Citation Nr: 1510010 Decision Date: 03/10/15 Archive Date: 03/17/15 DOCKET NO. 10-20 701 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to service connection for diabetes mellitus. 2. Entitlement to service connection for hypertension. 3. Entitlement to service connection for peripheral neuropathy of the upper extremities. 4. Entitlement to service connection for residuals of a pilonidal cyst. 5. Entitlement to service connection for a skin (body rash) disability. 6. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for a back disability. 7. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for an acquired psychiatric disorder, to include PTSD and depression. 8. Entitlement to an increased rating for bilateral hearing loss disability, currently evaluated as noncompensable. 9. Entitlement to total rating for compensation purposes based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL Appellant, L. P. (spouse), and T.E. (daughter) ATTORNEY FOR THE BOARD T. Wishard, Counsel INTRODUCTION The Veteran had active military service from October 1967 to November 1971. These matters come before the Board of Veterans' Appeals (Board) from February 2008, March 2010, and March 2012 rating decisions of the Department of Veterans Affairs (VA), Regional Office (RO) in Houston, Texas. In September 2013, the Veteran and witnesses testified before a Decision Review Officer in Houston, Texas. A transcript of that hearing is of record. In December 2013, the Veteran and witnesses testified at a Travel Board hearing before the undersigned Veterans Law Judge. A transcript of that hearing is of record. These matters were most recently before the Board in April 2014 when the Board remanded them. The newly reopened issues of entitlement to service connection for a back disability and an acquired psychiatric disability, and the issues of entitlement to service connection for a skin disability, entitlement to an increased rating for bilateral hearing loss disability, and entitlement to TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDINGS OF FACT 1. The Veteran did not have service in Vietnam, Korea, or Thailand. 2. The competent credible evidence of record is against a finding that the Veteran was exposed to herbicides in service. 3. The earliest clinical evidence of diabetes, hypertension, and peripheral neuropathy is more than 30 years after separation from service. 4. The competent credible evidence of record does not support a finding that the Veteran has diabetes mellitus, hypertension, and peripheral neuropathy of the upper extremities, causally related to, or aggravated by, active service, or a service-connected disability. 5. The competent credible evidence of record does not support a finding that the Veteran has residuals of a pilonidal cyst. 6. In an unappealed November 1978 rating decision, the RO denied the Veteran's claim of entitlement to service connection for a back disability. 7. Evidence received since the November 1978 rating decision raises a reasonable possibility of substantiating the claim of entitlement to service connection for a back disability. 8. In an unappealed November 1978 rating decision, the RO denied the Veteran's claim of entitlement to service connection for a psychiatric disability. 9. Evidence received since the November 1978 rating decision raises a reasonable possibility of substantiating the claim of entitlement to service connection for an acquired psychiatric disability. CONCLUSIONS OF LAW 1. The criteria for service connection for diabetes mellitus have not been met. 38 U.S.C.A. §§ 1101, 1110, 1154, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2014). 2. The criteria for service connection for hypertension have not been met. 38 U.S.C.A. §§ 1101, 1110, 1154, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310 (2014). 3. The criteria for service connection for peripheral neuropathy of the upper extremities have not been met. 38 U.S.C.A. §§ 1101, 1110, 1154, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310 (2014). 4. The criteria for service connection for residuals of a pilonidal cyst have not been met. 38 U.S.C.A. §§ 1101, 1110, 1154, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304 (2014). 5. Evidence received since the November 1978 RO decision that denied service connection for a back disability, which was the last final denial with respect to this issue, is new and material; the claim is reopened. 38 U.S.C.A. §§ 5108, 7105 (West 2002); 38 C.F.R. § 3.156, 20.302, 20.1103 (2014). 6. Evidence received since the November 1978 RO decision that denied service connection for a psychiatric disability, which was the last final denial with respect to this issue, is new and material; the claim is reopened. 38 U.S.C.A. §§ 5108, 7105 (West 2002); 38 C.F.R. § 3.156, 20.302, 20.1103 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). See also Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Dingess v. Nicholson, 19 Vet. App. 473 (2006). Notice has been provided to the Veteran in November 2007 and September 2009. VA has a duty to assist the Veteran in the development of the claims. The claims file includes service treatment records (STRs), post service medical records, and the statements of the Veteran and other lay statements in support of his claims. The Board has considered the statements and perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claims for which VA has a duty to obtain. The Veteran testified that he is not in receipt of Social Security Administration (SSA) disability benefits; thus no further action with regard to SSA records is warranted. The Veteran has reported that he was hospitalized for three weeks and/or three months in service to due to his back and/or his skin; however, the Board finds, based on the Veteran's STRs which note dates of treatment, post service clinical records with noted histories, and his inconsistent statements, that he is less than credible as to such; thus, an attempt to obtain additional in service records is not warranted. The Board has considered whether a VA examination is warranted for diabetes, hypertension, and/or peripheral neuropathy, but finds that it is not. The most competent credible evidence of record does not reflect that the Veteran was exposed to herbicides in service, or that he has one of the above disabilities causally related to, or aggravated by, active service. In addition, the competent credible evidence does not reflect that the Veteran has a pilonidal cyst, symptoms of such, or residuals of such. Thus, a VA examination for such is not warranted. (As discussed in further detail below, the Veteran asserts a back disability due to surgery for a pilonidal cyst, rather than an actual residual of a cyst.) McLendon v. Nicholson, 20 Vet. App.79, 81 (2006) VA is not required to obtain a medical opinion for a claimant seeking to reopen a previously and finally disallowed claim prior to a determination that new and material evidence has been received. See Paralyzed Veteran's of Am. v. Sec'y of Veterans Affairs, 345 F.3d 1334 (Fed. Circ. 2003). Based on the foregoing, the Board finds that all relevant facts have been properly and sufficiently developed in this appeal and no further development is required to comply with the duty to assist the Veteran in developing the facts pertinent to the claims. Essentially, all available evidence that could substantiate the claims has been obtained. Service connection Establishing service connection generally requires medical evidence or, in certain circumstances, lay evidence of the following: (1) A current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) nexus between the claimed in-service disease and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed.Cir.2007); Hickson v. West, 12 Vet. App. 247 (1999); Caluza v. Brown, 7 Vet.App. 498 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table). For some "chronic diseases," presumptive service connection is available. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. With "chronic disease" shown as such in service (or within the presumptive period under § 3.307), so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). For the showing of a 'chronic disease' in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Id. If not manifest during service, where a veteran served continuously for 90 days or more during a period of war, or during peacetime service after December 31, 1946, and the 'chronic disease' became manifest to a degree of 10 percent within 1 year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307. The term "chronic disease," whether as shown during service or manifest to a compensable degree within a presumptive window following service, applies only to those disabilities listed in 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. Feb. 21, 2013). In each case where service connection for any disability is being sought, due consideration shall be given to the places, types, and circumstances of such Veteran's service as shown by such Veteran's service record, the official history of each organization in which such Veteran served, such Veteran's medical records, and all pertinent medical and lay evidence. 38 U.S.C.A. § 1154(a). Under 38 C.F.R. § 3.310, service connection may be granted for disability that is proximately due to or the result of a service-connected disease or injury, or for the degree of disability resulting from aggravation of a nonservice-connected disability by a service-connected disability. See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). Presumptive service connection - herbicide exposure VA regulations provide that certain diseases associated with exposure to herbicide agents may be presumed to have been incurred in service even if there is no evidence of the disease in service, provided the requirements of 38 C.F.R. § 3.307(a)(6) are met. 38 C.F.R. § 3.309(e). A Veteran who, during active 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 C.F.R. § 3.307(a). The last date on which such a Veteran shall be presumed to have been exposed to an herbicide agent shall be the last date on which he or she served in the Republic of Vietnam during the period beginning on January 9, 1962 and ending on May 7, 1975. A Veteran who, during active service, served between April 1, 1968, and August 31, 1971, in a unit that, as determined by the Department of Defense, operated in or near the Korean DMZ in an area in which herbicides are known to have been applied during that period, 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. The term "herbicide agent" means a chemical in an herbicide, including Agent Orange, used in support of the United States and allied military operations in the Republic of Vietnam during the Vietnam era. If a Veteran was exposed to an herbicide agent during active service, the following diseases shall be service-connected if the requirements of 38 C.F.R. § 3.307(a)(6) are met, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 C.F.R. § 3.307(d) are also satisfied: Chloracne or other acneform disease consistent with chloracne; Type 2 diabetes (also known as Type II diabetes mellitus or adult-onset diabetes); Hodgkin's disease; chronic lymphocytic leukemia; B cell leukemia, Parkinson's disease, multiple myeloma; non-Hodgkin's lymphoma; early onset peripheral neuropathy; porphyria cutanea tarda; prostate cancer; respiratory cancers (cancer of the lung, bronchus, larynx or trachea); soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma); and ischemic heart disease, (including, but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina), shall be service-connected if the requirements of 38 C.F.R. § 3.307(a)(6) are met, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 C.F.R. § 3.307(d) are also satisfied. 38 C.F.R. § 3.309(e). The diseases listed at 38 C.F.R. § 3.309(e) shall have become manifest to a degree of 10 percent or more at any time after service, except that chloracne or other acneform disease consistent with chloracne, porphyria cutanea tarda, and early onset peripheral neuropathy shall have become manifest to a degree of 10 percent or more within a year after the last date on which the Veteran was exposed to an herbicide agent during active military, naval, or air service. 38 C.F.R. § 3.307(a)(6)(ii). Where the evidence does not warrant presumptive service connection, the United States Court of Appeals for the Federal Circuit has determined that an appellant is not precluded from establishing service connection with proof of direct causation. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). New and Material Evidence (NME) In general, RO decisions that are not timely appealed are final. See 38 U.S.C.A. § 7105; 38 C.F.R. § 20.200. An exception to this rule is 38 U.S.C.A. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. The Board must consider the question of whether new and material evidence has been received because it goes to the Board's jurisdiction to reach the underlying claim and adjudicate the claim de novo. See Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001); Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996). If the Board finds that no such evidence has been offered, that is where the analysis must end, and what the RO may have determined in that regard is irrelevant. Barnett, supra. Further analysis, beyond consideration of whether the evidence received is new and material is neither required nor permitted. Id. at 1384. See also Butler v. Brown, 9 Vet. App. 167, 171 (1996). "New" evidence is existing evidence not previously submitted to agency decision makers. "Material" evidence is 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 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). In determining whether evidence is new and material, the "credibility of the evidence is to be presumed." Justus v. Principi, 3 Vet. App. 510, 513 (1992). However, lay assertions of medical causation cannot serve as the predicate to reopen a claim under § 5108. See Moray v. Brown, 5 Vet. App. 211, 214 (1993). In order for evidence to be sufficient to reopen a previously disallowed claim, it must be both new and material. If the evidence is new, but not material, the inquiry ends and the claim cannot be reopened. See Smith v. West, 12 Vet. App. 312, 314 (1999). If it is determined that new and material evidence has been submitted, the claim must be reopened. Analysis The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence pertinent to the issues on appeal. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. Initially, the Board has considered the Veteran's contention that he was exposed to herbicides (i.e. Agent Orange) in service. The Veteran's service personnel records do not support a finding of service in Vietnam, Korea, or Thailand. The Veteran's service personnel records reflect that he had no overseas service. Thus, he is not entitled to the presumptions of 38 C.F.R. §§ 3.307 and 3.309. The Veteran's military occupational specialty (MOS) in service was an anti-air warfare battery man. The Veteran contends that he was exposed to herbicides while stationed at Twenty Nine Palms, California, during war games and by cleaning equipment that had returned from Vietnam. He testified that after cleaning the equipment, he would be "burned" and was "just raw all over from the stuff". The Veteran is competent to testify that he participated in "war games" and cleaned dirty vehicles; however, he is not competent to determine that the vehicles were covered in Agent Orange or any other herbicide. There is no presumption of "secondary exposure" to herbicides based on being in proximity to, or working on, aircraft that flew over Vietnam or handling equipment once used in Vietnam. The Veteran's contention that he was exposed to herbicides while serving in the United States from touching equipment is not sufficient evidence that he was actually exposed to herbicides. The Veteran has not demonstrated that he is competent to identify herbicides, including those (2,4-D; 2,4,5-T and its contaminant TCDD; cacodylic acid; and picloram) for which presumptions of service connection may apply. 38 C.F.R. § 3.307(a)(6) (2014). The lay statements are also not competent evidence on this issue. The Board finds that the most probative evidence shows that the Veteran was not exposed to any herbicide during his service. Diabetes The Veteran is not entitled to presumptive service connection for diabetes under 38 C.F.R.§ 3.307(a)(6) and38 C.F.R. § 3.309(e) because he did not have herbicide exposure in service. Moreover, the Veteran has not asserted, and the evidence does not reflect, that he is entitled to service connection on a direct incurrence basis, unrelated to herbicides. The Veteran testified that he did not have diabetes in service. His October 1971 report of medical examination for separation purposes reflects that his urine was negative for sugar or albumin. An October 1978 record, more than six years after separation from service, also reflects that his urine was negative for glucose. The Veteran contends that he was diagnosed with diabetes in approximately 2009, more than 30 years after separation from service. (See September 2013 DRO hearing transcript, page 19.) The lapse of time between service separation and the earliest documentation of a current disability is a factor for consideration in deciding a service connection claim. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). There is no competent credible evidence of record that the Veteran has diabetes causally related to, or aggravated by, active service. The Veteran has not been shown to possess the requisite training or credentials needed to render a competent opinion as to medical diagnosis or causation in matters of diabetes, to include factors such as obesity, age, and diet. (VA clinical records reflect that the Veteran has obesity.) He has not been shown to be competent to state that his diabetes is causally related to any chemical exposure in service, to include any type of chemicals used in cleaning vehicles. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Hypertension Hypertension is not a disorder that may be presumed to be related to herbicide exposure. VA has specifically determined that the term ischemic heart disease does not include hypertension.38 C.F.R. § 3.309(e), See Note 3. Thus, even if the Veteran had herbicide exposure in service, which he did not, service connection on a presumptive basis would not be warranted. The Veteran's representative has indicated that the Veteran's hypertension may be secondary to diabetes. Service connection is not warranted on a secondary basis because the Veteran is not service connected for diabetes. The evidence does not reflect that the Veteran had hypertension in service. The Veteran's October 1971 report of medical examination for separation purposes reflects that his blood pressure was 124/76, which has not been shown to be indicative of hypertension. In addition, the evidence does not reflect that he had hypertension to a compensable degree within one year of separation from service. The Veteran asserted to a November 2011 clinician that he was treated for Lisinopril for one day in service but it was discontinued due to side effects. The Board acknowledges that the Lisinopril is drug used to treat hypertension. The Board finds that the Veteran's statement as to Lisinopril in service is less than credible given the record as a whole, to include clinical records, and the Veteran's noted blood pressure in service. The VA clinical records reflect that Lisinopril was to be initiated in 1997 and that the Veteran subsequently stated that it caused breathing problems. (See October 1997 VA clinical record.) In addition, the Veteran has testified that he did not have hypertension in service. (See Board hearing transcript, page 23.) There is no competent credible evidence of record that the Veteran has hypertension causally related to, or aggravated by, active service. The Veteran has not been shown to be competent to render an opinion on the etiology of his hypertension, to include factors such as weight, age, diet, and diabetes. He has not been shown to be competent to state that his hypertension is causally related to any chemical exposure in service, to include chemicals used in cleaning vehicles. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Peripheral neuropathy of the upper extremities The Veteran is not service-connected for diabetes; thus, service connection for peripheral neuropathy, as secondary to diabetes, is not warranted. In addition, the Veteran has not been shown to have early onset peripheral neuropathy or herbicide exposure, or peripheral neuropathy within one year of separation from service; thus service connection under 38 C.F.R. §§ 3.307 and 3.309 is not warranted. Moreover, the Veteran has not asserted, and the evidence does not reflect, that he is entitled to service connection on a nonpresumptive direct incurrence basis unrelated to herbicides. His October 1971 report of medical examination for separation purposes is negative for any findings of peripheral neuropathy. There is no competent credible evidence of record that the Veteran has peripheral neuropathy causally related to, or aggravated by, active service. The Veteran has not been shown to possess the requisite training or credentials needed to render a competent opinion as to medical diagnosis or causation of such, to include any relationship between peripheral neuropathy, diabetes, and chemical exposure in service, to include chemicals used in cleaning vehicles. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Residuals of a pilonidal cyst There is no competent credible evidence that the Veteran has residuals of a pilonidal cyst; thus, service connection for such is not warranted. Sanchez-Benitez v. West, 13 Vet. App. 282 (1999). Brammer v. Derwinski, 3 Vet. App. 223 (1992). The Veteran was treated for a suspected pilonidal cyst in service, but has not provided evidence of a current pilonidal cyst, or residuals of such. July 1971 STRs reflect that the Veteran has asserted that he has a back disability due to a surgery for a pilonidal cyst in service. June 1971 STRs reflect that the Veteran had a small very tender pilonidal cyst over the distal sacrum; however, a subsequent July 1971 STR reflects that upon further examination in the operating room, there was no definite definitive evidence of a pilonidal cyst or sinus, although there were two small midline dimples. It was felt that the Veteran did not have pilonidal cyst disease but "merely thickening over the coccyx due to an abnormal prominence and right lateral deviation of the coccyx without any evidence of cystic or sinus tract disease." In essence, the Veteran has not contended that his continues to have a pilonidal cyst, a scar from a pilonidal cyst, or a disability caused by, or aggravated by a pilonidal cyst. Rather, he contends that his treatment in service for a suspected pilonidal cyst caused a back disability. His claim for service connection for a back disability is handled in the remand below. As the preponderance of the evidence is against the claim for residuals of a pilonidal cyst, the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). NME- Back Historically, in November 1978, the RO denied the Veteran's claim for service connection for a back disability because the current examination showed no residuals of disease or injury of the lumbosacral spine. The Veteran did not appeal the decision and it became final. In February 2008, the RO again denied the Veteran's claim for service connection for a back disability. (The RO failed to note that the claim had previously been denied in 1978.) A December 2011 QTC examination report reflected that the Veteran has a diagnosis of degenerative arthritic changes. It was noted that he had minimal thoracic spine ventral spurring of the mid and lower thoracic spine disc spaces, and moderate bilateral facet joint hypertrophy at the L5-S1 level. The Board finds that new and material has been received because the Veteran now has a current disability, a necessary element which was missing at the time of the last final denial. Thus, the evidence raises a reasonable possibility of substantiating the claim and the claim is reopened. Shade v. Shinseki, 24 Vet. App. 110 (2010). NME -Acquired psychiatric disability Historically, in November 1978, the RO denied the Veteran's claim for service connection for a psychiatric disability because the evidence did not reflect a psychiatric disability in service. It was noted that post service, the Veteran was depressed but that there was no basis to grant service connection for such. The Veteran did not appeal the decision and it became final. In February 2008, the RO denied the Veteran's claim for entitlement to service connection for depression. In March 2010, the RO denied the Veteran's claim for service connection for PTSD. (The RO failed to note that a claim for service connection for an acquired psychiatric disability had previously been denied in 1978.) At the time of the Veteran's denial in 1978, he had not alleged any incident of service which caused an acquired psychiatric disability. He noted that he has nerves and that he had been told that his nerves were probably related to his headaches and back problems. The Veteran's accredited representative stated at the December 2013 Board hearing that while training in service, the Veteran experienced stressful situations, to include misfirings of missiles, and to this day, he has nightmares about that. (See Board hearing transcript, page 25.) For purposes of determining whether new and material evidence has been received, the credibility of the statement is presumed. Justus, 3 Vet. App. at 513. The Board finds that new and material has been received because the Veteran has alleged a new basis for his acquired psychiatric disability. Thus, the evidence raises a reasonable possibility of substantiating the claim and the claim is reopened. Shade, 24 Vet. App. at 110. ORDER Entitlement to service connection for diabetes mellitus is denied. Entitlement to service connection for hypertension is denied. Entitlement to service connection for bilateral upper extremity peripheral neuropathy is denied. Entitlement to service connection for residuals of a pilonidal cyst is denied. Since new and material evidence has been received to reopen the claim of entitlement to service connection for a back disability, the claim is reopened, and the appeal is allowed to this extent. Since new and material evidence has been received to reopen the claim of entitlement to service connection for an acquired psychiatric disability, the claim is reopened, and the appeal is allowed to this extent. REMAND Reopened Back Disability Having reopened the Veteran's claim, the Board must now determine whether the reopened claim of entitlement to service connection for a back disability may be granted on the merits, de novo. The Board finds that a clinical opinion is necessary prior to Board adjudication. The Veteran has asserted that he has a back disability due to a surgery for a pilonidal cyst in service. On July 7, 1971, the Veteran was taken into the operating room and given spinal anesthesia. As noted above, upon examination, it was clinically felt that the Veteran did not have pilonidal cyst disease but "merely thickening over the coccyx due to an abnormal prominence and right lateral deviation of the coccyx without any evidence of cystic or sinus tract disease." The Veteran was discharged to full duty and found to be fit for the same. The Veteran's July 23, 1971 STR reflects that he reported that he had injured his back in an automobile accident that morning. Upon examination, he was tender in the left lateral lumbar paraspinous group. A July 26, 1971 STR reflects that the Veteran was still getting pain in the small of back. The Veteran reported that he had a defective tail bone. It was noted that he "now has m. spasm in upper back not related to coccyx or lumbar spine." The Veteran's October 1971 report of medical examination for separation purposes is negative for a back disability. Post service January 1976 private records reflect that the Veteran had back pain since bending over and attempting to pick up a piece of iron on January 14, 1976. It was noted that he had pain in the upper back and right rib cage since that time. It was also noted that he has "had no typical low back pain." It was noted that x-rays were negative for a lumbar spine disability. A January 30, 1976 Radiology consultation report reflects a very minimal scoliosis with convexity to the right centered at D4-D5 which may be positional. It was noted that bony structures and disc spaces are intact. A February 1976 record also notes that x-rays of the dorsal spine were negative. A February 1976 Gulf Coast Hospital record reflects a diagnosis of acute back strain. It was noted that x-rays indicated "no specific bony abnormality about the lumbar spine." He had a normal lumbar spine with no fracture, bone destruction, or spondylolisthesis noted, and with vertebral bodies appearing well-maintained. An August 1978 Medical Certificate and History reflects that the Veteran had complaints of low back pain. The Veteran reported that he had had low back pain since he had a cyst in service. Upon examination, there was "no obvious problem". An August 1978 orthopedic clinic note reflects that the Veteran reported low back pain since 1971 associated with radiation to the shoulder, but with no leg symptoms. It was noted that he does heavy lifting at work, and takes no medication. The x-rays were negative for a disability. An October 1978 VA Form 21-2545 reflects the Veteran's statement that he had been hospitalized in approximately May or June of 1971 in service, and has had severe back pains since that time. An October 1978 VA orthopedic examination report reflects that the Veteran gave a history of having an onset of periodic low back pain in May 1971 while performing heavy lifting. He reported that he was treated in a hospital for two to three weeks and giving bed rest. Upon examination, the diagnosis was "lumbosacral spine no residuals of disease or injury found objectively on the physical examination or x-ray examination." The Board finds that the Veteran's contention of two to three weeks, or longer, of bed rest due to back pain is less than credible given the record as a whole, to include the STRs. The STRs note that he was returned to full duty after bed rest for an anesthesia induced headache, note the dates of treatment, and note that he was in a motor vehicle accident two weeks after examination in the operating room; thus, indicative against hospitalization and bed rest for several weeks. An August 1997 VA clinical record reflects that multiple views of the lumbosacral spine are not remarkable except for loss of the lordotic curve. The interspaces were all within normal width. A November 2011 private (QTC) record reflects that the Veteran reported that his back problem is not injury related. He reported that he was treated for a back lump in service, and that his back was "messed up". Based on the foregoing, the Board finds that a VA examination and opinion, with consideration of the earlier clinical records, may be useful to the Board in adjudicating the Veteran's claim. Reopened acquired psychiatric disability The Veteran's STRs reflect that in December 1968, he noted on his report of medical history that he had not had a nervous trouble of any sort. Notably, he did not check "no" for any other disability, and he checked "yes" for two other disabilities. Thus, the Board is unsure as to whether the Veteran meant to check "no" for the nervous trouble question. Post service, January 1976 records reflect that the Veteran was seen for a back injury of January 14, 1976. It was noted that the Veteran "seems somewhat lethargic and depressed." Records reflect that the Veteran had been unable to work since the incident. February 1976 recheck records for the Veteran's back reflect that the Veteran seemed "less depressed" and "somewhat depressed". In his October 1978 VA Form 21-2545, the Veteran stated that he has "very nervous conditions". The October 1978 VA general medical examination report reflects that the Veteran reported that he has "nerves that are driving him wild and needs help." He further reported that he had been told that his headaches were probably due to his nerves and also that his back problems were probably tied in with his nerves also or vice versa. The examiner stated that it was his impression "that this man is quite depressed and desperately needs help." The diagnosis was that the Veteran "is depressed and withdrawn and just can't seem to fit in a work-home life pattern as a civilian." It was noted that the Veteran was "referred to admitting for a possible admission to the hospital and work up and rehabilitation" however, it does not reflect if this was for the history of chronic back pain or the depression, both of which were listed as diagnoses. A 1997 VA social worker record reflects that the Veteran was treated for depression and his back in the early 1970s at VAMC Houston. The diagnosis was dysthymic disorder with exacerbation of depression associated with chronic pain and other health conditions. VA clinical records reflect that the Veteran had been treated for years for dysthymia and personality disorder (December 1999), that his dysthymic symptoms were affected by occasional family/financial stressors, that his mood was exacerbated by his mother's health (2001), that his depressed mood was mostly due to pain issues, to include his chronic back pain (2001, 2010), and that his depression was related to things people said regarding his interracial marriage and not getting disability compensation (2011). 2012 VA clinical records reflect an onset date of depression in 1975, which would be more than three years after separation from service. As noted above, an October 1978 VA record reflects that the Veteran was referred for possible hospital admission, a 1997 record reflects that the Veteran was treated for depression in the early 1970s, and VA clinical records reflect a depression onset date of 1975. The Board finds that VA should attempt to obtain, and associate with the claims file, VA clinical records, if any, from November 1971 through December 1979, from the Houston, Texas VAMC. The records indicate that the Veteran's acquired psychiatric disability is related to his health concerns, to include his back pain. Thus, it is inextricably intertwined with this claim for service connection for a back disability, which is being remanded. The Veteran should be provided with a VA examination. In rendering an opinion as to whether it is as likely as not that the Veteran has an acquired psychiatric disability causally related to active service, the examiner should consider the entire claims file, to include the above noted clinical records. Skin (Body rash) The Veteran contends that while in service, he had a body rash, for which he took Benadryl, which seemed to help. (See DRO hearing transcript, page 13.) He contends that it is due to cleaning equipment which had returned from Vietnam. (See Board hearing transcript, page 17.) The Veteran's STRs are negative for complaints of, or treatment for, a rash. The Veteran's December 1968 report of medical history reflects that he denied ever having had skin diseases. The Veteran's October 1971 report of medical examination for separation (release from active duty) reflects that his skin was normal upon examination. In 1978, the Veteran filed a claim for service connection for psychiatric and back disabilities; however he did not file a claim for a skin disability at that time. An October 1978 general medical VA examination reflects that the Veteran's skin was within normal limits. Notably, the Veteran noted having had back trouble, nerve trouble, occasional headaches, and diarrhea off and on for several months. The earliest evidence of a skin disability is more than 20 years after separation from service. Based on the foregoing, the Board finds that any statement as to a chronic skin disability in service or since service, is less than credible, and need not be considered by a VA examiner. A December 1998 VA dermatology record reflects that the Veteran wanted a refill on Benadryl for an itchy rash that comes and goes and has been controlled for years with antihistamines. 2002 and 2003 records reflect that the Veteran had a rash since January 2002, for which he was using Gold Bond and Aveeno bath powder. He was diagnosed with spongiotic dermatitis and symptoms consistent with PLC/PLEVA. VA clinical records note that the Veteran is treated by a private physician, and that he has been diagnosed with xerosis with pruritus, generalized dermatitis pleva, and chronic and subacute spongiotic dermatitis. An August 2006 VA clinical record of a telephone call reflects that the Veteran reported that medication seems to make him itch. October 2006 and January 2007 VA clinical records reflect that the Veteran's anti-depressant medication may be causing a chronic itching. Thus, the issue of entitlement to service connection for a body rash is inextricably intertwined with the issue of entitlement to service connection for an acquired psychiatric disability. Rating Hearing Loss The Veteran was provided with audiology examinations in January 2010, October 2011, and January 2012. At the December 2013 Board hearing, the Veteran's accredited representative requested another examination for the Veteran's hearing loss disability. (See Board hearing transcript, pages 28-29.) In correspondence dated in January 2015, the Veteran stated that his "hearing has definitely gotten worse." (He also stated that he now has to use hearing aids; however, the Board notes that the Veteran has been wearing hearing aids since at least 2010.) Because the Veteran asserts that his disability has worsened since the January 2012 examination, and it has been more than three years since that examination, the Board finds that another examination is warranted. The Veteran is entitled to a new VA examination where there is evidence that his disability has worsened since the last examination. Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994). TDIU The issue of entitlement to TDIU is inextricably intertwined with the rating issue being remanded. Thus, it must also be remanded. Accordingly, the case is REMANDED for the following action: 1. Attempt to obtain, and associate with the claims file, Houston VAMC clinical records, to include in patient treatment, if any, from November 1971 through December 1979. 2. Ask the Veteran to identify all medical providers (VA and private) from whom he has received treatment for a skin disability, and complete and return a provided VA Form 21-4142, Authorization and Consent to Release Information, for the identified treatment records, for each medical treatment provider identified. After obtaining completed VA Forms 21-4142, the AOJ should attempt to obtain all identified pertinent medical records, and associate them with the claims file. 3. After completion of the foregoing, schedule the Veteran for an appropriate VA examination to determine the current nature and likely etiology of the Veteran's back disability. The claims folder and copies of all pertinent records should be made available to the examiner. Based on the examination and review of the record, the examiner should answer the following: Is it at least as likely as not (50 percent or greater) that the Veteran has a back disability causally related to, or aggravated by, active service. The examiner should consider the entire claims file, to include a.) July 1971 STRs which reflect that the Veteran had "thickening over the coccyx due to an abnormal prominence and right lateral deviation of the coccyx"; b.) the Veteran's July 23 and 26, 1971 STRs which note pain in the small of back and upper back not related to coccyx or lumbar spine; c.) the October 1971 report of medical examination for separation purposes; d.) January and February 1976 private radiology and clinical records which note a January 14, 1976 incident, normal lumbar spine upon x-ray, and very minimal scoliosis; e.) the August 1978 examination with x-ray findings; f.) the October 1978 VA examination findings; and g.) the August 1997 VA x-rays findings. The examiner should discuss whether the Veteran has a congenital defect and if so, whether it was permanently aggravated/worsened due to active service. A complete rationale must be provided for all opinions. If the examiner cannot provide an opinion without resort to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. 4. Thereafter, after obtaining and associating with the claims file VA records, if any, from the 1970s for the Veteran, schedule the Veteran for an appropriate VA examination to determine the current nature and likely etiology of any diagnosed psychiatric disability. The claims folder and copies of all pertinent records must be made available to the examiner for review. Based on the examination and review of the record, the examiner should address the following: Is it at least as likely as not (50 percent or greater) that the Veteran has an acquired psychiatric disability causally related to, or aggravated by, active service. The examiner should consider the entire claims file, to include: a.) the Veteran's STRs; b.) January and February 1976 clinical records which note depression; c.) the October 1978 VA examination report; and d.) the diagnoses of dysthymic disorder, personality disorder, and depression due to factors to include chronic pain, and marital and family issues. (With regard to PTSD, the examiner should not consider any alleged in-service stressor which has not been verified by VA.) A complete rationale must be provided for all opinions. If the examiner cannot provide an opinion without resort to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. 5. Thereafter, if the clinical opinion is that the Veteran has an acquired psychiatric disability causally related to, or aggravated by, active service, obtain a clinical opinion as whether it is at least as likely as not (50 percent or greater) that the Veteran has a skin disability causally related to, or aggravated by, medication used to treat an acquired psychiatric disability. An adequate rationale which notes the related and/or aggravated skin disability and the medication should be provided. The clinician should not consider any statement as to a rash in service, and continuing since service, as the Board has found such statements to be less than credible. 6. Schedule the Veteran for an audiology examination to ascertain the current extent of his hearing loss disability. Associate all clinical findings with the claims file. The examiner is requested to delineate all symptomatology associated with, and the current severity of, the hearing loss disability. The appropriate Disability Benefits Questionnaire (DBQs) should be filled out for this purpose, if possible. 7. Thereafter, after undertaking any other development deemed appropriate, readjudicate the issues on appeal (back, skin, acquired psychiatric, hearing loss rating, TDIU). If a benefit sought on appeal is not granted, issue a supplemental statement of the case and provide the Veteran, and his representative with an appropriate opportunity to respond. The case should then be returned to the Board for further appellate consideration 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 2014). ______________________________________________ M. E. LARKIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs