Citation Nr: 1301208 Decision Date: 01/11/13 Archive Date: 01/16/13 DOCKET NO. 05-35 086 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for a skin disability (previously diagnosed as prurigo nodularis), to include psoriasis. 2. Entitlement to service connection for an acquired psychiatric disability, to include posttraumatic stress disorder (PTSD). 3. Entitlement to service connection for arteriosclerotic heart disease. 4. Entitlement to service connection for hypertension, to include as secondary to an acquired psychiatric disorder, to include PTSD. 5. Entitlement to an increased rating for pilonidal cyst, rated as 10 percent disabling from April 2004. 6. Entitlement to an effective date earlier than April 19, 2004 for a compensable rating for pilonidal cyst. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD T. Wishard, Counsel INTRODUCTION The Veteran had active military service from November 1968 to November 1972. These matters come before the Board of Veterans' Appeals (Board) from a December 2004 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, Puerto Rico. These matters were previously before the Board in August 2008 and were remanded for further development. They have now returned to the Board for further appellate consideration. The Board finds that the RO substantially complied with the mandates of its remands and will proceed to adjudicate the appeal. Previously the issue of entitlement to service connection for arteriosclerotic heart disease with hypertension was before the Board. As arteriosclerotic heart disease and hypertension are separate diseases, and only one is subject to presumptive service connection, the Board has separated the claim into two separate issues. The issue of whether new and material evidence has been received to reopen a claim of entitlement to service connection for a skin disability (previously diagnosed as prurigo nodularis), to include psoriasis, the issue of entitlement to service connection for an acquired psychiatric disability, to include PTSD, and the issue of entitlement to service connection for hypertension, to include as secondary to an acquired psychiatric disorder, are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran had service in Vietnam in 1970, and is, therefore, presumed to have been exposed to herbicides. 2. The Veteran has a diagnosis of coronary artery disease (CAD). 3. Throughout the rating period on appeal, the Veteran's service-connected pilonidal cyst, status post surgery, has been manifested by complaints of a scar which is occasionally painful and warm; objectively, the Veteran has one superficial well healed stable scar approximately 5 centimeters (2 inches) in length over his right buttock, which is tender at touch, with no adherence to underlying tissue, and no elevation or depression of the surface contour of the scar on palpation. CONCLUSIONS OF LAW 1. Coronary artery disease (CAD), was incurred in active service. 38 U.S.C.A. §§ 1110, 1112, 1113, 1116, 1137, 5107 (West 2002 & Supp 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2012). 2. Throughout the rating period on appeal, the criteria for an evaluation in excess of 10 percent for pilonidal cyst, status post surgery, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.7, 4.10, 4.40, 4.45, 4.59, 4.118, Diagnostic Codes 7801-7805 (as in effect prior to and from October 23, 2008). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). See also Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Dingess v. Nicholson, 19 Vet. App. 473 (2006). See also Vazquez-Flores v. Shinseki, 24 Vet. App. 94 (2010). The duty to notify was met through VA notice provided to the Veteran in June 2004, October 2004, and March 2006. With regard to the duty to assist, the claims file contains the appellant's service treatment records (STRs), service personnel records, examination and treatment records, and the statements of the Veteran in support of his claims. The Board has carefully reviewed the statements and concludes that there has been no identification of further available evidence not already of record for which VA has a duty to obtain. The Board has also perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the appellant's claim for which VA has a duty to attempt to obtain. VA examinations were obtained in September 2004 (skin) October 2009 (heart) and March 2008 (skin). 38 C.F.R. § 3.159(c) (4). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the VA examinations obtained in this case are adequate, as they are based on physical examinations of the Veteran and interviews with him regarding his symptoms. The reports of VA examinations provide findings relevant to adjudicate the issues. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion has been met. 38 C.F.R. § 3.159(c) (4). Based on the foregoing, the Board finds that all relevant facts have been properly and sufficiently developed in this appeal and no further development is required to comply with the duty to assist the Veteran in developing the facts pertinent to his claims. Legal criteria Service connection is warranted if it is shown that a Veteran has a disability resulting from an injury incurred or a disease contracted in active service or for aggravation of a pre-existing injury or disease in active military service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2012). Service connection may also be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. See 38 C.F.R. § 3.303(d). Establishing service connection generally requires medical evidence or, in certain circumstances, lay evidence of the following: (1) A current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) nexus between the claimed in-service disease and the present disability. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed.Cir.2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed.Cir.2007); Hickson v. West, 12 Vet.App. 247, 252 (1999); Caluza v. Brown, 7 Vet.App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table). In Robinson v. Shinseki, 312 Fed. Appx. 336 (2009), the Court held that, in some cases, lay evidence will be competent and credible evidence of etiology. Whether lay evidence is competent in a particular case is a question of fact to be decided by the Board in the first instance. The Court set forth a two-step analysis to evaluate the competency of lay evidence. First, Board must first determine whether the disability is the type of injury for which lay evidence is competent evidence. If so, the Board must weigh that evidence against the other evidence of record-including, if the Board so chooses, the fact that the Veteran has not provided any in-service record documenting his claimed injury -to determine whether to grant service connection. The Board observes that this Federal Circuit decision is nonprecedential. However, see Bethea v. Derwinski, 252, 254 (1992) [a non-precedential Court decision may be cited "for any persuasiveness or reasoning it contains"]. The Board believes that if Bethea applies to the utility of Court decisions, it surely applies to the utility of decisions of a superior tribunal, the Federal Circuit. Presumptive service connection- herbicide exposure VA regulations provide that certain diseases associated with exposure to herbicide agents may be presumed to have been incurred in service even if there is no evidence of the disease in service, provided the requirements of 38 C.F.R. § 3.307(a)(6) are met. 38 C.F.R. § 3.309(e) (2012). A Veteran who, during active service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the Veteran was not exposed to any such agent during that service. 38 C.F.R. § 3.307(a). The last date on which such a Veteran shall be presumed to have been exposed to an herbicide agent shall be the last date on which he or she served in the Republic of Vietnam during the period beginning on January 9, 1962 and ending on May 7, 1975. The term "herbicide agent" means a chemical in an herbicide, including Agent Orange, used in support of the United States and allied military operations in the Republic of Vietnam during the Vietnam era. If a Veteran was exposed to an herbicide agent during active service, the following diseases shall be service-connected if the requirements of 38 C.F.R. § 3.307(a)(6) are met, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 C.F.R. § 3.307(d) are also satisfied: Chloracne or other acneform disease consistent with chloracne; Type 2 diabetes (also known as Type II diabetes mellitus or adult-onset diabetes); Hodgkin's disease; chronic lymphocytic leukemia; B cell leukemia, Parkinson's disease, multiple myeloma; non-Hodgkin's lymphoma; acute and subacute peripheral neuropathy; porphyria cutanea tarda; prostate cancer; respiratory cancers (cancer of the lung, bronchus, larynx or trachea); soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma); and ischemic heart disease, (including, but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina), shall be service-connected if the requirements of 38 C.F.R. § 3.307(a)(6) are met, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 C.F.R. § 3.307(d) are also satisfied. 38 C.F.R. § 3.309(e). The diseases listed at 38 C.F.R. § 3.309(e) shall have become manifest to a degree of 10 percent or more at any time after service, except that chloracne or other acneform disease consistent with chloracne, porphyria cutanea tarda, and acute and subacute peripheral neuropathy shall have become manifest to a degree of 10 percent or more within a year after the last date on which the Veteran was exposed to an herbicide agent during active military, naval, or air service. 38 C.F.R. § 3.307(a)(6)(ii). Where the evidence does not warrant presumptive service connection, the United States Court of Appeals for the Federal Circuit has determined that an appellant is not precluded from establishing service connection with proof of direct causation. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). Rating Disabilities - in general Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2012). When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. Id. § 4.3. Further, a disability rating may require re-evaluation in accordance with changes in a Veteran's condition. It is thus essential in determining the level of current impairment that the disability is considered in the context of the entire recorded history. Id. § 4.1. This appeal originates from a rating decision that granted service connection and assigned the initial rating. Accordingly, "staged" ratings may be assigned, if warranted by the evidence. Fenderson v. West, 12 Vet. App. 119 (1999). Rating Scars The Board observes that, while the Veteran's claim was pending, new rating criteria for evaluating skin disabilities became effective on October 23, 2008; however, these regulations apply only to claims filed on or after October 23, 2008. See 73 Fed. Reg. 54712 (September 23, 2008). DC 7801 provides ratings for scars, other than the head, face, or neck, that are deep or that cause limited motion. Scars that are deep or that cause limited motion in an area or areas exceeding 6 square inches (39 sq. cm.) are rated 10 percent disabling. Scars in an area or areas exceeding 12 square inches (77 sq. cm.) are rated 20 percent disabling. Scars in an area or areas exceeding 72 square inches (465 sq. cm.) are rated 30 percent disabling. Scars in an area or areas exceeding 144 square inches (929 sq.cm.) are rated 40 percent disabling. Note (1) to Diagnostic Code 7801 provides that scars in widely separated areas, as on two or more extremities or on anterior and posterior surfaces of extremities or trunk, will be separately rated and combined in accordance with 38 C.F.R. § 4.25. Note (2) provides that a deep scar is one associated with underlying soft tissue damage. 38 C.F.R. § 4.118. DC 7802 provides ratings for scars, other than the head, face, or neck, that are superficial or that do not cause limited motion. Superficial scars that do not cause limited motion, in an area or areas of 144 square inches (929 sq. cm.) or greater, are rated 10 percent disabling. Note (1) to Diagnostic Code 7802 provides that scars in widely separated areas, as on two or more extremities or on anterior and posterior surfaces of extremities or trunk, will be separately rated and combined in accordance with 38 C.F.R. § 4.25. Note (2) provides that a superficial scar is one not associated with underlying soft tissue damage. 38 C.F.R. § 4.118. DC 7803 provides a 10 percent rating for superficial unstable scars. Note (1) to DC 7803 provides that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2) provides that a superficial scar is one not associated with underlying soft tissue damage. 38 C.F.R. § 4.118. DC 7804 provides a 10 percent rating for superficial scars that are painful on examination. Note (1) to DC 7804 provides that a superficial scar is one not associated with underlying soft tissue damage. Note (2) provides that a 10-percent rating will be assigned for a scar on the tip of a finger or toe even though amputation of the part would not warrant a compensable rating. 38 C.F.R. § 4.118. DC 7804 also directs the rater to see 38 C.F.R. § 4.68 (amputation rule). 38 C.F.R. § 4.118. DC 7805 provides that other scars are to be rated on limitation of function of affected part. 38 C.F.R. § 4.118. Analysis The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the medical evidence for the issue on appeal. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzalez v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. Arteriosclerotic heart disease An October 2009 VA examination report reflects that the Veteran has a diagnosis of coronary artery disease (CAD). The Veteran's DD 214 reflects foreign service of one year, and the remarks section notes service in Vietnam. The Veteran's service personnel records also reflect service in Vietnam in 1970. As the evidence reflects that the Veteran served in Vietnam during the prescribed time period, he is entitled to the presumption of exposure to herbicides. Moreover, affirmative evidence does not exist to rebut that presumption. Service connection is warranted on a presumptive basis for a specific list of diseases set forth under 38 C.F.R. § 3.309(e) as listed above. As the Veteran's diagnosed disability of CAD is among the diseases recognized under 38 C.F.R. § 3.309(e), as a disease associated with exposure to certain herbicide agents, and in light of the fact that there is no evidence of an intercurrent cause of CAD, the Board concludes the Veteran is entitled to a grant of service connection for his CAD on a presumptive basis. 38 C.F.R. § 3.309(e). The Board notes that the Veteran has contended that his CAD is due to PTSD. As CAD may be granted on a presumptive basis, the Board need not address it on a secondary basis. Rating Pilonidal Cyst The Veteran's service-connected residuals of a pilonidal cyst are evaluated as noncompensable prior to April 19, 2004, and as 10 percent disabling effective from April 19, 2004. In a statement received in April 2004, the Veteran asserted that an increased evaluation was warranted. As the Veteran's claim was received by VA in April 2004, the rating period on appeal is from April 2003, one year prior to the date of receipt of the increased rating claim provided that the evidence reflects a worsening of the disability during that one year time period. 38 C.F.R. § 3.400(o)(2) (2012). See also Gaston v. Shinseki, 605 F.3d 979 (Fed. Cir. 2010). However, in accordance with 38 C.F.R. §§ 4.1 and 4.2 (2012) and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the history of the disability is for consideration in rating a disability. In a March 2010 rating decision, the RO granted an evaluation of 10 percent disabling from April 19, 2004. The Veteran underwent a VA examination in September 2004. The examination report reflects that the Veteran had a "linear scar about 2 inches long over his right buttock." A March 2008 VA examination report reflects that the Veteran had a 5 centimeter long surgical scar which was well healed. The Veteran reported sporadic recurrent pain at the site, as well as occasional warmth. Upon clinical examination, there was tenderness to touch. There was no adherence to underlying tissue. There was no elevation or depression of the surface contour of the scar on palpation. The scar was noted to be superficial and normal in skin color. The diagnosis was residual of pilonidal cyst scar tender at touch. The report is negative for any finding that the scar causes a limitation of motion. DC 7801 provides ratings for scars, other than the head, face, or neck, that are deep or that cause limited motion. As the evidence is against a finding that the Veteran has a deep scar or one that causes limitation of motion, DC 7801 is not applicable. DC 7802 provides ratings for scars, other than the head, face, or neck, that are superficial or that do not cause limited motion. The Veteran's scar has been clinically found to be superficial. Superficial scars that do not cause limited motion, in an area or areas of 144 square inches (929 sq. cm.) or greater, are rated 10 percent disabling. As the Veteran's scar is not 144 square inches or greater, it is not entitled to a compensable rating under DC 7802. DC 7803 provides a 10 percent rating for superficial unstable scars. The March 2008 VA examination report reflects that the Veteran's scar is not unstable. Thus, the Veteran is not entitled to a rating under DC 7803. DC 7804 provides a 10 percent rating for superficial scars that are painful on examination. The evidence of record reflects that the Veteran has one superficial scar that is tender to touch. Thus, a rating is 10 percent is warranted. DC 7805 provides that other scars are to be rated on limitation of function of affected part. There is no evidence that the Veteran has a limitation of function due to his superficial scar. In sum, a 10 percent rating, and no higher, is warranted for the entirety of the rating period on appeal. The Board has considered whether the Veteran would be entitled to a higher evaluation under the rating criteria in effect from October 23, 2008, but finds that he is not. The Board has also considered the doctrine of giving the benefit of the doubt to the appellant, under 38 U.S.C.A. § 5107 (West 2002), and 38 C.F.R. § 3.102 (2012), but does not find that the evidence is of such approximate balance as to warrant its application. Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Extra schedular Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). An extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1) . The evidence in this case does not show that the Veteran has manifestations of the skin disability that are not contemplated by the rating criteria or such an exceptional disability picture that the available schedular evaluation for the service-connected disability is inadequate. The rating criteria contemplates scar pain, stability, size, location, limitation of motion, and whether the scar is deep, adheres to underlying tissue, or is superficial. Therefore, a further analysis under Thun v. Peake, 22 Vet App 111 (2008) and referral for consideration of 38 C.F.R. § 3.321(b)(1) are not warranted. Total Rating for Compensation Based on Individual Unemployability (TDIU) TDIU is an element of all appeals of an increased rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). Entitlement to TDIU is raised where a Veteran : (1) submits evidence of a medical disability; (2) makes a claim for the highest rating possible; and (3) submits evidence of unemployability. Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). However, TDIU is not raised in an increased rating claim unless the Roberson requirements are met. Jackson v. Shinseki, 587 F.3d 1106 (Fed. Cir. 2009). In the present claim, the evidence of record does not reasonably raise a claim for entitlement to TDIU based on the Veteran's service-connected disability. Therefore, remand or referral of a claim for TDIU is not necessary as there is no evidence of unemployability due to service-connected disabilities. ORDER Entitlement to service connection for coronary artery disease (CAD) is granted. Entitlement to a rating in excess of 10 percent for residuals of a pilonidal cyst is denied. REMAND Skin disability (previously diagnosed as prurigo nodularis), to include psoriasis. In an October 1982 rating decision, the RO denied the Veteran's claim for entitlement to service connection for a skin disability. The Veteran again filed a claim for a skin disability in approximately 1986. At that time, he indicated that he had had black spots on his body which he believed were due to exposure to Agent Orange. He further alleged that he had had the spots since within a year of separation from service. A 1986 VA examiner diagnosed the Veteran with prurigo nodularis, a skin disability. In an October 1987 rating decision, the RO, which noted that the Veteran's claim had been previously denied in October 1982, again denied the Veteran's claim. In a May 1989 decision, the Board considered the Veteran's claim on a de novo basis and found that a skin disorder was not the result of, incurred in, or aggravated, by service, to include exposure to herbicides. In May 1994, the RO reopened the Veteran's claim for entitlement to service connection for prurigo nodularis, claimed as a skin disability and denied it. In an October 1997 decision, the Board denied the Veteran's claim because it was not well grounded. In 2004, the Veteran filed a claim for a skin disability. A September 2004 VA examination report reflects a diagnosis of psoriasis. In a December 2004 rating decision, the RO denied the Veteran's claim for entitlement to service connection for psoriasis. The Veteran's contentions now are essentially the same as they were when he previously filed his claim and it was denied by the RO in 1982, 1987, and 1994, and by the Board in 1989 and 1997; he contends that he has a skin disability due to exposure to herbicides in service. The Board notes that the Veteran's skin disability was diagnosed as prurigo nodularis in 1986 and as psoriasis in 2004. Prurigo nodularis is technically different than psoriasis; however, the Veteran's contentions are the same (i.e. skin disability of itchy rash/spots all over his body) The Board has considered whether the Veteran has filed a new claim "based upon distinctly diagnosed diseases or injuries . . . or whether it is evidence tending to substantiate an element of a previously adjudicated matter." Velez v. Shinseki, 23 Vet. App. 199 (2009). The diagnoses should be considered to determine the nature of the appellant's current condition relative to the claim he did submit. Clemons v. Shinseki, 23 Vet. App. 1 (2009). Thus, the Veteran's claim is essentially a claim to reopen a previously denied claim of entitlement to service connection for a skin disability. As such, the RO should have provided the Veteran with proper notice as to the criteria for reopening a previously denied claim, and adjudicated the issue as one of whether new and material evidence had been received to reopen a previous denied claim. Kent v. Nicholson, 20 Vet. App. 1 (2006). Acquired Psychiatric Disability, to include PTSD When a stressor claimed by a Veteran is related to the Veteran's fear of hostile military or terrorist activity, service connection may be warranted if a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of posttraumatic stress disorder and that the Veteran's symptoms are related to the claimed stressor. In the present case, the Veteran's claimed stressors have not been verified. Veteran has been diagnosed with PTSD by private examiners; however, such is insufficient to warrant service connection for PTSD as his clamed stressors are not verified. The Veteran underwent a VA examination in February 2010. The examiner found that the Veteran did not meet the DSM IV criteria for a diagnosis of PTSD. The examiner noted a diagnosis of "depression not otherwise specified by history." As noted above, an appellant's diagnoses which arise from the same symptoms for which he is seeking benefits, do not relate to entirely separate claims not yet filed by the appellant. Rather, these diagnoses should be considered to determine the nature of the appellant's current condition relative to the claim he did submit. Clemons, 23 Vet. App at 1. As the evidence indicates that the Veteran may have a diagnosis of depression, and in consideration of Clemons, the Board finds that the Veteran's claim for entitlement to service connection for PTSD should encompass a claim for entitlement to service connection for any acquired psychiatric disability. The Board finds that a supplemental clinical opinion with an opinion as to whether the Veteran has any acquired psychiatric disability causally related to active service, may be useful to the Board in adjudicating the Veteran's claim. Hypertension, to include as secondary to an acquired psychiatric disability, to include PTSD. The Veteran avers that he has hypertension due to, or aggravated by, an acquired psychiatric disability. As the Veteran's claim for entitlement to service connection for an acquired psychiatric disability is remanded herein, the inextricably intertwined issue of entitlement to service connection for hypertension as due to an acquired psychiatric disability must also be remanded. Effective date earlier than April 19, 2004 for a compensable rating for pilonidal cyst In a March 2010 rating decision, the RO granted an evaluation of 10 percent effective from April 19, 2004, the date of claim for increase, for the Veteran's pilonidal cyst. In a statement received by VA in June 2010, the Veteran asserted than his effective date should be "at least" the date he originally filed a claim for service connection in 1982. The claims file does not contain a statement of the case (SOC) on this issue of an earlier effective date. Where an SOC has not been provided following the timely filing of a notice of disagreement, a remand, not a referral is required by the Board. Manlincon v. West, 12 Vet. App. 238 (1999). Accordingly, the case is REMANDED for the following action: 1. Issue appropriate notice for the issue of whether new and material evidence has been received to reopen a claim of entitlement to service connection for a skin disability (previously diagnosed as prurigo nodularis), to include as due to herbicide exposure. The Veteran should be informed of the reason(s) for his prior final denial and what evidence is necessary to reopen the claim. 2. Request the February 2010 VA examiner, or another appropriate clinician if he is unavailable, to provide a supplemental opinion as to whether it is at least as likely as not (50 percent or greater) that the Veteran has an acquired psychiatric disability, to include depression, causally related to his military service. If the clinician cannot provide an adequate opinion without another VA examination, schedule the Veteran for such an examination. The claims folder should be reviewed in conjunction with such examination and the examination report should indicate that such a review was performed. Any opinion expressed should be accompanied by a complete rationale. 3. After undertaking any other development deemed appropriate, to include obtaining a clinical opinion on the issue of entitlement to service connection for hypertension as secondary to an acquired psychiatric disability if warranted, the RO should readjudicate the issues on appeal. If any benefit sought on appeal is not granted, the RO should issue a supplemental statement of the case and provide the Veteran and his representative with an appropriate opportunity to respond. The case should then be returned to the Board for further appellate consideration. 4. Issue a statement of the case pursuant to the notice of disagreement received in June 2010 as to the March 2010 rating decision, which in pertinent part, assigned an effective date of April 19, 2004 for the Veteran's pilonidal cyst disability. Only if the Veteran completes an appeal as to issue by the timely filing of a substantive appeal should such issue be certified to the Board for appellate consideration. 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). 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. 2012). ______________________________________________ M. E. LARKIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs