Citation Nr: 1626542 Decision Date: 07/01/16 Archive Date: 07/14/16 DOCKET NO. 11-22 561 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUE Entitlement to service connection for a skin disability, to include as due to Agent Orange exposure. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD S. Keyvan, Counsel INTRODUCTION The Veteran served on active duty from May 1967 to December 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from the October 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, Puerto Rico. In March 2012, the Veteran testified at the San Juan RO. A transcript of that proceeding is associated with the Veteran's claims file. The issues of entitlement to service connection for diabetes mellitus, an esophageal/stomach disability, urinary disability, and colon disability were raised by the record in the August 2011 VA Form 9, but were not adjudicated by the Agency of Original Jurisdiction (AOJ). The issues of peripheral neuropathy of the upper extremities and erectile dysfunction have been raised in the March 2016 Application for Disability compensation, but have not been adjudicated by the AOJ. Therefore, the Board does not have jurisdiction over them, and they are referred to the AOJ for appropriate action. 38 C.F.R. § 19.9(b) (2015). This matter was previously before the Board in April 2014 at which time it was remanded for additional development. It is now returned to the Board. The appeal is REMANDED to the AOJ. VA will notify the Veteran if further action is required. REMAND Unfortunately, an additional remand is necessary before appellate review may proceed in this matter. The Veteran's service personnel records reflect that he had service in the Republic of Vietnam from September 1967 to December 1968. In the absence of affirmative evidence to the contrary, he is presumed to have been exposed to herbicides during his Vietnam service. See 38 C.F.R. § 3.307(d)(6)(iii). Although psoriasis is not a recognized presumptive disorder of herbicide exposure, the possibility exists that the Veteran's psoriasis is related to herbicide exposure on a direct basis. See Stefl v. Nicholson, 21 Vet. App. 120 (2007); see also Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). Pursuant to the April 2014 Board remand, the Veteran was scheduled for a VA dermatological examination to determine whether his psoriasis is related to his military service, to include his exposure to Agent Orange in service. During the evaluation, the VA examiner noted that the Veteran had a history of a skin rash since returning from Vietnam. The VA examiner noted that the skin lesions had continued intermittently, and he had recently been followed by a physician for the past few years with temporary improvement. Based on his discussion with, as well as his evaluation of the Veteran, the VA examiner diagnosed the Veteran as having psoriasis that covered over forty percent of his total body area, and 5 to 20 percent of his exposed body area. According to the examiner, psoriasis is an immune-mediated skin condition of unknown etiology, although a genetic basis has been postulated. The examiner determined there to be no relationship between the Veteran's herbicide exposure and his psoriasis; however, he did find that a stressful situation, such as a war, could precipitate the disease in a predisposed patient. Upon finding that a stressful situation could precipitate psoriasis in a predisposed patient, the VA examiner has alluded to the possibility that the Veteran's service in the military, to include his period of service in Vietnam, may have triggered or hastened his psoriasis. The VA examiner, however, did not address, or conduct any tests to address, whether the Veteran was predisposed to developing psoriasis. Moreover, the VA examiner did not state specifically whether the Veteran's military service, and specifically his service in Vietnam, triggered or activated his psoriasis. Indeed, the use of equivocal language makes the statement speculative in nature. It is well established that medical opinions that are speculative, general, or inconclusive in nature do not provide a sufficient basis upon which to support a claim. McLendon v. Nicholson, 20 Vet. App. 79, 85 (2006). If VA undertakes to provide a medical examination, the Board must ensure that such examination is adequate. See Barr v. Nicholson, 21 Vet. 303, 311 (2007). In this case, the Board does not find the VA examiner's opinion to be adequate as the medical examiner did not provide a clear and valid rationale in support of his opinion. As it is still unclear whether the Veteran's psoriasis is related to his military service, a remand for another VA medical opinion is necessary. 38 C.F.R.§ 3.159(c)(4)(i). Accordingly, the case is REMANDED for the following action: 1. Obtain and associate with the claims file records of VA treatment of the Veteran dated after July 2014. 2. Then, once these records have been obtained and associated with the claims file, schedule the Veteran for another VA examination with a VA dermatologist to determine the nature and etiology of any psoriasis present. The paperless claims folder, including all records on VBMS and Virtual VA, must be made available to the examiner in conjunction with the examination. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed, and all pertinent pathology should be noted in the examination report. The examiner should also conduct any testing necessary to determine whether the Veteran's psoriasis is genetic in nature, and whether the Veteran is predisposed to developing psoriasis. Consideration should be given to the Veteran's history and particularly to any statements regarding continuity of symptoms since service. Following a review of the record, the examiner should address whether the Veteran's psoriasis is genetic in nature, and whether the Veteran is predisposed to developing psoriasis. The examiner should then express an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's psoriasis had its onset during his military service, to include as a result of his period of service in Vietnam. Specifically, the examiner should address whether the stressful situation-namely, serving during the Vietnam War, and being stationed in Vietnam from September 1967 to December 1968, triggered/activated the Veteran's psoriasis. The examiner must support any opinion provided with a complete rationale. If the examiner determines that he or she cannot provide an opinion without resorting to speculation, the examiner should explain the inability to provide an opinion, identifying precisely what facts could not be determined. In particular, he or she should comment on whether an opinion could not be provided because the limits of medical knowledge have been exhausted or whether additional testing or information could be obtained that would lead to a conclusive opinion. 3. After completing the above, and undertaking any additional evidentiary development deemed necessary, readjudicate the issue on appeal. If any benefit sought is not granted, the Veteran and his representative should be provided with a supplemental statement of the case. An appropriate period of time should be allowed for response before the case is returned to the Board 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). This claim must be afforded expeditious treatment. The law requires that all claims remanded by the Board or by the United States Court of Appeals for Veterans Claims (Court) for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). _________________________________________________ JAMES L. MARCH Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2014), only a decision of the Board is appealable to the Court. 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).