Citation Nr: 1316576 Decision Date: 05/21/13 Archive Date: 05/29/13 DOCKET NO. 10-47 199 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Diego, California THE ISSUE Entitlement to service connection for a skin disorder. ATTORNEY FOR THE BOARD Sara Schinnerer, Counsel INTRODUCTION The Veteran served on active duty from March 1987 to April 1991. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California. In a November 2010 rating decision, the RO granted entitlement to service connection for right wrist ganglion cyst, and assigned a 10 percent evaluation, effective December 2, 2008. Therefore, the issue is no longer before the Board, as the Veteran has been granted full benefits sought on appeal. Although the statement of the case addressed the Veteran's disagreement with the denial of entitlement to service-connection for a hearing loss disorder, the Veteran specifically limited his VA Form 9, substantive appeal, to the issue of service connection addressed herein. The appeal is remanded to the RO via the Appeals Management Center in Washington, DC. REMAND The Veteran contends that his current skin disorder had its onset during field activity while in service. He further contends that his disorder worsened during his subsequent deployment to Southwest Asia, as a result of exposure to the elements and wearing dirty fatigues, while serving in Desert Storm. In this regarding, in his November 2009 notice of disagreement, the Veteran reported that his rash began on his lower back, neck, and head, but continued to spread from such areas to his left leg and other parts of his body. At the outset, the Board notes that the Veteran's service has not been verified. In addition, the record contains only copies of some of the Veteran's service treatment records submitted by the Veteran. There is no indication that the RO attempted to verify the Veteran's service or obtain his service treatment records. As such, the RO should confirm the Veteran's period(s) of service, to include obtaining his service personnel records, as well as his complete service treatment records. See 3.159 (c) (2) (2012). Copies of the Veteran's available service treatment records include a September 1989 record which notes the Veteran sought treatment for a rash located on his waist area for a week. At the time of treatment, the Veteran reported that his symptoms included itching, which began in the field and had worsened. He reported that he was not sure if he was exposed to poison ivy. Examination revealed redness of the abdomen and lower back region, as well as scaling of the lower back region. The assessment was probable poison ivy. Following service, private treatment records dated in December 1995 demonstrate the Veteran sought treatment for an itchy rash on his waist region that started a year ago, and the rash on the other parts of his body started six months ago; the assessment was a lichenified lesion on the left posterior waist, maculopapular lesions around the neck, and possible tinea of an unspecified region. Records dated in August 1996 include the Veteran's complaints of itching and scaling on his back for months; the assessment was possible seborrhea or tinea. An August 1996 pathology report indicates a final diagnosis of lichen simplex chronicus of the back. Records dated in August 1997 note similar complaints and indicate diagnoses of seborrheic dermatitis, as well as a right leg lesion diagnosed as compound nevus. Records dated in March 2009 note findings of dryness on the back of the legs, as well as plaques on the scalp and right side groin; the assessment was lichen simplex chronicus and alopecia areata resolved. Records dated in November 2009 note findings of plaques on the left leg, as well as lesions on the left leg, neck, and low back. The Veteran was afforded a VA examination in March 2011. The examiner noted that the Veteran was treated for a rash on his abdomen and low back in September 1989 during service. The examiner further noted the aforementioned post-service treatment records and diagnoses. Upon examination, the examiner diagnosed lichen simplex chronicus by history apparently completely resolved; active dermatitis that involved two lesions of the left leg; and superficial inflammation of the left axilla. The examiner opined that the Veteran's current conditions were not related to his in-service rash or caused by or a result of exposure to environmental hazards during the Gulf War. The March 2011 VA examination is inadequate for purposes of adjudicating the appeal. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The March 2011 VA examiner noted the Veteran's treatment for a rash during service as well as his post-service symptomatology and diagnoses, however failed to address whether the in-service symptoms were early manifestations of any of the Veteran's current diagnoses. Further, the examiner did not provide a rationale for any of the opinions rendered. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Finally, although the examiner noted that the Veteran's lichen simplex chronicus had completely resolved, such diagnosis was noted in a March 2009 private record during the course of the present appeal. The requirement for a current disability is satisfied if there is evidence of the disability at any time since the Veteran's claim in December 2008, even if the disability is not currently present. McClain v. Nicholson, 21 Vet. App. 319 (2008). Accordingly, the case must be remanded in order for the Veteran to be afforded another VA examination to determine whether any diagnosed skin disorder had its onset in service, or is otherwise related to service. Accordingly, the case is remanded for the following actions: 1. The RO must obtain confirmation from the appropriate service department of all of the Veteran's periods of service. 2. The RO must obtain the Veteran's complete service treatment records, as well as his service personnel records and associate them with the claims file. 3. The RO must contact the Veteran and afford him the opportunity to identify or submit any additional pertinent evidence in support of his claim. Based on his response, the RO must attempt to procure copies of all records which have not previously been obtained from identified treatment sources. All attempts to secure this evidence must be documented in the claims file by the RO. If, after making reasonable efforts to obtain named records the RO is unable to secure same, the RO must notify the Veteran and (a) identify the specific records the RO is unable to obtain; (b) briefly explain the efforts that the RO made to obtain those records; (c) describe any further action to be taken by the RO with respect to the claim; and (d) that he is ultimately responsible for providing the evidence. The Veteran and his representative must then be given an opportunity to respond. 4. The Veteran must be afforded an appropriate VA examination to determine the nature and etiology of his current skin disorders. The Veteran's claims file and all records on Virtual VA must be made available to the examiner, and the examiner must specify in the report that the claims file and Virtual VA records have been reviewed. The examiner must specify the dates encompassed by the Virtual VA records. All pertinent symptomatology and findings must be reported in detail. Any diagnostic tests and studies must be accomplished. Based on the clinical examination, a review of the evidence of record, and with consideration of the Veteran's statements, the examiner must state whether any currently diagnosed skin disorder, to include the March 2009 diagnosis of lichen simplex chronicus and the March 2011 diagnoses of active dermatitis of the left leg and superficial inflammation of the left axilla is related to the Veteran's active military service. In providing such opinions, the examiner must comment on the September 1989 service treatment record which shows treatment for a rash located on the Veteran's abdomen and lower back. To the extent possible, the examiner must indicate whether the in-service rash was an early manifestation of any current skin disorder. A complete rationale for all opinions must be provided. If the examiner cannot provide the requested opinion without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. The examiner must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the examiner must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. The report prepared must be typed. 5. The RO must notify the Veteran that it is his responsibility to report for the examination and to cooperate in the development of his 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 the aforementioned examination, documentation must be obtained that shows that notice scheduling the examination was sent to the last known address. It must also be indicated whether any notice that was sent was returned as undeliverable. 6. The examination report must be reviewed by the RO to ensure that it is in complete compliance with the directives of this remand. If the report is deficient in any manner, the RO must implement corrective procedures. 7. Once the above actions have been completed, the RO must readjudicate the Veteran's claim on appeal, taking into consideration any newly acquired evidence. If the benefit sought remains denied, a supplemental statement of the case must be provided to the Veteran and his representative. After the Veteran has had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. No action is required by the Veteran until he receives further notice; however, he may present additional evidence or argument while the case is in remand status at the RO. Kutscherousky v. West, 12 Vet. App. 369 (1999). _________________________________________________ JOY A. MCDONALD Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2012).