Citation Nr: 1314255 Decision Date: 04/30/13 Archive Date: 05/15/13 DOCKET NO. 07-13 292A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to service connection for diabetes mellitus, type II (DM), to include as due to herbicide exposure. 2. Entitlement to service connection for hypertension, to include as due to DM and/or herbicide exposure. 3. Entitlement to service connection for a skin disability, to include as due to DM and/or herbicide exposure. REPRESENTATION Veteran represented by: Vietnam Veterans of America ATTORNEY FOR THE BOARD Saira Spicknall, Counsel INTRODUCTION The Veteran served on active duty from February 1970 to December 1971. This matter comes to the Board of Veterans' Appeals (Board) on appeal from September 2006 and July 2009 rating decisions of the Nashville, Tennessee Department of Veterans Affairs (VA) Regional Office (RO). This case was previously remanded by the Board in March 2012 for additional development. A review of the Virtual VA paperless claims processing system reflects that additional records have been added to the present appeal. These records include VA medical records from October 2002 to January 2013. A supplemental statement of the case (SSOC) was issued in January 2013, which addressed this additional evidence. The issue of entitlement to service connection for hypertension, to include as due to DM and/or 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. Affording the Veteran the benefit of the doubt, the information of record indicates that he was present within the land borders of Vietnam during the Vietnam War; and thus exposure to herbicide agents in service may be presumed. 2. The Veteran has been diagnosed with DM. 3. Affording the Veteran the benefit of the doubt, the satisfactory and probative medical evidence of record has shown that skin disabilities diagnosed as acanthosis nigricans and diabetic foot ulcer are related to his DM. 4. The satisfactory and probative evidence of record demonstrates that skin disabilities diagnosed as seborrheic keratosis, a rash on the legs, cutaneous candidiasis, contact dermatitis, post inflammatory hyperpigmentation, and chronic folliculitis did not originate during the Veteran's active service or for many years thereafter and are not related to his active service or service-connected DM. CONCLUSIONS OF LAW 1. The criteria for the establishment of presumptive service connection for DM, to include as due to herbicide exposure, are met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303 , 3.307, 3.309 (2012). 2. The criteria for the establishment of service connection for skin disabilities diagnosed as acanthosis nigricans and diabetic foot ulcer, to include as due to DM, are met. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2012). 3. The criteria for the establishment of service connection for skin disabilities diagnosed as seborrheic keratosis, a rash on the legs, cutaneous candidiasis, contact dermatitis, post inflammatory hyperpigmentation and chronic folliculitis, to include as due to DM and/or herbicide exposure, have not been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act (VCAA) The VCAA, codified, in part, at 38 U.S.C.A. § 5103, was signed into law on November 9, 2000. Implementing regulations were created, codified at 38 C.F.R. § 3.159 (2012). VCAA notice consistent with 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1) (2012). The United States Court of Appeals for Veterans Claims (Court) held in Pelegrini v. Principi, 18 Vet. App. 112 (2004) that to the extent possible the VCAA notice, as required by 38 U.S.C.A. § 5103(a) (West 2002), must be provided to a claimant before an initial unfavorable decision on a claim for VA benefits. Pelegrini, 18 Vet. App. at 119-20; see also Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Prior to the initial adjudication of the Veteran's claims for service connection in the September 2006 and July 2009 rating decisions, he was provided notice of the VCAA in July 2006. An additional VCAA letter was sent in March 2012. The VCAA letters indicated the types of information and evidence necessary to substantiate the claim, and the division of responsibility between the Veteran and VA for obtaining that evidence, including the information needed to obtain lay evidence and both private and VA medical treatment records. The Veteran also received notice in July 2006 and March 2012, pertaining to the downstream disability rating and effective date elements of his claims, and was furnished statements of the case (SOCs) in April 2007 and May 2010 with subsequent re-adjudication in May 2010 and January 2013 SSOCs. Dingess v. Nicholson, 19 Vet. App. 473 (2006); see also Mayfield and Pelegrini, both supra. All relevant evidence necessary for an equitable resolution of the issues on appeal has been identified and obtained, to the extent possible. The evidence of record includes service treatment records, service personnel records, private medical records, VA outpatient treatment reports, adequate VA examinations and statements from the Veteran and his representative. The Board notes that the June 2012 and January 2013 VA examination reports reflect that the examiners reviewed the Veteran's past medical history, documented his current medical condition, and rendered appropriate diagnoses and opinions consistent with the remainder of the evidence of record, and with supporting rationale. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Consequently, the Board concludes that the medical examinations, especially taken together, are adequate for adjudication purposes. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). The Veteran has not indicated that he has any further evidence to submit to VA, or which VA needs to obtain. There is no indication that there exists any additional evidence that has a bearing on this case that has not been obtained. The Veteran and his representative have been accorded ample opportunity to present evidence and argument in support of his appeal. All pertinent due process requirements have been met. See 38 C.F.R. § 3.103 (2012). Pertinent Laws and Regulations Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303(a) (2012). In addition, service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In order to establish service connection for a claimed disorder on a direct basis, there must be: (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of the in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). Service connection may also be established on a secondary basis for a disability which is proximately due to or the result of a service connected disease or injury; or, for any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progression of the nonservice-connected disease. 38 C.F.R. § 3.310(a)-(b); Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). For purposes of establishing service connection for a disability resulting from exposure to herbicide agents, a veteran who had active military, naval, or air service in the Republic of Vietnam during the Vietnam Era, beginning on January 9, 1962, and ending on May 7, 1975, will be presumed to have been exposed to an herbicide agent during that service, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. 38 U.S.C.A. § 1116(f); 38 C.F.R. §§ 3.307(a)(6)(iii), 3.309(e). "Service in the Republic of Vietnam" includes service in the waters offshore and service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam. Id. The following diseases are deemed associated with herbicide exposure, under current VA law: AL amyloidosis, chloracne or other acneform diseases consistent with chloracne, Type 2 diabetes, Hodgkin's disease, ischemic heart disease (including, but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease, including coronary artery disease (including coronary artery spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina), all chronic B-cell leukemias (including, but not limited to, hairy-cell leukemia and chronic lymphocytic leukemia), multiple myeloma, non-Hodgkin's lymphoma, Parkinson's disease, acute and subacute peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx, or trachea), and soft-tissue sarcomas (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). The foregoing diseases shall be service connected if a veteran was exposed to an herbicide agent during active military, naval, or air service, if the requirements of 38 U.S.C.A. § 1116, 38 C.F.R. § 3.307(a)(6)(iii) are met, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 U.S.C.A. § 1113 (West 2002); 38 C.F.R. § 3.307(d) are also satisfied. 38 U.S.C.A. §§ 501(a), 1116; 38 C.F.R. § 3.309 (e). The diseases listed at § 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). Notwithstanding the foregoing presumption provisions, a claimant is not precluded from establishing service connection for disability due to exposure to herbicides with proof of direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994); Ramey v. Brown, 9 Vet. App. 40, 44 (1996), aff'd sub nom, Ramey v. Gober, 120 F.3d 1239 (Fed. Cir. 1997), cert. denied, 118 S. Ct. 1171 (1998). The determination as to whether the requirements for service connection are met is based on an analysis of all of the evidence of record and the evaluation of its credibility and probative value. 38 U.S.C.A. § 7104(a) (West 2002); 38 C.F.R. § 3.303(a) (2012). See Baldwin v. West, 13 Vet. App. 1 (1999). When there is an approximate balance of positive and negative evidence regarding a material issue, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2012). See Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001). If the Board determines that the preponderance of the evidence is against the claim, then it has necessarily found that the evidence is not in approximate balance, and the benefit of the doubt rule will not be applicable. Ortiz, 274 F.3d at 1365. With regard to VA examinations, the Board notes that the most recent examination is not necessarily and always controlling; rather, consideration is given not only to the evidence as a whole but to both the recency and adequacy of examinations. See Powell v. West, 13 Vet. App. 31, 35 (1999). Analysis 1. DM The Veteran essentially contends that he developed DM due to exposure to herbicides during service in the Vietnam War. Specifically, he contends that, while he served aboard U.S. Naval ships during his active service, he was appointed as a postal clerk and had to go on shore to pick up mail, which included going on shore in Vietnam while his ship was docked in the offshore waters of the Gulf of Tonkin. See Statements dated August 2011 and April 2012; see also Informal Hearing Presentation dated March 2013. The Board notes that the Veteran served on active duty in the U.S. Navy from February 1970 to December 1971. His service information provided by the National Personnel Records Center (NPRC) demonstrates that he served aboard the U.S.S. William H. Standley (DLG 32), which was in the official waters of the Republic of Vietnam from February 1971 to March 1971, from April 1971 to May 1971, from May 1971 to June 1971 and at the end of June 1971. His service personnel records also reflect that he was nominated for assistant postal clerk in December 1970 and this position was revoked in May 1971, due to the fact that he was transferred to another division. Therefore, as the Veteran's service information indicates he may have been present within the land borders of Vietnam during the Vietnam War, he will be presumed to have been exposed to an herbicide agent during that service. The Board accepts the statements made by the Veteran as competent and credible evidence that he set foot in the Republic of Vietnam. 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see Buchanan v. Nicholson, 451 F. 3d 1331, 1336 (Fed. Cir. 2006); Barr v. Nicholson, 21 Vet. App. 303 (Fed. Cir. 2007). In particular, the Board finds that the Veteran's statements are credible when considered with the other evidence of record. See Caluza v. Brown, 7 Vet. App. 498, 511-12 (1995). Specifically, the evidence of record contains no notation in an official document contradicting the Veteran's accounts of his service. Additionally, although the Veteran's service personnel records do not include any notation indicating in-service travel to Vietnam, the records indicate that the Veteran served as an assistant postal clerk from December 1970 to May 1971 aboard the U.S.S. William H. Standley (DLG 32) during the time the ship was in the official waters of the Republic of Vietnam. The post service medical evidence of record, including a VA Agent Orange registry letter and examination dated in April 2006, VA outpatient treatment reports from October 2002 to January 2013, private treatment records from July 2008 to June 2010, and a January 2013 VA examination for DM, reflects that the Veteran has been treated for and diagnosed with DM. Accordingly, after a careful review of the record and resolving all doubt in the Veteran's favor, the Board has determined, based upon the satisfactory and probative evidence set forth above, that presumptive service connection for DM is warranted. As the Veteran has presented credible lay evidence, corroborated by his service information indicating that he set foot in Vietnam during the Vietnam Conflict, the Board finds that on balance, the evidence of record collectively shows that the Veteran was present in Vietnam during the Vietnam War as claimed. Therefore, the Veteran is presumed to have been exposed to herbicides during his active service and his diagnosed DM, is presumed to be service connected. 38 U.S.C.A. § 1116(a); 38 C.F.R. §§ 3.102, 3.303, 3.309(e) (2012). See also 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 2. Skin Disability While the Veteran has been presumed to have been exposed to herbicides, as discussed above, the Board initially observes that no currently diagnosed skin disabilities are diseases which has been deemed associated with herbicide exposure for the purposes of establishing service connection on a presumptive basis. 38 U.S.C.A. § 1116(a); 38 C.F.R. § 3.309(e) (2012). Therefore, service connection for his skin disability will be analyzed on a direct basis. See Combee, 34 F.3d at 1042; see also Ramey, 9 Vet. App. at 44 (1996), aff'd sub nom, Ramey v. Gober, 120 F.3d 1239 (Fed. Cir. 1997), cert. denied, 118 S. Ct. 1171 (1998). The Veteran contends that his current skin disability, variously diagnosed, is due to his exposure to herbicides during his active service or, alternatively, is due to his DM. Service treatment reports reflect no findings of a skin disability upon the Veteran's entrance into active service. Other than a scar noted on the left side, the January 1970 entrance examination revealed no abnormalities of the skin upon clinical evaluation and the Veteran did not report any history of a skin disability in the January 1970 Report of Medical History. He was treated for and diagnosed with pediculosis pubis in March 1970 and was thereafter treated for and diagnosed with a rash on the chin and neck in July 1970, at which time he was prescribed to stop shaving. Again, other than a scar noted on the left side, the November 1971 separation examination revealed no abnormalities of the skin upon clinical evaluation. The post service medical evidence of record includes a VA Agent Orange registry letter and examination dated in April 2006, VA outpatient treatment reports from October 2002 to January 2013, private treatment records from July 2008 to June 2010, a June 2012 VA examination of the skin and a January 2013 VA examination of the skin. This evidence reflects that the Veteran has been variously treated for and diagnosed with skin disabilities, including folliculitis, post inflammatory pigment changes, seborrheic keratosis, a rash on the legs, cutaneous candidiasis, contact dermatitis, diabetic foot ulcer, post inflammatory hyperpigmentation, and acanthosis nigricans. In the June 2012 VA examination, the Veteran reported that he currently had a problem on both legs, characterized as sores on the skin with lesions that give fever, drain, come and go, and leave dark discolorations. He said they were first noted in 1995, some 20 years after his service. The Veteran provided a history in service of setting foot on land in the Republic of Vietnam and that he got frequent irritation and infection of his skin in service. He also stated he was provided a no shave certificate in service by the corpsman. The Veteran was diagnosed with post inflammatory hyperpigmentation, most likely secondary to recurrent chronic folliculitis. The examiner also noted there was evidence of previous tinea cruris, otherwise his examination was negative. In a January 2013 VA examination of the skin, the Veteran was diagnosed with diabetic foot ulcer, chronic folliculitis, and acanthosis nigricans. The examiner found that the Veteran had evidence of acanthosis nigricans around his neck and axilla area bilaterally, and there were no diabetic foot ulcers noted on the current examination on either foot or toe. She also noted that the Veteran had very dry skin on his legs, with a few patches on the back of the left thigh that were slightly scaly and hyperpigmented but no erythema, pustules or drainage, and were non tender to touch. The examiner observed that the Veteran had multiple old and healed hyperpigmented areas on his shins, which the Veteran related to his folliculitis condition. The examiner noted there was no evidence of any active folliculitis at that time. She opined that the Veteran's current skin conditions had no known correlation with his military history. She found that acanthosis nigricans was secondary to the poorly controlled DM, as were his diabetic foot ulcers. The examiner also found that the chronic folliculitis started in the 1990's, which was 20 years after service, and therefore the timeline would be against any exposure to Agent Orange or herbicides or the Veteran's military service to be the cause of his chronic folliculitis. The chronic folliculitis was not found to be secondary to DM either. The examiner concluded that there was no correlation between chronic folliculitis and DM which she was aware of and that DM did not cause folliculitis. Skin Disabilities Diagnosed as Acanthosis Nigricans and Diabetic Foot Ulcer After a careful review of the record and resolving all doubt in the Veteran's favor, the Board has determined, based upon the satisfactory and probative evidence set forth above, that service connection for a skin disabilities diagnosed as acanthosis nigricans and diabetic foot ulcer, to include as due to DM, is warranted. The Board notes initially, that the Veteran has been service connected for DM in this decision, to which he claims his skin disability is related. The medical evidence of record also demonstrates that the Veteran is currently diagnosed with several skin disabilities, including acanthosis nigricans and diabetic foot ulcers. There is also a positive medical opinion of record, relating the Veteran's acanthosis nigricans and diabetic foot ulcers to his service-connected DM. The medical opinions provided by the June 2012 VA examiner and the January 2013 VA examiner were based upon a review of the claims file, the medical expertise of each specialist, and were supported with an adequate rationale. Therefore, these opinions are afforded significant probative value. The June 2012 VA examiner diagnosed the Veteran with post inflammatory hyperpigmentation, most likely secondary to recurrent chronic folliculitis. Thereafter, the January 2013 VA examiner diagnosed the Veteran with diabetic foot ulcer, chronic folliculitis and acanthosis nigricans and opined that the Veteran's current skin conditions had no known correlation with the Veteran's military history. However, she found that acanthosis nigricans was secondary to the poorly controlled DM, as were his diabetic foot ulcers. Finally, the examiner found that the chronic folliculitis was not related to any exposure to Agent Orange or herbicides or the Veteran's military service and was not secondary to DM either. Therefore, the Board finds that the January 2013 VA medical opinion, taken together with the rest of the evidence of record, places the evidence in relative equipoise that the Veteran's skin disability, specifically his acanthosis nigricans and diabetic foot ulcers, are secondary to DM, and the benefit of the doubt rule will therefore be applied to resolve doubt in favor of the Veteran. Accordingly, on balance, the evidence of record collectively shows that the Veteran's skin disability, specifically acanthosis nigricans and diabetic foot ulcers, is proximately due to and the result of his service-connected DM. Thus, as the evidence supports the Veteran's claim, service connection for a skin disability, diagnosed as acanthosis nigricans and diabetic foot ulcer, to include as due to DM, is warranted. 38 C.F.R. §§ 3.102, 3.303, 3.310 (2012). See also 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Other Variously Diagnosed Skin Disabilities, Including Post Inflammatory Hyperpigmentation and Chronic Folliculitis After a careful review of the record, the Board has determined, based upon the satisfactory and probative evidence set forth above, that service connection for skin disabilities diagnosed as seborrheic keratosis, a rash on the legs, cutaneous candidiasis, contact dermatitis, post inflammatory hyperpigmentation and chronic folliculitis, to include as due to DM and/or herbicide exposure, is not warranted. While the Veteran has been presumed to have been exposed to herbicides, as discussed above, and is currently diagnosed with seborrheic keratosis, a rash on the legs, cutaneous candidiasis, contact dermatitis, post inflammatory hyperpigmentation and chronic folliculitis, the probative evidence of record does not demonstrate a nexus between any of these skin disabilities and either his active service, to include herbicide exposure, or his DM. Service treatment reports reflect that the treated for and diagnosed with pediculosis pubis in March 1970 and was thereafter treated for and diagnosed with a rash on the chin and neck in July 1970, at which time he was prescribed to stop shaving. Thereafter however, the November 1971 separation examination revealed no abnormalities of the skin upon clinical evaluation. The post service medical evidence of record also reflects that the Veteran has been variously treated for and diagnosed with skin disabilities, including folliculitis, post inflammatory pigment changes, seborrheic keratosis, a rash on the legs, cutaneous candidiasis, contact dermatitis, post inflammatory hyperpigmentation. The earliest diagnosis of any of these skin disabilities of record was made in November 2003, wherein the Veteran was treated for lesions on the upper body, diagnosed as seborrheic keratosis, approximately 32 years after his separation from active service. Further, there is no competent, credible, and probative evidence of record indicating a nexus between the Veteran's currently diagnosed seborrheic keratosis, a rash on the legs, cutaneous candidiasis, contact dermatitis, post inflammatory hyperpigmentation and chronic folliculitis and his active service. At no point has the Veteran asserted that any of these skin disabilities began during his active service or have continued since that time. In fact, in various statements of record the Veteran has reported that his skin disabilities, including folliculitis and hyperpigmented lesions and a rash, began in 1995 at the earliest and his statements only include assertions relating his skin disabilities to his active service, including herbicide exposure, as well as to his DM. See VA Form 21-526, Application for Compensation, dated May 2006; see also notice of disagreement (NOD) dated November 2006; VA examinations dated June 2012 and January 2013. In addition, the Veteran has not contended at any point that seborrheic keratosis, cutaneous candidiasis or contact dermatitis are skin disabilities for which he was claiming service connection. The Board observes the Veteran is not competent to diagnose or medically attribute any in-service symptom to a current disorder, to relate his current skin disabilities to his active service or to relate his current skin disabilities to any other disability. Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). The evidence does not demonstrate that the Veteran has the requisite medical competence to diagnose a skin disability or identify any etiology thereof. Id. As in Jandreau, the Veteran's assertions of causality have been investigated by competent medical professionals and found without merit. While the Agent Orange Registry letter, dated in April 2006, reported that the results of his laboratory tests indicated "Agent Orange cause" and included DM, a rash on the legs and hypertension, no medical opinion or rationale was provided which linked these disabilities to herbicide exposure or the Veteran's active service. The June 2012 VA examiner diagnosed the Veteran with post inflammatory hyperpigmentation, most likely secondary to recurrent chronic folliculitis. Thereafter, the January 2013 VA examiner found that the Veteran's current skin conditions had no known correlation with his military history. In her rationale she explained that the chronic folliculitis started in the 1990's, which was 20 years after service, and therefore the timeline would be against any exposure to Agent Orange or herbicides or the Veteran's military service to be the cause of his chronic folliculitis. In her examination she also observed that the Veteran had multiple old and healed hyperpigmented areas on his shins, which he had related to his folliculitis condition. The examiner noted there was no evidence of any active folliculitis at that time. In addition, she concluded that the chronic folliculitis was not found to be secondary to DM either, finding that there no correlation between chronic folliculitis and DM which she was aware of and that DM did not cause folliculitis. As noted earlier in this decision, these medical examinations, along with the conclusions and opinions by the VA examiners, especially when taken together, are adequate and are afforded significant probative weight. Given the medical complexity of this issue, the Board finds that the VA examinations, diagnoses and opinions outweigh any lay opinion provided by the Veteran. Accordingly, the probative evidence of record does not demonstrate a nexus between the Veteran's for skin disabilities diagnosed as seborrheic keratosis, a rash on the legs, cutaneous candidiasis, contact dermatitis, post inflammatory hyperpigmentation and chronic folliculitis, and his active service, to include as due to DM and/or herbicide exposure. Therefore, service connection for skin disabilities diagnosed as seborrheic keratosis, a rash on the legs, cutaneous candidiasis, contact dermatitis, post inflammatory hyperpigmentation and chronic folliculitis, is not warranted. In reaching the conclusion above the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim for service connection for skin disabilities diagnosed as seborrheic keratosis, a rash on the legs, cutaneous candidiasis, contact dermatitis, post inflammatory hyperpigmentation and chronic folliculitis, to include as due to DM and/or herbicide exposure, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). ORDER Service connection for DM, to include as due to herbicide exposure, is granted. Service connection for a skin disabilities diagnosed as acanthosis nigricans and diabetic foot ulcer, to include as due to DM, is granted. Service connection for skin disabilities diagnosed as seborrheic keratosis, a rash on the legs, cutaneous candidiasis, contact dermatitis, post inflammatory hyperpigmentation and chronic folliculitis, to include as due to DM and/or herbicide exposure, is denied. REMAND Although the Board regrets any further delay in adjudicating the Veteran's claim, pursuant to the duty to assist, the issue of service connection for hypertension, to include as due to DM and/or herbicide exposure, must be remanded for further development. In March 2012, the Board remanded the Veteran's claims, in part, to provide the Veteran with adequate VA examinations and opinions with respect to the disabilities on appeal. The Veteran was provided a VA examination for hypertension in January 2013. He was diagnosed with hypertension, noted has having been diagnosed in the early 1990s. The examiner opined that the Veteran's hypertension was diagnosed years after he left the military and it appeared to be essential hypertension, based on her review of the records and an interview with the Veteran. Therefore, in her opinion, she found that there was no correlation between the Veteran's diagnosis of hypertension and his military service, including Agent Orange or herbicide exposure, or his DM. She noted that DM did not cause hypertension and there was no known correlation the examiner was aware of linking Agent Orange or herbicide exposure in Vietnam to hypertension. The Board observes, and the Veteran's representative has correctly pointed out, that the January 2013 VA examiner did not provide an opinion regarding whether hypertension had been aggravated by DM, in considering the claim for service connection for hypertension on a secondary service connection basis. The duty to assist requires that VA make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate a claim. In claims for disability compensation, it requires that VA provide medical examinations or obtain medical opinions when necessary for an adequate decision. 38 C.F.R. § 3.159. A medical examination or medical opinion is deemed to be necessary if the record does not contain sufficient competent medical evidence to decide the claim, but includes competent lay or medical evidence of a current diagnosed disability or persistent or recurrent symptoms of disability, establishes that a veteran suffered an event, injury, or disease in service, or has a disease or symptoms of a disease manifest during an applicable presumptive period, and indicates the claimed disability or symptoms may be associated with the established event, injury, or disease. 38 C.F.R. § 3.159(c)(4) (2012). The U.S. Court of Appeals for Veterans Claims (Court) has held the types of evidence that "indicate" that a current disability "may be associated" with military service include credible evidence of continuity and symptomatology such as pain or other symptoms capable of lay observation. See McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). The Board notes that where a veteran's service-connected disability causes an increase in a nonservice-connected disability, the veteran is entitled to service connection for that incremental increase in severity attributable to the service-connected disability. See Allen v. Brown, 7 Vet. App. 439 (1995). Based on the evidence noted above, and as the Veteran is now service-connected for DM and the medical evidence of record reflects he has been treated for and diagnosed with hypertension, the Board finds that an adequate VA etiology opinion is required to facilitate appellate review in order to determine whether it is at least as likely as not (50 percent or greater probability) that hypertension was aggravated by his service-connected DM. McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006); Locklear v. Nicholson, 20 Vet. App. 410 (2006); see also Waters v. Shinseki, 601 F.3d 1274, 1276 (2010); Allen v. Brown, 7 Vet. App. 439; Barr v. Nicholson, 21 Vet. App. at 311. The nature of the claimed disorder is such that a medical opinion based on a review of the claims folder and examination of the Veteran would be of great value in evaluating the claim. As the record reflects the Veteran had received continuing treatment at VA and the last VA medical records associated with the file are from January 2013, ongoing medical records should also be obtained. 38 U.S.C.A. § 5103A(c) (West 2002); see also Bell v. Derwinski, 2 Vet. App. 611 (1992) (VA medical records are in constructive possession of the agency, and must be obtained if the material could be determinative of the claim). Accordingly, the case is REMANDED for the following action: 1. The AMC/RO should obtain and associate with the claims file any pertinent medical records adequately identified by the Veteran, to include all VA medical records from January 2013 to the present. All records which are not duplicates of those already in the claims file should be associated with the claims file. The RO/AMC should document whether or not these documents were available. 2. Thereafter, the AMC/RO should arrange for the claims file to be forwarded to the VA examiner who provided the January 2013 examination of hypertension, or if unavailable, a similar specialist, to provide an adequate opinion as to whether the Veteran's hypertension was aggravated by the service-connected diabetes mellitus, type II. The examination report is to contain a notation that the examiner reviewed the claims file. The examiner is asked to answer the following: (a). Whether it is at least as likely as not (50 percent or greater probability) that the Veteran's currently diagnosed hypertension was aggravated or permanently worsened beyond the natural progression of the disorder by his service-connected diabetes mellitus, type II. (b). If it is determined that the Veteran's hypertension was aggravated by his service-connected diabetes mellitus, type II, to the extent that is possible, the examiner should indicate the approximate degree of disability or baseline before the onset of the aggravation. Please include a discussion of the reasons for all opinions provided and address any relevant evidence, to include: (1) the post service medical evidence; and (2) the examiner's own expertise in the field. 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. If an opinion cannot be expressed without resort to speculation, discuss why such is the case. In this regard, indicate whether the inability to provide a definitive opinion is due to a need for further information or because the limits of medical knowledge have been exhausted regarding the etiology of the disability at issue or because of some other reason. 3. Following completion of the foregoing, the AMC/RO must review the claims folder and ensure that all of the foregoing development has been conducted and completed in full. In particular, the AMC/RO should determine whether the examiner has responded to all questions posed. If not, the report must be returned for corrective action. 38 C.F.R. § 4.2 (2012). 4. After the requested development has been completed, the AMC/RO should readjudicate the merits of the Veteran's claim based on all the evidence of record, including any additional information obtained as a result of this remand. If the benefits sought on appeal remain denied, the Veteran and his representative, if any, should be furnished a supplemental statement of the case (SSOC) and given the opportunity to respond thereto. Thereafter, subject to current appellate procedures, the case should be returned to the Board for further appellate consideration, if in order. The Board intimates no opinion as to the ultimate outcome of this case. The Veteran need take no action unless otherwise notified. 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). 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). ______________________________________________ P.M. DILORENZO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs