Citation Nr: 1602784 Decision Date: 01/29/16 Archive Date: 02/05/16 DOCKET NO. 12-10 207 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder, to include post-traumatic stress disorder (PTSD). 2. Entitlement to service connection for a skin condition, to include erythematous rash, dermatitis, tinea corpus, eczema, malignant melanoma, left arm, to include as due to Agent Orange exposure. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and his spouse ATTORNEY FOR THE BOARD K. Fitch, Counsel INTRODUCTION The Veteran served on active duty from March 1971 to February 1973, to include service in the Republic of Vietnam. His decorations include the Combat Infantryman Badge. This matter comes before the Board of Veterans Appeals (Board) from an April 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Indianapolis, Indiana, that denied entitlement to service connection for a skin condition and PTSD. The Veteran and his spouse testified at a videoconference hearing before the undersigned in November 2015. A transcript of the hearing has been associated with the Veteran's claims file. Additional medical evidence was submitted following the hearing. While a waiver of initial RO consideration was discussed in the hearing, no signed waiver was submitted. However, as this matter is being remanded, no additional remand for initial RO consideration is required. In an August 2009 statement, the Veteran indicated that he had Gout as a result of medication taken for his service-connected disabilities. This matter is referred to the Agency of Original Jurisdiction (AOJ) for appropriate action. 38 C.F.R. §§ 3.155, 19.9(b) (2014 & 2015). The appeal is REMANDED to the AOJ. VA will notify the appellant if further action is required. REMAND In November 2015, the Veteran and his spouse testified that he had recently been diagnosed as having, and been treated for, PTSD at the VA outpatient clinic in New Albany, Indiana. The most recent records of the Veteran's treatment at VA date to January 2012. These indicate a diagnosis of adjustment disorder with depressed mood, with medications prescribed. There was no diagnosis related to PTSD. A February 1999 treatment record noted "traits of PTSD". The Veteran was afforded a VA examination in December 2009. While the Veteran was indicated to have some symptoms of PTSD (sleep disturbance, frequent nightmares, and short temper) no psychiatric disorder was diagnosed and no opinion was offered. The Veteran and his spouse also testified to a skin and psychiatric symptoms that the Veteran had experienced since his military service. His medical records indicate various diagnoses related to skin disorders, including status post malignant melanoma, left arm, as well as benign appearing nevi, nummular eczema, erythema, maculopolular lesions, seborrheic keratosis, and scaly skin. A VA examination dated in October 2006 noted no skin symptoms. No skin examination has been afforded since that time. This matter is remanded to obtain VA treatment records. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Further examinations are also required. VA's duty to assist includes providing a medical examination when is necessary to make a decision on a claim. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159; see also McLendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006) (noting that the third prong of 38 C.F.R. § 3.159(c)(4)(I), which requires that the evidence of record 'indicate' that the claimed disability or symptoms may be associated with service, establishes a low threshold); see also Locklear v. Nicholson, 20 Vet. App. 410 (2006). Finally, the Board notes that the RO received a response from the Social Security Administration in April 2012 regarding disability records. It was noted that records were attached via CD. However, these records do not appear to have been scanned into the Veteran's electronic file. In this regard, the Board notes that records from the Social Security Administration were associated with the claims file in November 2009. As it is not clear whether the April 2012 CD contains additional records, upon remand, the AOJ should ensure that the records referred to in the April 2012 correspondence are associated with the Veteran's file. Accordingly, the case is REMANDED for the following action: 1. Obtain all records for treatment for a psychiatric disability, to include PTSD and a skin disorder, from both the Louisville VA Medical Center and the New Albany VA outpatient clinic. 2. Associate with the Veteran claims file, the Social Security Administration disability documents received by VA in April 2012. 3. If any requested records cannot be obtained, advise the Veteran of the missing records, the efforts made to obtain them, and of what further actions will be taken with regard to the claims on appeal 4. Schedule the Veteran for a VA examination to determine whether any psychiatric disorders that have been present at any time since 2009 are related to service, including in-service stressors. The examiner must review the claims folder and a copy of this remand. The examiner should respond to the following: a) Does the Veteran meet the criteria for a diagnosis of PTSD? b) If PTSD is diagnosed, the examiner should specify any stressors that provide the basis of the diagnosis and state whether any supporting stressor consists of fear of hostile military or terrorist activity. b) If the examiner finds that the Veteran has a diagnosed psychiatric disorder other than PTSD, did such disorder have its onset during active duty, within one year of active duty, or is such condition otherwise related to the Veteran's military service (including any in-service stressor)? c) If adjustment disorder with depressed mood is not found on the current examination, the examiner should state whether the prior diagnosis was made in error, or that disorder has gone into remission. If the disorder has gone into remission, the examiner should deem it a current disability and provide an opinion as to whether it had its onset in service or is otherwise related to service, including an in-service stressor. The examiner should provide reasons for these opinions. The examiner must consider the statements by the Veteran and his spouse as competent evidence regarding the incurrence of his claimed disorder and the continuity of symptomatology. If the examiner cannot provide an opinion without resorting to speculation, the examiner must explain whether this is due to the limits of the examiner's medical knowledge, the limits of medical knowledge in general, or there is additional evidence, which if obtained, would permit the opinion to be provided. 5. Arrange for a VA examination to determine whether any current skin condition is related to the Veteran's military service. The examiner must review the claims file. The examiner should respond to the following: (a) Did any skin current disorder (identified at any time since 2009) have its onset during active duty, or is it otherwise related to the Veteran's military service, to include exposure to herbicides, including Agent Orange? The examiner must take into account the competent testimony of the Veteran and his spouse that he has had a skin disorders since he returned from service in Vietnam. The examiner is advised that melanoma would be presumed service connected if shown in service and any time thereafter or if active within a year of service. The examiner should provide reasons for these opinions. The examiner must consider the statements by the Veteran and his spouse as competent evidence regarding the incurrence of his claimed disorder and the continuity of symptomatology. If the examiner cannot provide an opinion without resorting to speculation, the examiner must explain whether this is due to the limits of the examiner's medical knowledge, the limits of medical knowledge in general, or there is additional evidence, which if obtained, would permit the opinion to be provided. 8. If any claim on appeal remains denied, issue a supplemental statement of the case, to include the presumptions afforded combat veterans. Then return the case to the Board, if otherwise in order. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). _________________________________________________ Mark D. Hindin Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2014), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2015).