Citation Nr: 1331318 Decision Date: 09/27/13 Archive Date: 10/01/13 DOCKET NO. 05-12 744 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUES 1. Entitlement to service connection for skin cancers, diagnosed as malignant melanoma and basal cell carcinoma, to include as secondary to inservice herbicide exposure. 2. Entitlement to service connection for skin disabilities, diagnosed as actinic keratosis, seborrheic keratosis, and benign neoplasms of basal cell epithelioma, to include as secondary to inservice herbicide exposure. 3. Entitlement to service connection for squamous cell carcinoma, to include as secondary to inservice herbicide exposure. 4. Entitlement to service connection for dermatitis, to include as secondary to inservice herbicide exposure. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD W. Yates, Counsel INTRODUCTION The Veteran served on active duty from September 1966 to June 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2004 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Detroit, Michigan. The October 2004 rating decision, in pertinent part, determined that new and material evidence had not been submitted to reopen the Veteran's claim of entitlement to service connection for skin cancer. It also denied the Veteran's claim of entitlement to service connection for a skin disability of the hands. The Veteran timely filed an appeal of these issues. In December 2008, the Board determined that the Veteran had submitted new and material evidence to reopen his claim seeking entitlement to service connection for skin cancer. The Board then remanded the reopened issue, along with the issue of service connection for a skin disability of the hands, for additional evidentiary development. The Board subsequently remanded this matter for further evidentiary development in January 2011, and again in June 2012. The issues on appeal have been recharacterized to properly reflect all skin disabilities for which the Veteran has been diagnosed during the course of this appeal. Clemons v. Shinseki, 23 Vet. App. 1 (2009) (holding that when a claimant makes a claim, he is seeking service connection for symptoms regardless of how those symptoms are diagnosed or labeled); McClain v. Nicholson, 21 Vet. App. 319 (2007). The issues of entitlement to service connection for squamous cell carcinoma and for dermatitis are remanded to the RO via the Appeals Management Center in Washington, DC. FINDINGS OF FACT 1. The Veteran served in the Republic of Vietnam from June 1967 to June 1968. 2. The Veteran's malignant melanoma and basal cell carcinoma did not have their onset during active service or within the first post-service year, and were not the result of an event, injury, or disease incurred in active service, to include inservice herbicide exposure. 3. The Veteran's actinic keratosis, seborrheic keratosis, and benign neoplasms of basal cell epithelioma are not the result of an event, injury, or disease incurred in active service, to include inservice herbicide exposure. CONCLUSIONS OF LAW 1. The criteria for service connection for skin cancer, diagnosed as malignant melanoma and basal cell carcinoma, to include as secondary to inservice herbicide exposure, have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2013). 2. The criteria for service connection for skin disabilities, diagnosed as actinic keratosis, seborrheic keratosis, and benign neoplasms of basal cell epithelioma, to include as secondary to inservice herbicide exposure, have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist Upon receipt of a substantially complete application for benefits, VA must notify the claimant what information or evidence is needed in order to substantiate the claim and it must assist the claimant by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5103(a), 5103A; 38 C.F.R. § 3.159(b) (2013); see Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The notice required must be provided to the claimant before the initial unfavorable decision on a claim for VA benefits, and it 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 the claimant is expected to provide. 38 U.S.C.A. §§ 5103(a); 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). The notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) veteran status; 2) existence of a disability; 3) a connection between the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Upon receipt of an application for a service-connection claim, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. Additionally, this notice must include notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Where a Veteran seeks to reopen a previously denied claim, the notice must inform the Veteran of both the reopening criteria and the criteria for establishing the underlying claim for service connection. See Kent v. Nicholson, 20 Vet. App. 1 (2006). The Board finds that VA's duty to notify was satisfied by a letters sent to the Veteran in May 2004, June 2004, and January 2009. Although the final letter was not sent until after the RO's initial unfavorable decision in October 2004, the Veteran's claim was subsequently readjudicated by the RO in multiple supplemental statements of the case. Prickett v. Nicholson, 20 Vet. App. 370, 377-78 (2006) (VA cured the failure to afford statutory notice to claimant prior to initial rating decision by issuing notification letter after decision and readjudicating claim and notifying claimant of such readjudication in the statement of the case). The duty to assist the Veteran has also been satisfied. The RO has obtained, or taken all reasonable steps to obtain, the Veteran's available service treatment records, and all available VA and private treatment records identified by the Veteran. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In June 2009, a VA skin examination was conducted. This examination was performed by a VA examiner who had reviewed the Veteran's claims file, reviewed with the Veteran his history of skin problems, examined the Veteran, and included rationale for the conclusions reached. In addition, a supplemental VA medical opinion was obtained in February 2011. This medical opinion was provided by a VA examiner that reviewed the Veteran's claims file, including his prior examination findings, and submitted a medical opinion with supporting rationale. The VA skin examination and supplemental medical opinion are adequate for evaluation purposes. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); 38 C.F.R. § 3.159(c) (4). The Veteran has not claimed that either the examination or supplemental medical opinion were inadequate. In January 2011 and June 2012, the Board remanded this matter to the RO directing: (1) that an attempt be made to locate any available treatment records from the VA hospital in Allen Park, Michigan, and from the VA Ann Arbor Healthcare System from the 1970s; (2) that the Veteran be asked to identify and complete a VA Form 21-4142 for any other treatment providers that he has seen for his skin disabilities; and (3) that a supplemental medical opinion be obtained addressing the etiology of the Veteran's skin disabilities. In September 2012, the RO sent correspondence to the Veteran requesting that he complete and return an authorization form for each health care provider that has treated him for a skin disability. The RO subsequently took all reasonable actions to locate records relating to the treatment claimed by the Veteran from the 1970s. In a December 2012 memorandum, the RO outlined the steps taken to obtain any available treatment records from the VA medical centers in Ann Arbor and in Detroit, Michigan, since 1970. In a June 2013 memorandum, the RO outlined the steps taken to obtain available treatment records from the Allen Park VA medical center since 1970. As noted in the memorandum, the RO's requests for these records were answered in the negative, and the Veteran was appropriately notified of these results. Finally, the RO obtained a supplemental medical opinion addressing the etiology of the Veteran's current skin disabilities in February 2011. Accordingly, the directives of the Board's January 2011 and June 2012 remands have been accomplished. See Stegall v. West, 11 Vet. App. 268 (1998). There is no sign in the record that additional evidence relevant to the issues being addressed is available and not part of the record. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). Laws and Regulations Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service. 38 U.S.C.A. §§ 1110. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To establish service connection for a disability resulting from a disease or injury incurred in service, or to establish service connection based on aggravation in service of a disease or injury which pre-existed service, there must be (1) competent evidence of the current existence of the disability for which service connection is being claimed; (2) competent evidence of incurrence or aggravation of a disease or injury in active service; and (3) competent evidence of a nexus or connection between the current disability and the disease or injury incurred or aggravated in service. Horn v. Shinseki, 25 Vet. App. 231, 236 (2010). In many cases, medical evidence is required to meet the requirement that the evidence be "competent". However, when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). Service connection for certain diseases, such as malignant tumors, may be established on a presumptive basis by showing that it manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 C.F.R. §§ 3.307(a)(3), 3.309(a). In certain cases, service connection can be presumed if a Veteran was exposed to an herbicide agent (including Agent Orange) during active service. Presumptive service connection is warranted for the following disorders: chloracne or other acneform disease consistent with chloracne; Type II diabetes; Hodgkin'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); and, soft-tissue sarcoma (other than ostrosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). Presumptive service connection for these disorders as a result of Agent Orange exposure is warranted if the requirements of 38 C.F.R. § 3.307(a)(6) are met. 38 U.S.C.A. § 1116; 38 C.F.R. § 3.309(e). The governing law provides that a "veteran who, during active military, naval, or air 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 U.S.C.A. § 1116(f). For the purposes of § 3.307, the term herbicide agent means a chemical in an herbicide used in support of the United States and allied military operations in the Republic of Vietnam during the Vietnam era. 38 C.F.R. § 3.307(a)(6)(i). Agent Orange is generally considered an herbicide agent and will be so considered in this decision. VA has determined there is no positive association between exposure to herbicides and any other condition for which VA has not specifically determined that a presumption of service connection is warranted. See Notice, 59 Fed. Reg. 341-346 (1994); see also 61 Fed. Reg. 41442-41449, 57586-57589 (1996). Notwithstanding the foregoing, regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d); see also Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). In other words, a presumption of service connection provided by law is not the sole method for showing causation in establishing a claim for service connection for disability due to herbicide exposure. See Stefl v. Nicholson, 21 Vet. App. 120 (2007) (holding that the availability of presumptive service connection for some conditions based on exposure to Agent Orange does not preclude direct service connection for other conditions based on exposure to Agent Orange). Factual Background and Analysis The Veteran served in the Army from September 1966 to June 1968, including service in the Republic of Vietnam from June 1967 to June 1968. His service treatment records are silent as to any inservice complaints of or treatment for a skin disability. The Veteran's separation examination, performed in June 1968, noted that his skin was normal. In December 1978, the Veteran was hospitalized for a possible coronary insufficiency. The hospitalization report noted that his skin was clear. A May 1993 dermatopatholology report noted diagnoses of seborrheic verruca, irritated and inflamed, left back; and nodular basal cell epithelioma, left chest. A June 1993 dermatopatholology report noted a diagnosis of residual nodular basal cell epithelioma with young scar and inflammation of the chest. A July 1993 dermatopatholology report noted a diagnosis of benign intradermal nevus of the right side of the lip. In August 1996, the Veteran submitted his original claim seeking service connection for skin cancer and skin rash. He indicated that his rash occurs each summer. In February 1997, a VA examination for skin disability was conducted. During the examination, the Veteran reported having had no problems with his skin "until two years after his military service (i.e., sometime in 1970)", when he began to notice a rash in his axillae, groin, and sometimes on his legs distal to his knees. As for the rash on his axillae, he reported that this occurs every summer and lasts about a week or so. As for the rash on his groin, he reported that this condition is seasonal, occurs every summer, coincides with the rash on his axillae, and also lasts about a week or so. As for the rash on his legs, he indicated that this condition is itchy and red. A physical examination was conducted, and the report concluded with diagnoses of multiple nevi on the trunk, arms and shoulders; skin tags on the groin; and history of basal cell epithelioma on the chest, status post excision. An August 2000 treatment report revealed a diagnosis of sebaceous cyst, right groin. A medical opinion letter, dated in February 2004, was received from P. M-L., M.D. In the letter, Dr. M-L. stated that the Veteran's basal cell epithelioma of the chest "may or may not have anything to do with Agent Orange." In November 2007, multiple skin biopsies were taken. A November 2007 surgical pathology report noted findings of hypertrophic actinic keratosis from the mid upper back; basal cell carcinoma, superficial type, right upper back; and malignant melanoma, lentigo maligna type, left upper arm. In March 2009, a VA examination for skin was conducted. The VA examiner noted that the Veteran's claims file had been reviewed. Following a physical examination, the report listed diagnoses of benign and malignant skin neoplasms, treated with excision or destruction. The VA examiner then opined that Veteran's malignant melanoma, basal cell epitheliomas, and actinic/seborrheic keratoses are not caused by or a result of his inservice exposure to Agent Orange. In support of this opinion, the VA examiner opined that Agent Orange, and more specifically dioxin, had been carefully studied for at least 40 years and to date no mention has been made that dioxin exposure has been associated with any increased incidence of the conditions diagnosed in this Veteran, including melanoma, basal epithelioma, or actinic or seborrheic keratosis. In June 2009, a VA examination for skin was conducted. The VA examiner noted that the Veteran's claims file had been reviewed. In discussing the Veteran's actinic and seborrheic keratoses, the report noted that these conditions are intermittent and insidious over many years, that the lesions resolve with treatment, and new ones occur. A physical examination was conducted, and the report listed diagnoses of malignant melanoma, left arm, status post excision; actinic and seborrheic keratoses; benign neoplasms, of the head, face, hand and forearms; and history of benign neoplasms of basal cell epithelioma. The VA examiner then opined that the Veteran's malignant melanoma, basal epitheliomas and actinic/seborrheic keratoses were not caused by or a result of his inservice exposure to Agent Orange. In support of this opinion, the VA examiner cited the lack of any evidence supporting a link between any of these conditions and herbicides, which have been studied for more than 40 years. In February 2011, a VA supplemental medical opinion was obtained. The VA examiner noted that the Veteran's claims filed had been reviewed. The examination report included a history of the Veteran's skin disabilities, and specifically noted the findings on the Veteran's VA skin examination in June 2009. As for the Veteran's basal cell epithelioma, the VA examiner noted this condition was also known as basal cell carcinoma, and was a malignant neoplasm of the skin. As for his seborrheic keratosis, the VA examiner described this condition as benign growths of skin associated with advancing age. The examiner noted that this condition is common in the general population, and has no clinical significance other than aesthetics. The examiner also described the Veteran's actinic keratosis as macular lesions appearing in sun-exposure areas of the body and are attributed to damage from ultraviolet radiation from the sun which damages dermal DNA resulting in pre-cancerous growth of skin cells which may give rise to squamous cell carcinoma. The report noted the primary risk factors for actinic keratosis is sun exposure. As for the Veteran's malignant melanoma, the report noted that this was a malignant neoplasm of the skin arising from melanocytes (pigment cells). It indicated that sun exposure increases the risk for malignant melanoma, but only slightly compared to persons with history of excessive sun exposure. The VA examiner opined that other than sun exposure, no particular aspect of the Veteran's service may be related to any of his claimed skin conditions. The VA examiner further opined that it was not medically possible to state, with any certainty, that any sun exposure experienced by the Veteran during service, as opposed to that experienced before or after service, is in any was causally related to the Veteran's claimed skin conditions, and any attempt to do so is a matter of mere speculation. In support of this opinion, the examiner stated that the Veteran would have experienced sun exposure before, during and after his military service. The VA examiner also noted that the Veteran's service treatment records were silent as to any treatment for severe sunburn. A December 2009 private treatment report noted findings and treatment for actinic keratoses and probable basal cell carcinoma on the right arm. The report noted that biopsies were performed in the basal cell carcinoma. A December 2009 histopathology report noted diagnoses of basal cell carcinoma of the right upper arm and squamous cell carcinoma of the right forearm. A December 2011 private treatment report noted treatment for actinic keratoses on the face and arms. A September 2012 treatment report noted findings of dermatitis on the face; rule out basal cell carcinoma on the mid lower back; and seborrheic keratosis, benign. The report noted that shave curettage was performed on the lesion on his mid lower back. A. Skin Cancers - Malignant Melanoma and Basal Cell Carcinoma Initially, the Board finds that malignant melanoma and basal cell carcinoma are not presumptively linked to herbicide exposure under the applicable regulations. 38 C.F.R. §§ 3.303, 3.307(a)(6), 3.309(e). The United States Court of Appeals for the Federal Circuit has held that when a claimed disorder is not warranted on a presumptive basis, direct service connection may nevertheless be established by evidence demonstrating that the disease was in fact "incurred" during service. See Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). The Veteran's military service records are negative for any evidence of skin disability. His separation examination, performed in June 1968, noted that his skin was normal. The Veteran has not alleged having any skin disability until two years after his military service, sometime in 1970, which is more than one year after his discharge from military service. Accordingly, for service connection to be granted there must be competent evidence of a nexus between the Veteran's malignant melanoma and/or basal cell carcinoma and his military service. The VA examiner in June 2009 concluded that the Veteran's malignant melanoma and basal cell carcinoma were not related to the Veteran's inservice exposure to herbicides. A subsequent VA medical opinion, dated in February 2011, concluded that neither condition could be attributed to the Veteran's military service, including his inservice sun exposure, with resorting to mere speculation. The Board finds the February 2004 medical opinion letter received from P. M-L., M.D., to be without any probative value. The "may or may not" terminology used in this opinion essentially renders it a nonopinion. The only evidence of record suggesting a link or nexus between the Veteran's malignant melanoma and basal cell carcinoma and his military service, including his inservice exposure to herbicide agents, comes from the Veteran himself. His statements, however, are not competent evidence on complex medical matters, and nexus between the Veteran's skin cancers and his military service is not shown. Due to the lack of nexus, direct service connection for the Veteran's malignant melanoma and basal cell carcinoma based on either herbicide or inservice sun exposure is not warranted. 38 C.F.R. §§ 3.303, 3.307(a)(6), 3.309(e). The Board has considered the provisions of 38 U.S.C.A. § 5107(b), but there is not such a state of approximate balance of the positive evidence with the negative evidence to otherwise warrant a favorable decision. Service connection for skin cancers, diagnosed as malignant melanoma and basal cell carcinoma, to include as secondary to inservice herbicide exposure, is not warranted. B. Skin Disabilities - Actinic Keratosis , Seborrheic Keratosis, and Benign Neoplasms of Basal Cell Epithelioma. The Veteran's currently diagnosed actinic keratosis, seborrheic keratosis, and benign neoplasms of basal cell epithelioma are not among the list of diseases enumerated under 38 C.F.R. § 3.309(e). Accordingly, the Board will proceed to evaluate the Veteran's claim under the provisions governing direct service connection, 38 U.S.C.A. § 1110 and 38 C.F.R. § 3.303. Combee v. Brown, 34 F.3d 1039 (1994). Evidence of record reflects that the Veteran has been diagnosed with several skin disabilities during the pendency of his claim. This includes for present purposes, actinic keratosis, seborrheic keratosis, and benign neoplasms of basal cell epithelioma. A finding of a nexus or casual relationship between the Veteran's currently diagnosed actinic keratosis, seborrheic keratosis, and benign neoplasms of basal cell epithelioma and in-service events is not shown. For his part, the Veteran has alleged that he first noticed a skin disability in 1970. This, however, is more than a year after his separation from military service. Objectively, the Veteran's service treatment reports are negative for any complaints of or treatment for a skin disability, and his June 1968 separation examination listed his skin as normal. Following his separation from service, a December 1978 hospitalization report noted that his skin was clear. The first objective evidence of record showing a diagnosis of or treatment for any of skin disability was in June 1993, 25 years after the Veteran's separation from military service. In this case, a skin disability is not alleged to have developed until over a year after the Veteran's separation from service. Moreover, the first evidence documenting a skin disability is not shown for 25 years after the Veteran's military service. The Board also notes that the passage of many years between discharge from active service and the medical documentation of a claimed disability is a factor that tends to weigh against a claim for service connection. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). The record also includes no probative medical opinion establishing a causal relationship between the Veteran's current skin disability and his military service, including presumed inservice herbicide exposure. VA examiners in June 2009 and February 2011 provided medical opinions that the Veteran's actinic keratosis, seborrheic keratosis, and benign neoplasms of basal cell epithelioma were not related to his inservice exposure to herbicide agents, and could not be linked to his military service without resorting to mere speculation. These opinions were based on a review of the Veteran's entire claims file, extensively discussed the medical evidence of record as well as the lay assertions of the Veteran, cited to medical literature research, and provided a detailed rationale for their conclusions. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (the probative value of a medical opinion comes from when it is the factually accurate, fully articulated, and sound reasoning for the conclusion, not the mere fact that the claims file was reviewed). The Board acknowledges the Veteran's contentions that his current skin disabilities are related to his presumed inservice herbicide exposure. Although the Veteran might sincerely have this belief, as a layperson, his statements are not competent evidence of a medical opinion regarding the etiology of his skin disabilities. See Barr, 21 Vet. App. at 307 (noting that lay testimony is competent to establish observable symptomatology but not competent to establish medical etiology or render medical opinions). In light of the cumulative record discussed above, the criteria to establish entitlement to service connection for a skin disability has not been established, either through medical or lay evidence. In arriving at the decision to deny the claim, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER Service connection for skin cancers, diagnosed as malignant melanoma and basal cell carcinoma, to include as secondary to inservice herbicide exposure, is denied. Service connection for skin disabilities, diagnosed as actinic keratosis , seborrheic keratosis, and benign neoplasms of basal cell epithelioma, is denied. REMAND The Veteran is seeking entitlement to service connection for squamous cell carcinoma and dermatitis. He attributes both of these skin disabilities to his inservice exposure to herbicides. Remand is required for compliance with VA's duty to assist the Veteran in substantiating his claims. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In considering the Veteran's claims for service connection for skin disabilities, the RO scheduled the Veteran for a VA examination of the skin in June 2009. The RO also obtained a supplemental VA medical opinion in February 2011. Following the June 2009 examination, and after the supplemental VA medical opinion was obtained, additional private treatment records were received which revealed additional skin disabilities that were not addressed in the June 2009 or February 2011 medical opinions. Specifically, a December 2009 histopathology report noted a diagnosis of squamous cell carcinoma of the right forearm. A September 2012 private treatment report noted a diagnosis of dermatitis of the face. Under these circumstances, the RO must obtain a new medical opinion, which considers all of the evidence now of record, addressing the etiology of the Veteran's current squamous cell carcinoma and dermatitis of the face. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (if VA provides the Veteran with an examination in a service connection claim, the examination must be adequate). Accordingly, the case is remanded for the following actions: 1. Obtain a supplemental medical opinion addressing the etiology of the Veteran's current squamous cell carcinoma of the right forearm and his dermatitis of the face. The claims folder and any pertinent records on Virtual VA must be made available to the examiner. After a review of the entire evidence of record, the examiner must render an opinion, in light of the service and post service evidence of record, as to: (a) whether it is at least as likely that the Veteran's current squamous cell carcinoma is the result of a disease or injury incurred during his military service, including exposure to herbicides such as Agent Orange, as it is the result of some other cause or factor. (a) whether it is at least as likely that the Veteran's current dermatitis is the result of a disease or injury incurred during his military service including exposure to herbicides such as Agent Orange, as it is the result of some other cause or factor. The Veteran's military occupational specialty, his statements regarding the history of inservice and post service skin problems, the objective medical findings upon entrance into and separation from his military service, post service examinations, and any other pertinent clinical findings of record, must be taken into account. If the examiner cannot provide the requested opinions 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. 2. The Veteran must be advised of the importance of reporting to the scheduled VA examination and of the possible adverse consequences, to include the denial of his claims, of failing, without good cause, to so report. See 38 C.F.R. § 3.655 (2013). A copy of the notification letter sent to the Veteran advising him of the time, date, and location of the scheduled examination must be included in the claims folder and must reflect that it was sent to his last known address of record. If he fails to report, the claims folder must indicate whether the notification letter was returned as undeliverable. 3. After completing the above actions, and any other development as may be indicated by any response received as a consequence of the actions taken in the paragraphs above, the claims remaining on appeal must be readjudicated. If either claim remains denied, a supplemental statement of the case must be provided to the Veteran and his representative. After the Veteran and his representative have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. 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). ____________________________________________ KATHLEEN K. GALLAGHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs