Citation Nr: 1338324 Decision Date: 11/21/13 Archive Date: 12/06/13 DOCKET NO. 09-47 725 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUES 1. Entitlement to service connection for a skin disability. 2. Entitlement to service connection for erectile dysfunction (ED). 3. Entitlement to service connection for bilateral ankle disabilities. 4. Entitlement to service connection for a sleep disorder. 5. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), depression, and anxiety. WITNESSES AT HEARING ON APPEAL The Veteran and his witness. ATTORNEY FOR THE BOARD Michael Wilson, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1963 to May 1967, including service at Nakhon Phanom Royal Thai Air Force Base from May 1966 to May 1977. This matter comes to the Board of Veterans' Appeals (Board) on appeal from April 2009 and May 2009 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Portland, Oregon. The Veteran and his witness, R. E., testified at a hearing before the undersigned Veterans Law Judge in September 2011. A transcript of that hearing is of record. The Board previously remanded the Veteran's current claims on appeal for further development in January 2012 and February 2013. In February 2013, the Board additionally denied service connection for bilateral hearing loss and remanded claims of entitlement to service connection for bilateral knee and foot disabilities. In a May 2013 rating decision, the RO subsequently granted service connection for bilateral knee strains, and for bilateral tinea pedis. This decision served as a complete grant of the benefits sought on appeal with respect to the Veteran's claimed bilateral knee and foot disabilities. The issue of entitlement to a total rating based on individual unemployability (TDIU) due to service-connected disabilities was previously referred to the Agency of Original Jurisdiction (AOJ) in the Board's prior February 2013 remand. It appears, however, that the AOJ still has not acted on this claim. Therefore, it is again referred to the AOJ for appropriate action. The issues of entitlement to service connection for a skin disability and for a sleep disorder are addressed in the REMAND portion of the decision below and are again REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the Veteran if further action is required on his part. FINDINGS OF FACT 1. There is no credible and competent evidence of record etiologically linking the Veteran's erectile dysfunction to his active service or to a service-connected disability. 2. There is no credible and competent evidence of record etiologically linking a bilateral ankle disability to the Veteran's active service or to a service-connected disability. 3. The Veteran does not have a current psychiatric disorder, to include PTSD, depression, and anxiety. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for erectile dysfunction have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2013). 2. The criteria for entitlement to service connection for a bilateral ankle disability have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2013). 3. The criteria for entitlement to service connection for a psychiatric disability, to include PTSD, depression, and anxiety, have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304(f) (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist In a December 2008 letter, the RO satisfied its duty to notify the Veteran under 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2013) and 38 C.F.R. § 3.159(b) (2013). The RO notified the Veteran of: information and evidence necessary to substantiate the claim; information and evidence that VA would seek to provide; and information and evidence that he was expected to provide. The Veteran was informed of the process by which initial disability ratings and effective dates are assigned, as required by Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The "duty to assist" contemplates that VA will help a claimant obtain records relevant to the claim, whether or not the records are in Federal custody, and that VA will provide a medical examination when necessary to make a decision on the claim. 38 C.F.R. § 3.159 (2013). VA has completed all reasonable actions possible to assist the Veteran with developing his claim for benefits in accordance with 38 U.S.C.A. § 5103A (West 2002) and 38 C.F.R. § 3.159(c) (2013). Relevant service treatment and private medical records have been associated with the claims file. Additionally, the Veteran has been afforded fully adequate VA examinations with respect to his claims. VA employees, including Board personnel, have two distinct duties when conducting hearings: The duty to explain fully the issues, and the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010) (per curiam) (interpreting the provisions of 38 C.F.R. § 3.103(c)(2)). At the Veteran's hearing the issues were identified, including the evidence required to substantiate each claim. There was also some discussion of potential evidence that could substantiate his claims. The Bryant duties were thereby met. Additionally, the Board finds that the RO/AMC substantially complied with the Board's February 2013 remand directives. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999); Stegall v. West, 11 Vet. App. 268 (1998). In this regard, the Board remanded the Veteran's claim to afford him VA examinations with respect to these claims. The requested examinations were conducted in March 2013. For the above reasons, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of the Veteran's service connection claims. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). II. Service Connection Service connection will be granted for a 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 (2012). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table). Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. See 38 C.F.R. § 3.303(d) (2012). Service connection may be established on a secondary basis for a disability that is proximately due to, the result of, or aggravated by a service-connected disease or injury. Regarding aggravation, VA will not concede aggravation of a nonservice connected disability by a service-connected disability unless there is a baseline for the claimed disability shown by medical evidence created prior to the claimed aggravation. 38 C.F.R. § 3.310(a); see also Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). In making all determinations, the Board must fully consider the lay assertions of record. Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009). A layperson is competent to report on the onset and continuity of current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). 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; Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (2007). 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. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v, 492 F.3d at 1376-77. As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza, 7 Vet. App. at 511. In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. Id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. See 38 U.S.C.A. § 5107 (West 2002); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Erectile Dysfunction Considering first the current disability requirement for the Veteran's claimed erectile dysfunction, the Board observes that ED was described in a July 1998 private treatment report. The report noted that his ED was likely medication related. An ED diagnosis was confirmed during a March 2013 VA genitourinary examination. Based on this evidence, the Veteran clearly has a current disability. See Walker, supra. With respect to in-service incurrence of erectile dysfunction, there is no evidence in the claims file to support a finding that the Veteran incurred his erectile dysfunction during or as a result of his service. His service treatment records (STRs) are devoid of any evidence of complaints of or treatment for ED during service. At this juncture, the Board finds it prudent to note that the Veteran has alleged exposure to Agent Orange during his service. The contention has been raised that he developed erectile dysfunction as secondary to herbicide exposure. During his September 2011 Board hearing, the Veteran testified that he served in South Vietnam and in Phnom Penh (Cambodia). His representative argued that receipt of the Vietnam Service Medal connoted his Vietnam service. However, such award is not dispositive of in-country service. Moreover, the personnel records do not reflect assignment within the Republic of Vietnam. The Veteran's AF Form 7 shows that he served at the Royal Thai Air Force base in Nakhon Phanom, Thailand from May 1966 to May 1967. This service in Thailand is sufficient to satisfy the requirements for the Vietnam Service Medal and the Republic of Vietnam Campaign Medal. See Manual of Military Decorations and Awards, A-6 (Department of Defense Manual 1348.33-M, September 1996). As such, receipt of these awards does not necessarily establish that the Veteran served in the Republic of Vietnam. A review of the Veteran's personnel records similarly fails to establish any service in the Republic of Vietnam or in the Korean demilitarized zone (DMZ) that would entitle him to a presumption of herbicide exposure. 38 C.F.R. § 3.307(a)(6) (2013). The Board notes that Department of Defense records indicate a significant use of herbicides on the fenced-in perimeters of military bases in Thailand during the Vietnam Era. The Veteran's personnel records note that he was a material facility specialist and a priority expediter. The specific duties of these positions, particularly whether they involved duty on or near the perimeters of Royal Thai Air Force, are unclear. Furthermore, the Veteran did not respond to a February 2012 request for additional evidence with regard to his daily activities while in Thailand. Thus, there is no way for the Board to determine whether or not he may have been exposed to herbicides along the perimeter of his base in Nakhon Phanom. Notably, however, irrespective of whether evidence could establish the Veteran's exposure to herbicides, the Board observes that erectile dysfunction is not one of the listed disabilities for which service connection may be awarded on a presumptive basis due to herbicide exposure. See 38 C.F.R. §§ 3.307, 3.309(d) (2013). Turning then the question of whether erectile dysfunction can be etiologically linked to the Veteran's service on a non-presumptive basis, he was afforded his VA genitourinary examination in March 2013 in order to ascertain the etiology of his ED. The examiner noted that ED was diagnosed, per the Veteran's report, in 1990. The examiner provided the opinion that the Veteran's ED was less likely than not incurred in or as a result of the Veteran's active service. The examiner based this opinion on a lack of evidence showing a diagnosis of ED during the Veteran's active service, and on his reported date of onset in 1990. The examiner additionally gave the opinion that the Veteran's ED was not at least as likely as not proximately due to, the result of, or chronically aggravated by his service-connected lumbar spine disability. Here, the examiner again noted the Veteran's reported date of onset of ED and noted that he had been taking hypertension medication since the early 1980s, including Atenolol, which is a known cause of ED. In providing this opinion the examiner cited to a medical treatise. Thus, rather than finding that the Veteran's ED was etiologically linked to his service either directly or secondarily, by means of his service-connected lumbar spine disability, the examiner has provided a clear, alternate etiology for the onset of the Veteran's ED. Based on the foregoing, the Board cannot make a finding that the Veteran's diagnosed ED was incurred during or as a result of his active service. While he has been treated for ED since 1990, there is no evidence of record attributing his ED to his service or to his service-connected lumbar spine disability. Rather, the March 2013 VA examiner provided a fully informed, fully articulated, and well reasoned opinion which attributed the Veteran's ED to his hypertension medication. See Nieves-Rodriguez, 22 Vet. App. at 304. The examiner's opinion is supported by contemporaneous medical evidence of record which additionally suggested that the Veteran's ED was induced by medication. The Veteran himself has not asserted that his ED was incurred during service. During his September 2011 Board hearing, he asserted that his ED probably began sometime in the early 1970s. However, he appeared uncertain about the onset of his ED, and when asked how the disability could be attributed to his service, he indicated that he was uncertain. The only specific contention of record is that the Veteran's ED was possibly incurred as a result of his service by means of his alleged herbicide exposure. As noted, however, his exposure to herbicides is not supported by the evidence of record; and regardless, service connection for ED is not available on a presumptive basis based on herbicide exposure. Accordingly, service connection for erectile dysfunction must be denied. Bilateral Ankle Disability Turning to the Veteran's claimed bilateral ankle disability, a residual left ankle sprain was diagnosed during his March 2013 VA examination. Based on this finding, the current disability requirement is met. See Walker, supra. The Veteran's STRs are devoid of any indication that he suffered from an ankle injury or disability during service. Nonetheless, he contended during his September 2011 hearing that he hit his ankles on bunkers and had falls during service to which he attributed his ankle disabilities. He also reported having hot and cold treatment on his ankles during service. In an effort to determine whether the Veteran had an ankle disability that could be etiologically linked to his service, he was afforded a VA examination in March 2013. The Veteran reported that he gets swelling in his ankles, which has progressively worsened. He noted that the swelling only occurred when he had pain, on the left side greater than right. He reported spraining his ankles a couple of times during service. He reported that he did not recall any residual pains after the sprains. He then reported having current weakness to the left ankle and pain, which he treated with ice and heat. The examiner provided the opinion that it was less likely than not that the Veteran's current residuals of an ankle sprain was incurred during or as a result of his active service. The examiner noted that there was no documentation of an ankle sprain or injury during service and that the record did not note a specific injury to the ankles. The examiner noted that during his Board hearing, the Veteran indicated that he did not recall an injury or accident to his ankles, but only discussed hitting his ankles on his bunkers during service. While clinical examination revealed findings consistent with chronic ankle sprains in the left ankle, the examiner could not reach a determination that the injury occurred during service. Based on this evidence, the Board cannot make a finding that the Veteran's current ankle sprains were at least as likely as not incurred during or as a result of service. Here, the March 2013 VA examiner noted the Veteran's contentions of "spraining his ankles a couple of times while [abroad]," and of hitting his ankles on bunkers, the examiner noted that he did not report residual pain. Moreover, in spite of the Veteran's contentions, the examiner reached the conclusion that the evidence of record could not support a finding that his current sprain residuals were at least as likely as not the result of his active service. The Board finds that the examiner's opinion was fully informed, fully articulated, and well reasoned. See Nieves-Rodriguez, 22 Vet. App. at 304. While the Veteran is competent to report experiencing ankle sprains during service, he is not competent to opine as to the etiology of his current ankle sprain residuals. See Jandreau, 492 F.3d at 1377. As it stands, his contentions regarding in-service injury are vague, and he has not clearly reported a continuity of ankle symptomatology since his separation from service. Where there is no competent or credible evidence of record showing that his ankle sprain residuals had their onset during service or are otherwise related to any in-service disease, event, or injury, service connection for bilateral ankle disabilities must be denied. Acquired Psychiatric Disorder The Veteran contends that he developed a psychiatric disorder, to include PTSD, as a result of multiple traumatic stressors during service. Namely, he contends that he suffered through mortar attacks on his base on a weekly basis. He additionally contends that he suffered a rocket attack after arriving at Thon Son Nhut Airbase in South Vietnam. The Veteran reported that the attack caused intense fear, nightmares, and sleep apnea. Thus, the Board observes that the Veteran's claimed PTSD is based on a fear of hostile military activity. To establish service connection for PTSD a Veteran must provide: (1) medical evidence diagnosing PTSD; (2) a link, established by medical evidence, between current symptoms of PTSD and an in-service stressor; and (3) credible supporting evidence that the claimed in-service stressor occurred. See 38 C.F.R. § 3.304(f) (2013). A Veteran may be granted service connection for any disease initially diagnosed after discharge, but only if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. See 38 C.F.R. § 3.303(d) (2013). On July 13, 2010, VA published a final rule that amended its adjudication regulations governing service connection for PTSD by relaxing, in certain circumstances, the evidentiary standard for establishing the occurrence of the required in-service stressor. See 75 Fed. Reg. 39843 (July 13, 2010), and 75 Fed. Reg. 41092 (July 15, 2010) (correcting the effective and applicability dates from July 12, 2010 to July 13, 2010). The amendment of 38 C.F.R. § 3.304(f) eliminates the requirement for corroborating evidence of the claimed in-service stressor if it is related to the Veteran's "fear of hostile military or terrorist activity." The new regulatory provision for this type of stressor requires that: (1) A VA psychiatrist or psychologist, or contract equivalent, must confirm that the claimed stressor is adequate to support a diagnosis of PTSD and (2) that the Veteran's symptoms are related to the claimed stressor; and (3) the claimed stressor must be consistent with the places, types, and circumstances of the Veteran's service. As noted previously, the Veteran's service in Vietnam has not been confirmed by the record. Nonetheless, the Board need not reach a determination regarding whether the claimed stressors are consistent with the places, types, and circumstances of his service, because the record fails to establish a current psychiatric diagnosis, to include PTSD. In this regard, the Veteran was afforded a VA mental health examination with a VA psychologist in March 2013. He reported the stressors of being exposed to rocket attacks while stationed at Thon Son Nhut Airbase, and exposure to weekly mortar attacks. The examiner noted that these alleged stressors met Criterion A (i.e., was adequate to support the diagnosis of PTSD), and that the stressor was related to the Veteran's fear of hostile military or terrorist activity. Nonetheless, after examining the Veteran, the examiner found that he did not meet the other diagnostic criteria for PTSD. Specifically, the examiner determined that the Veteran did not persistently reexperience the traumatic event (Criterion B), did not exhibit persistent avoidance of stimuli associated with the trauma (Criterion C), and did not have persistent symptoms of increased arousal (Criterion D). The Veteran did report, however, that he had difficulty falling or staying asleep. However, based on the absence of met diagnostic criteria, the examiner concluded that the Veteran did not meet the full criteria for PTSD. On examination of the Veteran, the examiner indicated that the only symptom potentially indicative of a mental health disorder was chronic sleep impairment. The examiner explained that the Veteran appeared to be psychologically healthy, and although he did report sleep problems, he noted that such symptoms appeared to be attributable to sleep apnea, and that a mental health diagnosis was not warranted for such sleep problems. The examiner further explained that the Veteran was not demonstrating PTSD symptoms and denied such when interviewed. He reported thinking about past Vietnam experiences, but denied this leading to anxiety and discomfort. The Veteran additionally reported during his examination that while he previously had problems with anxiety in the past, he had not taken Paxil for anxiety in over 10 years. He indicated that he was not taking any additional medications for anxiety and that he was not suffering from anxiety. The examiner also noted that he was not suffering from any depression or other mood disorders. The reports made by the Veteran are consistent with testimony he provided during his Board hearing. He noted that he had received treatment for anxiety in the past, in the 1980s and 1990s, but that he was not currently being treated for anxiety or other mental health issues. Upon a thorough review of the record, the Board observes that there is no evidence of treatment for any psychiatric condition in the record within the current appeal period. Moreover, the Veteran appears to discount the idea of currently suffering from any psychiatric disorder. Based on this record, the Board cannot find that the Veteran currently suffers from a current psychiatric diagnosis, to include PTSD, depression, or anxiety. In order to be considered for service connection, a claimant must first have a current disability. See Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992); Gilpin v. Brown, 155 F.3d 1353 (Fed. Cir. 1998) (service connection may not be granted unless a current disability exists). In the absence of currently diagnosed PTSD, service connection may not be granted. See also Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997). In this case, there is no medical evidence of record to support the Veteran's contention that he suffers from PTSD or any other psychiatric disability at any time during the appeals period. The Veteran's lay reports additionally would appear to weigh against his claim, especially where he has not subscribed to experiencing recent mental health symptoms. Accordingly, the Board finds that there is simply no evidence of record to warrant a finding of a current psychiatric disability. For this reason, the Board finds that the preponderance of the evidence is against the claim for service connection for an acquired psychiatric disability, to include PTSD, depression, and anxiety. For the reasons and bases provided above, the Board finds that the preponderance of the evidence is against the Veteran's claims for service connection for erectile dysfunction, for a bilateral ankle disability, and for an acquired psychiatric disorder, to include PTSD, depression, and anxiety. See Degmetich, 104 F.3d 1328 (Fed. Cir. 1997). The evidence in this case is not so evenly balanced so as to allow for application of the benefit of the doubt rule as required by law and VA regulations. See 38 U.S.C.A. § 5107 (West 2002). Accordingly, the Veteran's claims for service connection for erectile dysfunction, for a bilateral ankle disability, and for an acquired psychiatric disorder, to include PTSD, depression, and anxiety, are denied. ORDER Entitlement to service connection for erectile dysfunction is denied. Entitlement to service connection for a bilateral ankle disability is denied. Entitlement to service connection for a psychiatric disability, to include PTSD, depression, and anxiety, is denied. REMAND The Veteran's remaining claims are those of entitlement to service connection for a skin disability and for a sleep disorder. Unfortunately, another remand is required with respect to these issues in order to ensure completeness of the record upon which these claims will be decided. Sleep Disorder With respect to the Veteran's claimed sleep disorder, the Board is cognizant that he has consistently reported suffering from sleep disturbance for many years. Notably, as part of a May 2012 sleep study, his diagnosis included obstructive sleep apnea and hypersomnia. During his March 2013 VA examination, the examiner only discussed the sleep apnea diagnosis in the examination report. With respect to the Veteran's sleep history, only the circumstances surrounding his sleep apnea diagnosis were discussed. The examiner provided the opinion that the Veteran's sleep apnea was less likely than not incurred in or caused by an in-service injury, event, or illness. The examiner noted that the STRs were devoid of any evidence of a diagnosis of sleep apnea and noted that while the Veteran had symptoms of insomnia, in a January 2009 private medical report, he did not have snoring or apnea. In providing the examination report, the examiner did not appear to consider a diagnosis or etiology for any other sleep disorder, to include hypersomnia. Specifically, the examiner did not consider the Veteran's consistent reports of having some sort of sleep problem during service and since his separation from service. Additionally, he did not specifically discuss or provide an etiology opinion regarding the Veteran's diagnosed hypersomnia. Notably, during his March 2013 mental health examination, the Veteran reported having difficulty with sleep during service, and he reported taking medication for sleep since the 1970s. As the examiner clearly determined that the Veteran's sleep problems did not serve as a basis for a mental health examination, the true nature and etiology of the Veteran's sleep disorder remains elusive. For these reasons, remand is necessary in order to afford the Veteran a new VA examination to specifically consider any and all sleep disorders, to include hypersomnia, reasonably supported by the record. See Nieves-Rodriguez, 22 Vet. App. at 304. Skin Disability With respect to the Veteran's claimed skin disability, the Board notes at this juncture that service connection is now in effect for tinea pedis. Nonetheless, the Veteran reported in a February 2009 statement that his claimed skin disability included regions of his back, groin, feet, and hands. Thus, adequate consideration of a skin disability affecting regions of his body other than his feet remains at large. In this regard, the Board remanded the Veteran's skin disability claim in February 2013 in order to obtain additional comment from the March 2012 VA examiner with respect to the Veteran's currently diagnosed skin disabilities. In a May 2013 addendum opinion, the examiner simply provided a new opinion that the Veteran's claimed skin disability was less likely than not incurred in or caused by a claimed in-service injury, event, or illness. As a rationale for the opinion, the examiner indicated that the Veteran did not have a skin rash at the time of examination. Notably, the VA examiner did not address the question raised by the Board in the February 2013 remand with respect to whether the Veteran had a chronic dermatitis disability at present or at any time during his appeal period. Accordingly, remand is necessary in order to obtain an adequate medical opinion regarding the Veteran's claimed skin disability. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stegall v. West, 11 Vet. App. 268 (1998) (a remand by the Board imposes upon the Secretary of VA a concomitant duty to ensure compliance with the terms of the remand). Additionally, the Board notes that in the February 2013 remand, the AOJ was instructed to readjudicate the Veteran's skin disability claim based on all additional evidence, and to issue a supplemental statement of the case (SSOC) on this issue if it remained denied. The Veteran's claimed skin disability was not included in the most recent May 2013 SSOC. Thus, remand is also necessary for issuance of an SSOC. 38 C.F.R. § 20.1304 (2013); Stegall, supra. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a new VA dermatological examination. The claims file and a complete copy of this REMAND must be made available to and reviewed by the examiner in conjunction with the examination. The VA examiner should indicate that this has been accomplished. All necessary studies and tests should be conducted. The examiner should describe and diagnose all skin disabilities, except tinea pedis, found to be present, to include any skin disability affecting the Veteran's back, groin, and/or hands. The examiner should specifically determine whether the Veteran has a chronic dermatitis disability at present or whether he has had such disability at any time during the appeal period, from December 2008 onward. The examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any currently diagnosed skin disability, including dermatitis (if diagnosed any time since December 2008), had its clinical onset during active service or is related to any in-service disease, event, or injury. In providing this opinion, the examiner should specifically address the evidence of record showing that the Veteran suffered from skin conditions, including dermatitis, during his service, and address his report of a continuity of symptomatology since his separation from service. The examiner must provide a comprehensive report including complete rationales for all opinions and conclusions reached, citing the objective medical findings leading to the conclusions. 2. Schedule the Veteran for an appropriate VA examination to evaluate his claimed sleep disorder. The claims file and a complete copy of this REMAND must be made available to and reviewed by the examiner in conjunction with the examination. The VA examiner should indicate that this has been accomplished. All necessary studies and tests should be conducted. The examiner should describe and diagnose all sleep disorders found to be present, to specifically include sleep apnea and hypersomnia. The examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any such sleep disorder had its clinical onset during active service or is related to any in-service disease, event, or injury. In providing this opinion, the examiner must discuss the Veteran's consistent and credible reports of suffering from sleep problems during and since his separation from service. All relevant lay and medical evidence should be considered. The examiner must provide a comprehensive report including complete rationales for all opinions and conclusions reached, citing the objective medical findings leading to the conclusions. 3. Thereafter, review the claims file to ensure that the foregoing requested development has been completed. In particular, review the VA examination reports to ensure that they are responsive to and in compliance with the directives of this remand and if not, implement corrective procedures. See Stegall, supra. 4. Finally, readjudicate the Veteran's remaining service connection claims on appeal. If either claim remains denied, provide the Veteran and his representative with a supplemental statement of the case, and after they have had an adequate opportunity to respond, return this appeal to the Board for further appellate review. The Veteran 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). These claims 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). ______________________________________________ ERIC S. LEBOFF Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs