Citation Nr: 1318617 Decision Date: 06/07/13 Archive Date: 06/11/13 DOCKET NO. 10-14 159 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Whether new and material evidence has been received to reopen a claim for service connection for hypertension. 2. Entitlement to service connection for hypertension. 3. Entitlement to service connection for skin cancer. 4. Entitlement to service connection for right ankle degenerative arthritis as secondary to service-connected residuals of a left ankle fracture with a calcaneal spur. 5. Entitlement to service connection for bilateral knee degenerative joint disease (DJD) as secondary to service-connected residuals of a left ankle fracture with a calcaneal spur. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD Paul S. Rubin, Counsel INTRODUCTION The Veteran had active service in the U.S. Navy from November 1958 to November 1988. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a September 2007 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. In November 2012, in connection with the claim of service connection for skin cancer, the Board requested a specialist medical opinion from the Veterans Health Administration (VHA). 38 C.F.R. § 20.901(a) (2012). In response, a December 2012 VHA medical report was secured and associated with the claims folder for consideration. As required by VA law and regulation, the Board provided the Veteran and his representative copies of this report and afforded him time to respond with additional evidence or argument. See 38 C.F.R. § 20.903 (2012). In response, in April 2013, the Veteran's representative submitted additional argument and medical treatise evidence with a waiver of RO consideration for this evidence. See 38 C.F.R. § 20.1304(c) (2012). Thus, the case is again ready for Board consideration. A review of the Virtual VA paperless claims processing system does not reveal any additional documents pertinent to the present appeal. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). The issue of service connection for hypertension 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 RO denied service connection for hypertension in a January 1990 rating decision. The Veteran did not initiate an appeal. 2. Additional evidence received since the final January 1990 rating decision is new, relevant, and not cumulative of evidence already of record. 3. The Veteran's skin cancer was caused by ultraviolet light exposure as a welder during his active service. 4. Right ankle and bilateral knee arthritis are proximately due to or the result of the Veteran's service-connected left ankle disability. CONCLUSIONS OF LAW 1. The January 1990 rating decision that denied service connection hypertension is final. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. §§ 3.160(d), 20.200, 20.201, 20.302, 20.1103 (2012). 2. New and material evidence has been submitted since the last prior, final denial of the hypertension claim in January 1990, such that the claim is reopened. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156 (2012). 3. Skin cancer to the nose, left eyebrow, right elbow, and left forearm was incurred in active service. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2012). 4. Right ankle and bilateral knee arthritis is secondary to a service-connected left ankle disability. 38 C.F.R. § 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Duties to Notify and Assist For both the new and material evidence and service connection issues on appeal, review of the claims folder reveals compliance with the Veterans Claims Assistance Act of 2000 (VCAA), 38 U.S.C.A. § 5100 et seq. See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). The duty to notify was accomplished by way of VCAA letters from the RO to the Veteran dated in November 2006 and June 2007. As to the new and material evidence issue, the June 2007 VCAA notice letter is compliant with the United States Court of Appeals for Veterans Claims (Court's) decision in Kent v. Nicholson, 20 Vet. App. 1 (2006), since it sufficiently explained the bases of the prior January 1990 denial (i.e., the deficiencies in the evidence when the claim was previously considered). In any event, since the Board is reopening the new and material evidence issue for hypertension and granting the other service connection and secondary service connection issues on appeal, there is no need to discuss in detail whether there has been compliance with the notice and duty to assist provisions of the VCAA because, in light of the allowance of the claims, any error is inconsequential and, therefore, at most harmless error. See 38 C.F.R. § 20.1102; Bernard v. Brown, 4 Vet. App. 384, 392-94 (1993). With regard to the now reopened hypertension claim, the Board finds that further evidentiary development is needed and will be discussed herein below. Therefore, an analysis regarding compliance with the VCAA for the underlying claim of service connection for hypertension is not required at this time. New and Material Evidence - Hypertension The RO denied service connection for hypertension in a January 1990 rating decision. The RO notified the Veteran of that decision and apprised him of his procedural and appellate rights, but he did not initiate an appeal. Therefore, that decision is final based on the evidence then of record. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. §§ 3.160(d), 20.200, 20.201, 20.302, 20.1103 (2012). The RO denied service connection for hypertension in the final January 1990 rating decision because there was no probative evidence of a current hypertension. The medical evidence of record, including blood pressure readings at that time, did not establish a hypertension diagnosis either in-service, within one-year of service, or post-service. In the March 2010 Statement of the Case (SOC), the RO reopened the new and material evidence issue for hypertension and considered it on the merits. Regardless of the RO's actions, the Board has jurisdictional responsibility to determine whether a claim previously denied by the RO is properly reopened. See Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001) (citing 38 U.S.C.A. §§ 5108, 7105(c)). See also Barnett v. Brown, 83 F. 3d 1380 (Fed. Cir. 1996) and VAOPGCPREC 05-92 (March 4, 1992). Accordingly, the Board must initially determine whether there is new and material evidence to reopen the hypertension issue before proceeding to readjudicate the underlying merits of this claim. If the Board finds that no new and material evidence has been offered, that is where the analysis must end. The Veteran filed his application to reopen on the basis of new and material evidence in October 2006. Therefore, the amended regulation for new and material evidence applies. See 66 Fed. Reg. at 45,620 (applying the revised version of 38 C.F.R. § 3.156 to application to reopen filed on or after August 29, 2001). A claimant may reopen a finally adjudicated claim by submitting new and material evidence. New evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a) (2012). In determining whether evidence is new and material, the credibility of the evidence in question is presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). But see Duran v. Brown, 7 Vet. App. 216 (1994) ("Justus does not require the Secretary [of VA] to consider the patently incredible to be credible"). In Shade v. Shinseki, 24 Vet. App. 110, 117 (2010), the Court held that there is a low threshold for reopening the claim. New and material evidence within the meaning of 38 C.F.R. § 3.156(a) has been received since the previous, final January 1990 rating decision for hypertension. A private treatment record dated in December 2002 confirms a diagnosis of hypertension for the Veteran. Subsequent private treatment records also confirm this diagnosis of hypertension. In an October 2006 private medical opinion, Dr. A.B., MD., opined that the Veteran's hypertension began during his military service. Assuming the credibility of this evidence, this record now demonstrates medical evidence of current hypertension and relates to an unestablished fact, that is to say, this evidence is new and material and his hypertension claim is reopened. 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156(a). Governing Laws and Regulations for Service Connection Veterans are entitled to compensation from the VA if they develop disability "resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty." 38 U.S.C.A. § 1110 (wartime service), 1131 (peacetime service); 38 C.F.R. §§ 3.303, 3.306. In the absence of proof of a current disability, there can be no valid claim. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Under 38 C.F.R. § 3.303(a), service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service - the so-called "nexus" requirement. Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Under 38 C.F.R. § 3.303(d), disorders diagnosed after discharge may still be service connected if all the evidence, including pertinent service records, establishes the disorder was incurred in service. See Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). As to presumptive service connection, some diseases are chronic, per se, such as malignant tumors, and therefore will be presumed to have been incurred in service, although not otherwise established as such, if manifested to a degree of ten percent or more within one year after service. Even this presumption, however, is rebuttable by probative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of the facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). In essence, lay testimony is competent when it regards the readily observable features or symptoms of injury or illness and "may provide sufficient support for a claim of service connection." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336-37; Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Federal Circuit has held that medical evidence is not always or categorically required in every instance to establish the required nexus or linkage between the claimed disability and the Veteran's military service. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson, 581 F.3d at 1316. See also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). In short, when considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent on the issues of diagnosis and medical causation. Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011). In determining whether service connection is warranted, the Board shall consider the benefit-of-the-doubt doctrine. 38 U.S.C.A. 5107(b); 38 C.F.R. § 3.102; Alemany v. Brown, 9 Vet. App. 518 (1996); Gilbert v. Derwinski, 1 Vet. App. 49 (1991). Analysis - Service Connection for Skin Cancer The Veteran contends that his duties aboard ships in his military occupational specialty (MOS) as a welder or hull technician caused his skin cancer. Specifically, he believes that ultraviolet light associated with welding equipment precipitated the development of his skin cancer. He adds that as a welder he sustained frequent burns to the skin. During his 30 years as a welder in the Navy he adds he was constantly exposed to the sun in his duties. See October 2006 claim; November 2012 VHA request letter; April 2013 Informal Hearing Presentation (IHP). Upon review of the evidence of record, the Board grants the appeal for service connection for skin cancer to the nose, left eyebrow, right elbow, and left forearm. As mentioned, the first and most fundamental requirement for any service-connection claim is the existence of a current disability. Boyer, 210 F.3d at 1353; Brammer, 3 Vet. App. at 225. In this regard, a September 2007 VA skin examiner noted skin lesions on the bilateral arms and face that are "nonhealing." In a September 2007 biopsy report from Advanced Dermatology, basal cell carcinoma of the nasal tip, left eyebrow, right elbow, and left forearm was diagnosed. Thus, the Veteran has a current skin cancer diagnosis. Consequently, the determinative issue is whether the Veteran's skin cancer is attributable to his service. See Watson v. Brown, 4 Vet. App. 309, 314 (1993) ("A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or disease incurred in service."). See, too, Maggitt v. West, 202 F.3d 1370, 1375 (Fed. Cir. 2000). Service treatment records (STRs) dated from November 1958 to November 1988 are entirely negative for any complaints, treatment, or diagnosis of skin cancer or skin diseases. At the August 1988 retirement examination, the Veteran denied a history of skin diseases, and no skin diseases were found upon objective examination. However, the Veteran never alleges that symptoms of skin cancer began during service. Rather, his contention is that his in-service duties as a welder caused the post-service development of skin cancer due to decades of frequent ultraviolet light exposure. Post-service, within one-year of discharge, a June 1989 VA examiner documented several moles and scars scattered throughout the Veteran's body. There is no indication these moles or scars involved skin cancer at that time. Private treatment records dated in 2006 and 2007 document worsening squamous cell skin cancers on the face and bilateral arms. Post-service, with regard to a nexus, the evidence of record is mixed as to whether the Veteran's current skin cancer is the result of his MOS duties as a welder during his 30 years of military service. Holton, 557 F.3d at 1366. See also 38 C.F.R. § 3.303(a), (d). That is, the medical and lay evidence of record on this determinative issue of nexus includes several favorable and unfavorable medical opinions of record, as well as medical treatise evidence. The Board must determine, as a question of fact, both the weight and credibility of the evidence. Equal weight is not accorded to each piece of evidence contained in a record; every item does not have the same probative value. The Board must account for the evidence which it finds to be persuasive or unpersuasive, analyze the credibility and probative value of all material evidence submitted by and on behalf of a claimant, and provide the reasons for its rejection of any such evidence. See Struck v. Brown, 9 Vet. App. 145, 152 (1996); Caluza v. Brown, 7 Vet. App. 498, 506 (1995); Gabrielson v. Brown, 7 Vet. App. 36, 40 (1994); Abernathy v. Principi, 3 Vet. App. 461, 465 (1992); Simon v. Derwinski, 2 Vet. App. 621, 622 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164, 169 (1991). In evaluating the probative value of competent medical evidence, the Court has stated, in pertinent part: The probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches. . . . As is true with any piece of evidence, the credibility and weight to be attached to these opinions [are] within the province of the adjudicators; . . . Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). It is not error for the Board to favor the opinion of one competent medical expert over that of another when the Board gives an adequate statement of reasons or bases. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). As to the negative evidence against the claim, a December 2012 VHA dermatologist opined it is "NOT as likely as not" that use of torches and instruments and sun exposure consistent with the Veteran's duties as a welder over three decades of naval service ultimately caused the development of basal cell carcinoma on the face and upper extremities of the Veteran. The VHA physician remarked that the areas where skin cancer occurred on the Veteran would have been covered by protective equipment during the welding process. It was also noted there was no findings of sunburn in the STRs. The VHA physician cited medical treatise evidence dated in 1981, which showed that a study of welders did not show an increased risk of skin cancer. This opinion provides probative evidence against the claim. As to the positive evidence in support of the claim, Dr. A.B. in an October 2006 private medical opinion opined that "it is as likely as it is not" that the Veteran's skin cancer is related to his military service. Dr. A.B. stated that a review of STRs show that the Veteran had a history of recurrent burns from his job as a welder in the Navy. Dr. A.B. failed to provide any detailed rationale for his opinion. The failure of the physician to provide a basis for his/her opinion affects the weight or credibility of the evidence. Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). As to the positive evidence in support of the claim, in October 2007 Dr. J.M., D.O., a private dermatologist, opined that since welding does give off ultraviolet light, it is "a possibility" that this "could have been" a factor in the formation of the Veteran's skin cancer. Basal cell carcinoma was noted on the Veteran's nose, left temple, right arm, and left arm. The Board emphasizes that an equivocal medical opinion may still be competent, and cannot be considered "non-evidence." Hogan v. Peake, 544 F.3d 1295, 1297-98 (Fed. Cir. 2008). It must be considered in conjunction with the other evidence of record. An etiological opinion should be viewed in its full context and not characterized solely by the medical professional's choice of words. See Perman v. Brown, 5 Vet. App. 237, 241 (1993); Lee v. Brown, 10 Vet. App. 336, 338 (1997). The Court has pointed out that an absolutely accurate determination of etiology is not a condition precedent to granting service connection, nor is definite etiology or obvious etiology. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996). As to the positive evidence that somewhat supports the claim, in April 2013 the Veteran's representative submitted a medical journal article dated in August 2004 regarding the relationship between ultraviolet radiation from welding and the risk of skin cancer. The article indicated that arc welding produces the full spectrum of ultraviolet radiation. Arc welders may be at significantly increased risk of developing actinic and ocular damage, including malignancy, particularly if they have inadequate protection. Thermal burns from welding can contribute to this risk. The article assessed that "[i]t is possible arc welders are at greater risk of developing skin cancer that the general population, but there is a dearth of well designated studies in this area." One major study did not reveal an increased incidence of skin cancer in welders. However, the welders in that study were well protected and their length of exposure was limited, such that the findings could not be generalized to all welders. It was noted that many welders discard heavy welder's clothing and gloves in favor of short-sleeved shirts that exposed the hands, forearms, neck, and manubrium to a considerably increased level of ultraviolet radiation. Evidence linking welding to ocular melanoma is more established. (The Veteran has not been diagnosed with ocular melanoma). Ultimately, the article concluded that arc welding should be considered as a possible cause of skin cancer. Where medical article or treatise evidence, standing alone, discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least plausible causality based upon objective facts rather than on an unsubstantiated lay medical opinion, a claimant may use such evidence to meet the requirement for a medical nexus. Wallin v. West, 11 Vet. App. 509 (1998). However, an attempt to establish a medical nexus between service and a disease or injury solely by generic information in a medical journal or treatise "is too general and inclusive." Sacks v. West, 11 Vet. App. 314, 317 (1998) (a medical article that contained a generic statement regarding a possible link between a service-incurred mouth blister and a present pemphigus vulgaris condition did not satisfy the nexus element). Still, medical treatise evidence can provide important support when combined with an opinion of a medical professional. Mattern v. West, 12 Vet. App. 222, 228 (1999). See Rucker v. Brown, 10 Vet. App. 67, 73-74 (1997) (holding that evidence from scientific journal combined with doctor's statements was "adequate to meet the threshold test of plausibility"). In the present case, the Veteran has submitted a favorable medical opinion in support of his claim, as well as medical treatise evidence. As currently codified, VA law defines the "benefit of the doubt" doctrine as: When, after consideration of all evidence and material of record in this case before the Department with respect to benefits under laws administered by the Secretary, there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination in the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b). See also 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Here, there is an approximate balance of the positive and negative evidence. In the present case, both the favorable and unfavorable medical opinions and medical treatise evidence of record have respective weaknesses and strengths in probative value. And merely because skin cancer was not diagnosed during service, does not preclude service connecting it where, as here, there is probative medical evidence relating the disorder to ultraviolet light exposure from the Veteran's duties as a welder during service. See 38 C.F.R. § 3.303(d). Accordingly, resolving doubt in the Veteran's favor, the evidence supports service connection for skin cancer to the nose, left eyebrow, right elbow, and left forearm. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Governing Laws and Regulations for Secondary Service Connection In addition, a disability can be service connected on a secondary basis if it is proximately due to or the result of a service-connected condition. 38 C.F.R. § 3.310(a). Moreover, secondary service connection may be established, as well, by any increase in severity (i.e., aggravation) of a nonservice-connected condition that is proximately due to or the result of a service-connected condition. 38 C.F.R. § 3.310(b), effective October 10, 2006. See 71 Fed. Reg. 52,744-52,747 (September 7, 2006). See also Allen v. Brown, 7 Vet. App. 439, 448 (1995); Tobin v. Derwinski, 2 Vet. App. 34, 39 (1991). Where a service-connected disability aggravates a nonservice-connected condition, a Veteran may be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Allen, 7 Vet. App. at 448. In short, in order to establish entitlement to service connection on this secondary basis, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) evidence establishing a nexus (i.e., link) between the service-connected disability and the current disability. Analysis - Secondary Service Connection for Right Ankle and Bilateral Knees The Veteran contends that his current arthritis of the right ankle and both knees is caused by undue stress from his service-connected left ankle fracture. The Veteran maintains that the left ankle discomfort causes him to overcompensate on his right ankle and both knees. The Veteran does not contend, and the evidence does not show that his right ankle or bilateral knee arthritis was incurred directly during service. See October 2006 claim; December 2011 IHP. The Veteran has been service connected for residuals of a left ankle fracture with a calcaneal spur since 1988. The Board grants the appeal and finds that secondary service connection for right ankle arthritis and bilateral knee arthritis is warranted. The threshold criterion for service connection - on either a direct or secondary basis, is the existence of a current disability. Boyer, 210 F.3d at 1353; Brammer, 3 Vet. App. at 225. VA X-rays dated in September 2007 reveal degenerative changes of the right ankle and both knees. Earlier private X-rays of the knees dated in November 2001 also reveal arthritic changes in both knees. Thus, there is probative evidence the Veteran has current right ankle and bilateral knee disabilities in the form of arthritis. With regard to secondary service connection, most importantly, there is probative medical evidence of record that demonstrates the Veteran's current right ankle and bilateral knee arthritis is proximately due to or the result of his service-connected left ankle disability. 38 C.F.R. § 3.310(a); Velez v. West, 11 Vet. App. 148, 158 (1998). Specifically, Dr. A.B. in an October 2006 private medical opinion opined that the Veteran's service-connected left ankle disability causes "undue stress" on the right ankle and both knees. Although a September 2007 VA joint examiner assessed that it is "less likely than not" that the Veteran's current right ankle and bilateral knee conditions were the result of his left ankle condition, the VA examiner also added that such a secondary association "cannot be disproven." In addition, the September 2007 VA examiner concluded that arthritis of the right ankle and bilateral knees was "aggravated by the fact that the left ankle has difficulty." Also, somewhat supportive of these opinions is an earlier April 1989 VA examination, at which the Veteran reported symptoms of right knee pain developing since his left ankle injury in-service. Overall, these opinions provide strong evidence in support of secondary service connection for right ankle and bilateral knee arthritis. There is no contrary, negative opinion of record. Accordingly, the evidence supports secondary service connection for right ankle and bilateral knee arthritis. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The appeal is granted as to both those issues. The Board is granting secondary service connection for right ankle and bilateral knee arthritis on the basis of being the direct result of the Veteran's service-connected left ankle disability, as opposed to aggravation. ORDER The application to reopen the claim for service connection for hypertension is granted. Service connection for skin cancer to the nose, left eyebrow, right elbow, and left forearm is granted. Service connection for right ankle traumatic arthritis on a secondary basis is granted. Service connection for bilateral knee traumatic arthritis on a secondary basis is granted. REMAND As discussed, the claim of service connection for hypertension is reopened based on the submission of new and material evidence. However, before addressing the merits of the underlying service connection claim for hypertension, the Board finds that additional development of the evidence is required. STRs are negative for any complaints, treatment, or diagnoses of hypertension. Predominantly, the Veteran's blood pressure readings were not elevated during service. However, in 1987 and 1988, STRs document several instances of elevated blood pressure readings of 122/90 (January 1987 STR), 122/90 (June 1987 STR), 136/90 (May 1988 STR), 130/92 (September 1988 STR), and 140/90 (August 1988 retirement examination). See 38 C.F.R. § 4.104, Diagnostic Code 7101, Note 1 (the term hypertension means that the diastolic blood pressure (i.e., bottom number) is predominantly 90 mm or greater, and isolated systolic hypertension means the systolic blood pressure (i.e., top number) is predominantly 160 mm or greater with a diastolic blood pressure of less than 90 mm). Also, in May 1988, a positive exercise test suggested the presence of asymptomatic ischemia. Regardless, no formal diagnosis for hypertension was rendered in the STRs. Post-service, an April 1989 VA electrocardiogram (EKG) documented a normal blood pressure reading of 120/86. Regardless, a June 1989 VA examiner noted a "history of hypertension." Notably, the Veteran was described as a "heavy cigarette smoker." A private treatment record dated in December 2002 diagnosed hypertension. In an October 2006 private medical opinion, Dr. A.B. assessed that the Veteran's STRs show that he did have a diagnosis of hypertension while on active duty, such that his current hypertension is related to service. (Again, the Board observes that contrary to this opinion, STRs do not contain any formal diagnosis for hypertension). In October 2007, a VA heart examiner opined that STRs reveal no evidence of elevated blood pressure readings or cardiac complaints. However, this VA heart opinion is flawed as STRs do in fact reveal several instances of elevated blood pressure readings as well as ischemic suggestions. The RO must obtain a VA opinion (another VA examination is not necessary) from a VA clinician with regard to the Veteran's hypertension disability on the basis of in-service incurrence. See McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006); see also 38 U.S.C.A. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4). Specifically, the October 2007 VA heart examiner failed to consider relevant evidence of elevated blood pressure readings documented in the Veteran STRs in 1987 and 1988. A medical opinion based on an inaccurate factual premise has no probative value. See Reonal v. Brown, 5 Vet. App. 458, 460 (1993). Moreover, the probative value of a medical professional's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion." Bloom v. West, 12 Vet. App. 185, 187 (1999); see also Black v. Brown, 5 Vet. App. 177, 180 (1995). Therefore, the claims folder will be returned to a VA clinician who has not previously examined the Veteran to provide an addendum opinion with regard to the etiology of the Veteran's hypertension. See 38 C.F.R. § 4.2 (if the findings on an examination report do not contain sufficient detail, it is incumbent upon the rating board to return the report as inadequate for evaluation purposes). Another VA hypertension examination is not necessary in the present case, as it is now well-established that the Veteran has a diagnosis of hypertension. Accordingly, the hypertension service connection issue is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). Expedited handling is requested.) 1. The RO/AMC must secure a VA opinion (another VA examination is not necessary) from a VA clinician with regard to the Veteran's hypertension disability, on the basis of in-service incurrence. This clinician must be someone other than the October 2007 VA heart examiner. (Another VA examination is not necessary, as a diagnosis of current hypertension is already established). A qualified VA clinician must provide a medical opinion answering the following questions: (i) Is it "at least as likely as not" (meaning 50 percent or more probable) that the Veteran's current hypertension is related to his active service, to include evidence of elevated blood pressure readings documented in STRs in 1987 and 1988? (ii) If the clinician determines that the Veteran's hypertension is related to his active service, the clinician should also answer whether it is "at least as likely as not" (meaning 50 percent or more probable) that the Veteran's current hypertension is caused by his smoking / tobacco habit during service? (iii) The term "at least as likely as not" does not mean within the realm of medical possibility, but rather 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 that conclusion as it is to find against it. (iv) In making the above determinations, the reviewer's attention is drawn to the following specific items of evidence: STRs are negative for any complaints, treatment, or diagnoses of hypertension. Predominantly, the Veteran's blood pressure readings were not elevated during service. However, in 1987 and 1988, STRs document several instances of elevated blood pressure readings of 122/90 (January 1987 STR), 122/90 (June 1987 STR), 136/90 (May 1988 STR), 130/92 (September 1988 STR), and 140/90 (August 1988 retirement examination). Also, in May 1988, a positive exercise test suggested the presence of asymptomatic ischemia. For VA purposes, the term hypertension means that the diastolic blood pressure (i.e., bottom number) is predominantly 90 mm or greater, and isolated systolic hypertension means the systolic blood pressure (i.e., top number) is predominantly 160 mm or greater with a diastolic blood pressure of less than 90 mm). See 38 C.F.R. § 4.104, Diagnostic Code 7101, Note 1 Post-service, an April 1989 VA EKG documented a blood pressure reading of 120/86. A June 1989 VA examiner noted a "history of hypertension." Notably, the Veteran was described as a "heavy cigarette smoker." A private treatment record dated in December 2002 diagnosed hypertension. In an October 2006 private medical opinion, Dr. A.B. assessed that the Veteran's STRs show that he did have a diagnosis of hypertension while on active duty, such that his current hypertension is related to service. In October 2007, a VA heart examiner opined that the Veteran's STRs reveal no evidence of elevated blood pressure readings or cardiac complaints. 2. The RO/AMC must review the claims file and ensure that all of the foregoing development actions have been conducted and completed in full. If any development is incomplete, appropriate corrective action is to be implemented. If any report does not include adequate responses to the specific opinions requested, it must be returned to the providing physician for corrective action. See Stegall v. West, 11 Vet. App. 268, 271 (1998). 3. Thereafter, the RO/AMC must consider all of the evidence of record and readjudicate the issue of service connection for hypertension. If the benefit sought is not granted, issue a Supplemental Statement of the Case and allow the Veteran and his representative an opportunity to respond. Thereafter, if indicated, the case should be returned to the Board for the purpose of appellate disposition. No action is required of the Veteran until he is otherwise notified by the RO/AMC. By this action, the Board intimates no opinion, legal or factual, as to any ultimate disposition warranted in this case. 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). ______________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs