examinations are in order. The Board is further satisfied that the RO has substantially complied with its January 2012 remand directives as they pertain to the claims herein decided. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (substantial compliance, rather than strict compliance, with the terms of a Board engagement letter requesting a medical opinion is required). As directed by the Board, the RO secured the Veteran's worker's compensation records and afforded him VA examinations in connection with his claims. Service Connection Claim The Veteran seeks entitlement to service connection for lumbar and left knee disorders. He does not contend that he suffered any specific injury to his back in the service. As for his knee disorder the appellant asserts that he suffered shrapnel injuries to his left knee in Vietnam in 1969, which has caused his current disability. Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Service connection may also be warranted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The Veteran has a current diagnosis of lumbar degenerative disc disease and status-post total knee replacements secondary to severe degenerative knee disease, documented on VA examination in February 2012. Service treatment records reveal no complaints, findings, or diagnoses pertaining to a lumbar spine or left knee disorder specifically. At service entry the Veteran reported a history of recurrent back pain and an old left leg fracture, but he denied having residual problems. At three separate pre-induction examinations physicians found no abnormalities of the spine or lower extremities. In May 1969, the Veteran suffered shrapnel injuries to his abdomen, left shoulder, left leg, face, and ear. On separation from service, the Veteran raised no complaints regarding his lumbar spine or left knee, and the examining physician found no pertinent abnormalities. First, with respect to the notations on the Veteran's Report of Medical History, the Board finds that these notations, by themselves, are not enough to overcome the presumption that the appellant was sound at induction. 38 U.S.C.A. §§ 1111, 1137. This is especially so when considering the fact that the Veteran underwent examination on three separate occasions by physicians who found no abnormalities with his back or left knee. Moreover, the notation of an old left leg fracture does not specifically implicate the knee itself. In short, there is insufficient evidence establishing that a back or left knee disability clearly and unmistakably existed prior to service. Therefore, the presumption may not be rebutted, and the Board's analysis must begin with the question whether the Veteran's disabilities were incurred during active service. See Wagner v. Principi, 370 F. 3d 1089 (Fed. Cir. 2004) (indicating that, in cases where the presumption of soundness cannot be rebutted, the effect is that claims for service connection based on aggravation are converted into claims for service connection based on service incurrence); VAOPGCPREC 3-03. Regardless of any deficiency in the in-service documentation, the Veteran served in Vietnam and was awarded the Combat Infantryman's Badge and the Purple Heart. Pursuant to 38 U.S.C.A. § 1154(b), combat veterans may establish service incurrence of a disease or injury through satisfactory lay or other evidence which is consistent with the circumstances, conditions or hardships of service, even in the absence of official record of such incurrence. See also 38 C.F.R. § 3.304(d). Accordingly, the Board presumes the in-service incurrence of a left knee injury. The Veteran is not entitled to the combat presumption for his lumbar spine disability because he does not contend that any particular injury was sustained while on active duty or in combat. While the combat presumption can assist the Veteran in establishing the in-service injury, it does not aid in otherwise establishing a medical nexus. See Libertine v. Brown, 9 Vet. App. 521, 522-23 (1996). A VA examination is required for this purpose. In a January 1974 physician's statement, prepared approximately three and a half years after discharge, it was noted that the Veteran had shrapnel in the abdomen which had not been removed. The record did not document problems pertaining to the lumbar spine or left knee. At a February 1974 VA examination abnormalities of the lumbar spine and left knee were not found. A left thigh scar was documented. The scar was non-tender, was two inches, and was transverse of the anterior aspect of the left thigh above the knee. The scar was not fixed to the underling structure. The Veteran had a full range of left knee motion. In VA treatment records of January 2008, December 2008, and April 2009, the Veteran was assessed with left knee degenerative joint disease, "workman's comp related." In June 2008, the Veteran was afforded a VA examination. The appellant denied injuring his back in-service, but reported suffering a left knee shell fragment wound while on active duty. Postservice the Veteran stated that his back pain had been worsening over the prior two years since sustaining a left knee injury. With respect to the left knee he reported no postservice problems with the joint until 2005. The examiner was not provided with the claims file before the examination. The examiner noted that the Veteran sustained a work-related knee injury in 2005, but the examiner failed to address whether either the appellant's left knee or back disorders were related to service. The Board remanded the case in January 2012 in order to obtain an opinion addressing the etiology of the Veteran's disabilities. In February 2012, a VA examiner documented that the Veteran had no memory of any specific incident involving his back in the military. His contentions regarding the shrapnel injury were documented, as was his history of a 2005 work-related incident in which he struck his knee against a pipe. After this incident, the appellant reported having two surgeries and two knee replacements. With regard to the lumbar spine, the examiner opined that based on the claims file, the Veteran's history, and the examination, a lumbosacral disorder was not related to his military service. The examiner based this opinion on the fact that he saw no evidence of any injury or complaints of lower back pain in the service treatment records, and given the Veteran's statement that he did not injure his back in the military. The examiner determined that the Veteran's degenerative disc disease was due to years of daily wear and tear. With regard to the left knee, the examiner opined that it was less likely than not that the current disability is due to military service. The examiner based this opinion on the fact that the Veteran's in-service shrapnel injury was above the knee joint in the region of the quadriceps tendon. The examiner saw no involvement of joint function, and did not know of any shrapnel injury to the distal quadriceps which would cause left knee degenerative joint disease. The examiner further noted the Veteran's statements that he injured his knee at work, and subsequently underwent surgery and knee replacements. The record is devoid of any other evidence addressing the etiology of the Veteran's lumbar spine or left knee disorders. Hence, as the preponderance of the most probative and competent evidence is against the claims, they must be denied. In reaching this decision the Board notes that to the extent the Veteran contends, on his own behalf, that his lumbar spine and left knee disorders are related to service, he is not shown to possess any specialized training in any medical field to provide a competent medical opinion on this point. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). The Veteran's reports of observable symptomatology, along with examination reports and diagnostic test results, were reviewed by VA physicians so that a medical opinion could be obtained. The Board finds these medical opinions to be of greater probative value than the Veteran's lay contentions, as determining the etiology of lumbar degenerative disc disease and status-post total knee replacements secondary to severe degenerative knee disease requires medical expertise. To the extent the Veteran contends a continuity of symptomatology since service, the Board finds he is competent to report his symptoms. Charles v. Principi, 16 Vet. App. 370, 374-75 (2002) (finding the appellant competent to testify regarding symptoms capable of lay observation). The Board finds, however, that the medical evidence from the service treatment records and following his separation from service, is more credible than the Veteran's lay contentions, particularly when it is considered that this history was submitted in support of a claim for monetary benefits. Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (a pecuniary interest may be found to affect the credibility of testimony.) While arthritis could be service connected if it was compensably disabling within one year of separation from active duty, 38 C.F.R. §§ 3.307(a), 3.309(a), there is no medical evidence documenting compensably disabling lumbar or left knee arthritis within one year of the Veteran's discharge from active duty in July 1970. Hence, presumptive service connection is not warranted. In short, the Board has reviewed all service treatment records, all VA medical and private treatment records, as well as the VA examination reports. While there is evidence of a current diagnosis, and while the Veteran is entitled to consideration of 38 U.S.C.A. § 1154, without competent evidence linking his lumbar spine and left knee disorders to service, the benefits sought on appeal cannot be granted. As a preponderance of the evidence is against finding that the Veteran's disorders are related to his military service, the doctrine of reasonable doubt is not for application. See 38 C.F.R. § 3.102. The claims are denied. Increased Rating Claim Disability evaluations are determined by the application of a schedule of ratings which is based on the average impairment of earning capacity in civil occupations. See 38 U.S.C.A. § 1155. Separate diagnostic codes identify the various disabilities. The assignment of a particular diagnostic code is dependent on the facts of a particular case. See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis, and demonstrated symptomatology. In reviewing the claim for a higher rating, the Board must consider which diagnostic code or codes are most appropriate for application in the Veteran's case and provide an explanation for the conclusion. See Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995). In an October 2008 rating decision, the RO awarded service connection for PTSD and assigned a 30 percent evaluation, effective from his April 29, 2008 date of claim. The Veteran expressed his timely disagreement with the rating assigned and the present appeal ensued. Given that the Veteran appealed the initial evaluation assigned, the severity of his disability is to be considered during the entire period from the initial assignment of the disability rating to the present. Fenderson v. West, 12 Vet. App. 119 (1999). Pursuant to the General Rating Formula for Mental Disorders, the next higher rating of 50 percent is assigned where there is evidence of occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130. The use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each Veteran's disorder, and the effect of those symptoms on the claimant's social and industrial adaptability. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). In determining the appropriateness of the 30 percent evaluation assigned to the Veteran's disability, the Global Assessment of Functioning scores assigned by medical providers throughout the course of this appeal will be discussed. A Global Assessment of Functioning score of 41-50 contemplates serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). See American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) at 44-47. A Global Assessment of Functioning score of 51-60 contemplates moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). Id. A Global Assessment of Functioning score of 61-70 contemplates some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. Id. A Global Assessment of Functioning score is highly probative as it relates directly to the Veteran's level of impairment of social and industrial adaptability, as contemplated by the rating criteria for mental disorders. See Massey v. Brown, 7 Vet. App. 204, 207 (1994). Considering the Veteran's psychiatric symptomatology in light of the above, the Board finds that a rating in excess of 30 percent is not warranted for the Veteran's PTSD since April 29, 2008. At a June 2008 VA examination the Veteran arrived appropriately dressed. He was oriented, polite and cooperative throughout the evaluation. He reported having an excellent relationship with his wife, and that he saw his son weekly. He spoke to his sister at least once per month. He reported that he did not engage in other forms of socialization, recreation, or leisure activities, but also made clear that he never had, due to the fact that he worked seven days a week for many years. The Veteran stated that he had worked until 2006 when he had to stop due to severe knee problems. The Veteran reported that he had always suffered from an anger problem, that he had trouble sleeping, that he suffered from bad dreams, and that various cues would trigger flashbacks. He described himself as being a loner, and the examiner noted that the appellant was hypervigilent. It was clear to the examiner that the Veteran had stayed busy much of his life to avoid dealing with his memories. Mental status examination revealed that the appellant's mood was appropriate to content discussed, and his affect was relatively appropriate, ranging from labile to happy when describing his work experiences and the time he used to enjoy working. His speech was normal. There was no evidence of perceptual impairments, no history of a thought disorder, and no hallucinations or delusions. Thought content was appropriate to the interview. The Veteran spontaneously provided various pieces of information with regard to his history. There was no suicidal or homicidal ideation. His memory, insight, concentration, abstract reasoning, judgment, and impulse control were all intact. He was assigned a global assessment of functioning score of 59. The examiner noted he was not able to work due to medical problems and his psychiatric symptoms did not prevent employment. The examiner characterized the Veteran's PTSD as chronic and moderate. He noted the Veteran was also experiencing an adjustment disorder with mixed anxiety and a depressed mood as a consequence of his knee surgery and physical limitations. In a December 2008 private medical report, it was noted that the Veteran was engaged in biofeedback therapy to assist with his symptoms of stress, sleep disturbance, anxiety, depression, tension, irritability, and short temper. He was presenting for treatment on a semi-weekly basis and was motivated and cooperative. On VA examination in February 2012, a box was checked indicating that the Veteran's PTSD was found to cause occupational and social impairment due to mild or transient symptoms which decreased efficiency and the ability to perform occupational tasks only during periods of significant stress, or his symptoms were controlled by medication. The only symptoms identified were suspiciousness, chronic sleep impairment, and anger. A number of other symptoms, including those contemplated by the 50 percent rating criteria, were listed on the examination form, but the corresponding boxes were not checked by the examiner. The Veteran was found capable of managing his financial affairs. He was assigned a global assessment of functioning score of 79. Collectively, the medical evidence reflects that since April 29, 2008, the Veteran's PTSD is manifested by symptoms included among the criteria for a 30 percent rating under the General Rating Formula. The Veteran's symptoms have included anger, suspiciousness, anxiety, sleep impairment, and depression. Generally speaking, the Veteran functioned satisfactorily with routine behavior, self-care, and normal conversation. As for social and occupational functioning, the record reflected that the Veteran had maintained a happy marriage, and had a regular relationship with his son and sister. It was specifically determined that the appellant's inability to work was due to nonservice connected medical problems, not psychiatric symptoms associated with posttraumatic stress disorder. Overall, these symptoms are indicative of occupational and social impairment with no more than occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, the level of impairment for which a 30 percent rating is assigned. While during this period, the Veteran exhibited some symptoms that are among those included for a 50 percent rating under the General Rating Formula, the objective evidence preponderates against finding that the Veteran's overall symptomatology during this timeframe is characteristic of a 50 percent rating. In this regard, the Veteran has had disturbances of motivation and mood and difficulty establishing and maintaining relationships. He has not, however, exhibited any other symptomatology indicative of a 50 percent rating, including a flattened affect, circumstantial, circumlocutory, or stereotyped speech, a difficulty in understanding complex commands, impairment of long and short-term memory, an impairment of judgment, or impaired abstract thinking. The global assessment of functioning scores assigned since April 29, 2008 preponderate against entitlement to a rating in excess of 30 percent. The Veteran was assigned a score of 59 in June 2008, and a score of 79 in February 2012. As noted above, a score of 51-60 contemplates moderate symptoms, and a score of 61-70 contemplates some mild symptoms. These scores are not indicative of the severity of symptoms contemplated by a 50 percent evaluation or higher. In assessing the severity of the Veteran's PTSD, the Board has considered his assertions regarding his symptoms, which he is competent to provide. Layno v. Brown, 6 Vet. App. 465, 470 (1994). However, the criteria needed to support higher ratings require medical findings that are within the province of trained medical professionals. See Jones v. Brown, 7 Vet. App. 134, 137-138 (1994). As such, the Veteran's assertions are not considered more persuasive than the objective medical findings which, as indicated above, preponderates against entitlement to higher ratings than those assigned. The Board has considered whether the Veteran's disability presents an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards such that referral to the appropriate officials for consideration of extra-schedular ratings is warranted. See 38 C.F.R. § 3.321(b)(1); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). There are no exceptional or unusual factors with regard to the Veteran's PTSD. The threshold factor for extra-schedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluation for that service-connected disability is inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating schedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical.") Here, the rating criteria reasonably describe the Veteran's disability level and symptomatology, and provide for consideration of greater disability and symptoms than currently shown by the evidence. Thus, his disability picture is contemplated by the rating schedule, and the assigned schedular evaluation is, therefore, adequate. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). Consequently, referral for extra-schedular consideration is not warranted. Finally, the Board considered whether an inferred claim for a total disability rating based on individual unemployability has been raised Rice v. Shinseki, 22 Vet. App. 447 (2009). The Board acknowledges that the Veteran is no longer employed. He has not, however, alleged that he is unemployable on account of his PTSD. To the contrary, the June 2008 examiner noted he is unemployable due to his medical problems (e.g., due to post operative residuals of knee surgeries). As such, the Board finds that Rice is inapplicable in the present case. Accordingly, the Board finds that entitlement to a rating higher than 30 percent is not warranted since April 29, 2008. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the doubt doctrine; however, as the preponderance of the evidence is against assignment of a higher rating, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER Entitlement to service connection for a lumbar disorder is denied. Entitlement to service connection for a left knee disorder is denied. Entitlement to a disability rating in excess of 30 percent for PTSD is denied since April 29, 2008. REMAND The Board finds that additional development is necessary before the Veteran's claim for entitlement to service connection for a skin disability can be properly adjudicated. The Veteran has a current diagnosis of tinea versicolor. Service treatment records indicate that in July 1968, the Veteran sought treatment for a rash on his left cheek of two days duration. He was diagnosed with impetigo and prescribed three medications for treatment. As noted by the Board in January 2012, the June 2008 VA examination was inadequate. The examiner diagnosed the Veteran with tinea versicolor and noted that the appellant reported having had a rash since his service in Fort Dix. The examiner opined that tinea versicolor was not secondary to herbicide exposure. Notably, the examiner failed to provide any rationale for that opinion, and failed to address whether it was at least as likely as not that the claimant's skin disorder was otherwise related to service. A medical examination report must contain clear conclusions with supporting data, and a reasoned medical explanation connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Additionally, without explanation, the VA examiner dismissed the Veteran's lay statements that he had experienced a rash since service. Buchanan v. Nicholson, 451 F.3d 1331, 1335 (a Veteran's competent lay account of in-service symptomatology must be considered in the evaluation of his claims.) Accordingly, in January 2012 the Board remanded the claim for another VA examination. Following a February 2012 VA examination the examiner concluded that it was less likely than not that the Veteran's skin disability was related to military service. For a rationale, the examiner stated that a review of the Veteran's service records did not show any treatment for a skin condition in the military. The Board finds this opinion is based on an inadequate factual predicate given the July 1968 documentation of a skin problem. See Reonal v. Brown, 5 Vet. App. 458, 460 (1993) (holding medical opinions have no probative value when they are based on an inaccurate factual predicate, such as the Veteran's self-reported and inaccurate history). Under these circumstances, VA must obtain a supplemental medical opinion from the February 2012 VA examiner, if available. The RO should arrange for the Veteran to undergo new VA examination in connection with this claim only if the February 2012 VA examiner is not available, or if the designated examiner is unable to provide the requested opinion without reexamining the Veteran. On remand, the RO should also obtain and associate with the claims file all outstanding VA medical records. While the claims file currently includes treatment records dated through January 2012 from the East Orange Campus of the VA New Jersey Health Care System, more recent treatment records may now be available. Records generated by VA facilities that may have an impact on the adjudication of a claim are considered constructively in the possession of VA adjudicators during the consideration of a claim, regardless of whether those records are physically on file. See Dunn v. West, 11 Vet. App. 462, 466-67 (1998). As such, the RO must obtain any updated records of VA treatment, following the current procedures prescribed in 38 C.F.R. § 3.159(c) as regards requests for records from Federal facilities. Accordingly, the case is REMANDED for the following action: 1. The RO/AMC should obtain all outstanding, pertinent records of evaluation and/or treatment for a skin disorder from the East Orange Campus of the VA New Jersey Health Care System dated since January 2012. All records and/or responses received should be associated with the claims file. If the RO/AMC cannot locate such records, it must specifically document the attempts that were made to locate them, and explain in writing why further attempts to locate or obtain any government records would be futile. The RO/AMC must then: (a) notify the claimant of the specific records that it is unable to obtain; (b) explain the efforts VA has made to obtain that evidence; and (c) describe any further action it will take with respect to the claims. The claimant must then be given an opportunity to respond. 2. Thereafter, forward the entire claims file to the VA examiner that prepared the February 2012 report for an addendum opinion. (If that examiner is unavailable, forward records to another equally qualified physician examiner for opinion (to include examination) as directed below.) The examiner is to be provided access to the claims folder, a copy of this remand, and Virtual VA. The examiner must specify in the report that the claims file and Virtual VA records have been reviewed. The examiner is requested to review all pertinent records associated with the claims file and Virtual VA and opine whether it is at least as likely as not, i.e., is there a 50/50 chance, that any current skin disorder had its onset during service, or is in any other way causally related to his active service. In so doing, the examiner must specifically consider and discuss the July 1968 service treatment record, documenting the Veteran's diagnosis of impetigo and resulting treatment. All opinions must be supported by a clear rationale, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. If an opinion cannot be provided without resort to speculation, the examiner should the examiner must provide a reason why this is so. If the prior examiner is not available, or is unable to provide the requested opinion without examining the Veteran, the RO must arrange for the Veteran to undergo a VA dermatological examination by a physician to obtain an opinion responsive to the question posed above. All indicated tests should be accomplished, and all clinical findings reported in detail. The claims file and access to Virtual VA must be made available to the examiner for review prior to entering any opinions, and the examination report should include discussion of the Veteran's documented medical history and assertions. 3. The Veteran is to be notified that it is his responsibility to report for any examination and to cooperate in the development of the claim. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2012). In the event that the Veteran does not report for an examination, documentation should be obtained which shows that notice scheduling the examination was sent to the last known address. It should also be indicated whether any notice that was sent was returned as undeliverable. 4. After the development requested has been completed, the RO/AMC should review the examination report to ensure that it is in complete compliance with the directives of this REMAND. The RO/AMC must ensure that the examiner documents his/her consideration of Virtual VA. If the report is deficient in any manner, the RO/AMC must implement corrective procedures at once. 5. After the completion of any action deemed appropriate in addition to that requested above, the appellant's claim should be readjudicated. If the benefit sought remains denied, the appellant should be provided a supplemental statement of the case and given the opportunity to respond. 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). ______________________________________________ DEREK R. BROWN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs