Citation Nr: 1731067 Decision Date: 08/03/17 Archive Date: 08/11/17 DOCKET NO. 13-27 598 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUES 1. Entitlement to service connection for fibromyalgia. 2. Entitlement to service connection for a skin disability. 3. Entitlement to service connection for coronary artery disease (CAD). REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD S. Hoopengardner, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1979 to January 1985 and from June 1985 to August 1991. These matters come before the Board of Veterans' Appeals (Board) on appeal from an August 2012 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Lincoln, Nebraska (though jurisdiction lies with the Chicago, Illinois RO). The Veteran originally filed a claim in July 2011 that referenced skin rashes. As will be discussed further below, the evidence of record referenced multiple skin diagnoses and the Veteran's claim has therefore been expanded and characterized as indicated on the cover page. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). The Board notes that the September 2015 VA Form 8 (Certification of Appeal) listed a claim of entitlement to service connection for a psychiatric disorder. In this regard, the September 2014 Supplemental Statement of the Case (SSOC) listed a claim on appeal of "[s]ervice connection for an acquired psychiatric disorder, claimed, as post-traumatic stress disorder [PTSD], neuropsychological symptoms, and sleep disturbances." Subsequently in an October 2014 statement, the Veteran stated that "Veteran does not wish to continue claims for acquired psychiatric disorder. Veteran drops this claim." As such, this claim was withdrawn prior to the appeal being transferred to the Board in October 2015, irrespective of the mistaken September 2015 VA Form 8. See 38 C.F.R. § 20.204 (2017) (stating that "[u]ntil the appeal is transferred to the Board, an appeal withdrawal is effective when received by the agency of original jurisdiction [AOJ]"); 38 C.F.R. § 19.35 (2017) (stating that "certification is used for administrative purposes and does not serve to either confer or deprive the Board...of jurisdiction over an issue"). The issues of entitlement to service connection for a skin disability and CAD are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDING OF FACT The Veteran, a Persian Gulf War Veteran, has had fibromyalgia during the appeal period. CONCLUSION OF LAW Fibromyalgia is presumed to have been incurred as a result of the Veteran's active service in the Southwest Asia theater of operations during the Persian Gulf War. 38 U.S.C.A. §§ 1110, 1117 (West 2014); 38 C.F.R. §§ 3.303, 3.317 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION Considering the favorable outcome detailed below as to the grant of entitlement to service connection for fibromyalgia, VA's fulfillment of its duties to notify and assist do not need to be addressed. I. Legal Criteria Veterans are entitled to compensation from VA if they develop a disability resulting from personal injury suffered or disease contracted in line of duty. 38 U.S.C.A. § 1110 (West 2014); see also 38 C.F.R. § 3.303 (2017). For a veteran who had active service in the Southwest Asia theater of operations during the Persian Gulf War (a Persian Gulf veteran), presumptive service connection may be established for a qualifying chronic disability, which specifically includes a medically unexplained chronic multisymptom illness that is defined by a cluster of signs or symptoms, such as fibromyalgia. See 38 U.S.C.A. §§ 1117, 1118 (West 2014); 38 C.F.R. § 3.317 (2017). The Veteran's DD-214 for his period of active service from June 1985 to August 1991 noted that he received the Southwest Asia Service Medal. In addition, a December 2011 BIRLS (Beneficiary Identification Records Locator Subsystem) Veteran Identification screenshot of record noted "[Gulf War] In-Theater" service from October 1990 to May 1991 and the Veteran has referenced serving in Saudi Arabia, Kuwait and Iraq. See, e.g., September 2013 VA Form 21-0781 (Statement in Support of Claim for Service Connection for [PTSD]) and accompanying Veteran's Statement. Based on this evidence, the Board finds that the Veteran had active service in the Southwest Asia theater of operations during the Persian Gulf War and he is therefore a Persian Gulf Veteran. See 38 C.F.R. § 3.317(e) (2017) (defining the Southwest Asia theater of operations to include Iraq, Kuwait and Saudi Arabia), 38 C.F.R. § 3.2(i) (2017) (defining the Persian Gulf War as from "August 2, 1990 through date to be prescribed by Presidential proclamation or law"). Accordingly, he is eligible for presumptive service connection related to Persian Gulf veterans, as outlined above. II. Scope of Claim With regard to the scope of the Veteran's claim, the Veteran filed an informal claim in July 2011 for "undiagnosed gulf war illness." See July 2011 VA Form 21-0820 (Report of General Information). On the Veteran's July 2011 formal claim, on VA Form 21-526 (Veteran's Application for Compensation and/or Pension), he listed a disability of Gulf War Syndrome and stated "regarding the Gulf Sympt[]o[m]s, I have experienced and am being treated for chronic fatigue, skin rashes, muscle pain, neuropsychological symptoms, symptoms involving respiratory system, sleep disturbances, gast[r]ointestinal symptoms, [and] cardiovascular symptoms." In September 2013, the Veteran submitted a VA Form 21-526EZ (Application for Disability Compensation and Related Compensation Benefits) and listed a disability of fibromyalgia. On a September 2013 VA Form 9 (Appeal to [the Board]), the Veteran stated "I did file for claims of undiagnosed illnesses that are on the Gulf War illness list," that "I continue to have the symptoms for which I originally filed my claims; however, since my original filing my doctor has grouped some of the symptoms and has diagnosed me as having fibromyalgia" and that "I feel that in light of my service and my diagnosed and undiagnosed ailments I should be determined to have a service connection for fibromyalgia and gulf war illness for the remainder." The AOJ treated the fibromyalgia claim as part of the Veteran's pending appeal and in the September 2014 SSOC characterized an issue on appeal as "[s]ervice connection for fibromyalgia, claimed as chronic fatigue, muscle and joint pain, gastrointestinal symptoms, and sleep disturbance." As will be addressed further below, a September 2013 VA Form 21-0960C-7 (Fibromyalgia Disability Benefits Questionnaire [DBQ]) completed by Dr. A. diagnosed the Veteran with fibromyalgia. The DBQ noted that the Veteran currently had findings, signs or symptoms attributable to fibromyalgia and noted widespread musculoskeletal pain, stiffness, muscle weakness (in the legs), fatigue, sleep disturbances, paresthesias (in the legs), anxiety and irritable bowel syndrome. As such, this medical professional associated the symptoms claimed by the Veteran in July 2011 of fatigue, muscle pain, sleep disturbances and gastrointestinal symptoms with the diagnosed fibromyalgia. The other symptoms claimed by the Veteran in July 2011 appear to be related to other claims that have either been granted (as to the claimed symptoms involving the respiratory system, the August 2012 rating decision granted entitlement to service connection for asthma), are being remanded (as to the claimed skin rashes and cardiovascular symptoms, the skin disability and CAD claims are being remanded herein) or have been withdrawn (as to neuropsychological symptoms, as noted in the Introduction above, the Veteran withdrew a claim for entitlement to service connection for an acquired psychiatric disorder in October 2014). As will be outlined, entitlement to service connection for fibromyalgia is being granted and the Board finds that this grant encompasses all of the Veteran's claimed symptoms, beyond those associated with disabilities that have either been granted entitlement to service connection, have been withdrawn or are being remanded. Accordingly, the Board has characterized the issues on appeal as noted on the cover page, to include entitlement to service connection for fibromyalgia. III. Evidence and Analysis As referenced above, for a Persian Gulf War veteran, such as the Veteran in this case, entitlement to service connection is warranted on a presumptive basis for a qualifying chronic disability, which specifically includes a medically unexplained chronic multisymptom illness such as fibromyalgia. See 38 U.S.C.A. §§ 1117, 1118 (West 2014); 38 C.F.R. § 3.317 (2017). As such, a crucial issue is whether the Veteran has had fibromyalgia during the appeal period. See McClain v. Nicholson, 21 Vet. App. 319 (2007) (stating that "the requirement that a [veteran] have a current disability before service connection may be awarded for that disability... is satisfied when a [veteran] has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim"). The Veteran was afforded a May 2012 VA examination and a Gulf War General Medical Examination DBQ was completed. The examiner stated symptoms "are each likely related to...a disease with a clear and specific etiology and diagnosis." For the reasons discussed, the Board finds the opinion provided to be of limited probative value. The DBQ stated that "[m]uscle aching 'all over' may be related to continual use of statins for elevated cholesterol." The Board notes that this statement is of limited probative value in that it was speculative in nature through the use of the term "may be." The DBQ also stated that "[t]he [V]eteran also reports that he does 90 minutes of strenuous physical exercise daily, 6 or 7 days per week, including 1500 sit-ups per day, which in itself would be expected to cause generalized muscle aches and joint pains." The examiner also stated that "[t]he [V]eteran states that his muscle aches are primarily localized to his lower legs and ankle area; he was treated for Achilles tendonitis by his [primary care physician]" and reference was also made to a 1994 right shoulder rotator cuff surgery. The Veteran submitted a detailed November 2012 Notice of Disagreement (NOD) in which he stated that "[w]ithin 6 months of returning from Desert Storm/Shield I began having unexplained muscle and joint pain in my arms, legs, and back." He noted that the 1994 right shoulder surgery "relieved some of the daily pain in my right arms but not in my other arm, legs or back." He also stated that "I did not start exercising until Jan[uary]/Feb[ruary], 2010...My muscle and joint pain has always been with me since returning from Desert Storm/Shield" and "only doing this for the last 2 years has nothing to do with the last 20 years since returning from Desert Storm/Shield." The Veteran similarly stated in a December 2011 statement that "within a year of returning from the gulf war, I began having muscle aches in both shoulders and arms...To this day I still have muscle pain in both shoulders, lower back and legs." The Veteran's lay statements offer a history of prolonged muscle symptomatology that was not addressed by the May 2012 VA examiner, which limits the probative value of the provided opinion. The DBQ also stated that "[f]atigue is a common complaint in the presence of sleep disorders. The [V]eteran does shift work, and drinks at least 4 caffeinated beverages per day. He does not have a diagnosis of chronic fatigue syndrome, nor do his current symptoms meet the criteria for that condition." The Board notes that a July 2012 VA opinion, an addendum to a May 2012 VA PTSD examination, stated that "the [V]eteran does not have a disability pattern related to sleep problems." In addition, while a diagnosis of insomnia was referenced in private medical records, it does not appear that the Veteran has otherwise been diagnosed with a formal sleep disorder. As to fatigue, it appears that while the examiner stated the Veteran did not meet the criteria for a diagnosis of chronic fatigue syndrome, fatigue was not associated with another disability. The examiner also stated that the Veteran "was treated for Helicobacter pylori stomach infection [approximately] seven years ago, and has had no recurrence of gastrointestinal symptoms. He has no evidence of ongoing problems." In his November 2012 NOD, the Veteran stated that "I still have bouts with occasional diarrhea and constipation" and questioned how "talking to [the VA examiner]...for only five minutes about my stomach problems since returning from Desert Storm/Shield" could "lead to a conclusion of no continually of symptoms from service to present." It appears that the examiner was stating that the Veteran has a lack of present gastrointestinal symptomatology, rather than that such was associated with a specific disability. Also, the Veteran's lay statements describe ongoing gastrointestinal symptomatology that was not addressed by the May 2012 VA examiner, which limits the probative value of the provided opinion. Moreover, as noted above, the Veteran did not list fibromyalgia on his July 2011 claim and on the September 2013 VA Form 9 he stated that "since my original filing my doctor has grouped some of the symptoms and has diagnosed me as having fibromyalgia." Accordingly, evidence prior to September 2013 that did not note a diagnosis of fibromyalgia is not particularly relevant as there was no assertion of an earlier diagnosis. As such, while the May 2012 examiner did not diagnose fibromyalgia, such a diagnosis was also not specifically excluded and rather fibromyalgia appears to simply not have been addressed by the examiner. For the reasons discussed, the Board finds the May 2012 Gulf War General Medical Examination DBQ and opinion to be of limited probative value as to the issue of whether the Veteran has had fibromyalgia during the appeal period. As referenced above, of record is a September 2013 Fibromyalgia DBQ that was completed by Dr. A., a private doctor. The Board notes that the Veteran provided a July 2011 VA Form 21-4142 (Authorization and Consent to Release Information to the Department of Veterans Affairs (VA)) that noted treatment from Dr. A. from 2001 to the present for the condition of Gulf War Symptoms. Medical records were received from Dr. A. in January 2012 for the time period of November 2008 to October 2011 (the Board notes that the potentially incomplete time frame for the records received may have been a result of the AOJ's request, which requested records "relating to the [V]eteran's heart condition from 2009 to present"). The Board notes that an August 2011 treatment note stated that the Veteran "complains of joint pain. This was first noted in the 1990's, was gradual in onset, has been worsening over time. Pain is located at the right shoulder...Treatment history: surgery (Rotator cuff repair 1994)." This note also stated that the Veteran "complains of insomnia...was a serviceman in the Gulf War and ever since then it has been hard to get to sleep[] with the last 3 years being the worse." Diagnoses were noted of right shoulder pain, right rotator cuff syndrome status post repair 1994 and insomnia persistent. The medical records from Dr. A. did not include a diagnosis of fibromyalgia. No such diagnosis, however, would necessarily be expected at that time based on the Veteran's September 2013 VA Form 9. As noted, the Veteran stated that "since my original filing my doctor has grouped some of the symptoms and has diagnosed me as having fibromyalgia," which suggested that his diagnosis was more likely made more recently than the latest October 2011 records received. In any event, the Fibromyalgia DBQ completed by Dr. A. noted that the Veteran had been diagnosed with fibromyalgia and noted a date of diagnosis of 1994. A diagnosis of low back pain, with a date of diagnosis of 1994 was also noted. Additional diagnoses were noted as pertaining to fibromyalgia, specifically fatigue and insomnia, with a date of diagnosis noted for both of 1991. It was noted that the Veteran's chart was reviewed, presumably a reference to Dr. A.'s medical records related to the Veteran's treatment that had reportedly been ongoing since 2001. Under the medical history section, it was noted that "1991 returned from Gulf War had severe insomnia [and] fatigue" and "1994 started with [low back pain] and multiple trigger points [consistent with] fibromyalgia." Based on this medical history, it appears that the date of diagnosis of fibromyalgia noted by Dr. A. of 1994 was a retroactive diagnosis based on the Veteran's reported history. The DBQ also noted that continuous medication was required for control of fibromyalgia symptoms, that the Veteran was currently undergoing treatment for this condition and that the Veteran's fibromyalgia symptoms were refractory to therapy (it was noted that the Veteran slept better, but trigger points remained). As noted above, the DBQ also noted that the Veteran currently had findings, signs or symptoms attributable to fibromyalgia and noted widespread musculoskeletal pain, stiffness, muscle weakness (in the legs), fatigue, sleep disturbances, paresthesias (in the legs), anxiety and irritable bowel syndrome. The Veteran's fibromyalgia symptoms were noted to be present more than one-third of the time. Tender points were noted bilaterally at the lateral epicondyle and the gluteal. It was noted that the Veteran's fibromyalgia impacted the Veteran's ability to work, specifically that the Veteran "works but with pain [and] fatigue." For unclear reasons, following receipt of this positive private medical evidence that indicated a diagnosis of fibromyalgia, the AOJ requested a VA examination in August 2014 related to fibromyalgia. In this regard, the Board notes that 38 U.S.C.A. § 5125 (West 2014) states that: For purposes of establishing any claim for benefits...a report of a medical examination administered by a private physician that is provided by a claimant in support of a claim for benefits...may be accepted without a requirement for confirmation by an examination by a physician employed by the Veterans Health Administration if the report is sufficiently complete to be adequate for the purpose of adjudicating such claim. In addition, 38 C.F.R. § 3.304(c) (2017) provides that "[t]he development of evidence in connection with claims for service connection will be accomplished when deemed necessary but it should not be undertaken when evidence present is sufficient for this determination." Also, the United States Court of Appeals for Veterans Claims (Court) has stated that: Because it would not be permissible for VA to undertake...additional development if a purpose was to obtain evidence against an appellant's case, VA must provide an adequate statement of reasons or bases for its decision to pursue further development where such development reasonably could be construed as obtaining additional evidence for that purpose. See Mariano v. Principi, 17 Vet. App. 305 (2003). In any event, the Veteran was afforded a VA examination and a Fibromyalgia DBQ was completed in September 2014. The examiner noted that the Veteran's claims file was reviewed. The DBQ noted that the Veteran did not now have or had ever been diagnosed with fibromyalgia. Under the medical history section, it was noted that: VBMS records, and Virtual VA records have no mention of fibromyalgia or a simil[]ar disease. [The Veteran's] medical records in C-file have a complete physical examination by his [primary care physician] which does not record any symptoms or signs of a multisys[t]em disease or fibromyalgia like symptoms. The [V]eteran was not diagnosed with this condition by his [primary care physician]. On revi[]ew of systems today there is no []suggestion of this type of illness. There is no history of treatment for this type of illness. The DBQ also noted that continuous medication was not required for control of fibromyalgia symptoms, that the Veteran was not currently undergoing treatment for this condition, that the Veteran's fibromyalgia symptoms were not refractory to therapy and that the Veteran did not currently have findings, signs or symptoms attributable to fibromyalgia. In spite of unclear reasoning behind the AOJ obtaining the September 2014 VA fibromyalgia examination, the resulting DBQ is of record before the Board. Upon review, the Board finds that the September 2014 VA fibromyalgia DBQ is of limited probative value. As noted, of record is a September 2013 fibromyalgia DBQ that was completed by the Veteran's private doctor, Dr. A. This evidence was of record at the time that the September 2014 VA fibromyalgia DBQ was completed. Additionally, the AOJ's exam request specifically highlighted as potentially relevant evidence the September 2013 fibromyalgia DBQ completed by Dr. A. In spite of this evidence being of record and highlighted by the AOJ and the September 2014 VA fibromyalgia DBQ's notation that the Veteran's claims file was reviewed, no reference was made to the September 2013 fibromyalgia DBQ completed by Dr. A. Moreover, the September 2014 VA fibromyalgia DBQ made factually inaccurate statements that the Veteran had never been diagnosed with fibromyalgia, that "VBMS records, and Virtual VA records have no mention of fibromyalgia," that "[t]he [V]eteran was not diagnosed with this condition by his [primary care physician]" and that "[t]here is no history of treatment for this type of illness." Such statements are directly contradicted by the evidence of record at the time of September 2014 VA fibromyalgia DBQ, specifically by the September 2013 fibromyalgia DBQ completed by Dr. A. Overall, the September 2014 VA fibromyalgia DBQ included factually inaccurate statements that were contradicted by evidence of record and the DBQ was based on an inaccurate factual premise that the Veteran had not ever been diagnosed with fibromyalgia, in spite of the September 2013 fibromyalgia DBQ completed by Dr. A. that diagnosed fibromyalgia. Accordingly the Board finds that the September 2014 VA fibromyalgia DBQ is of limited probative value. See Reonal v. Brown, 5 Vet. App. 458 (1993) (stating that "[a]n opinion based upon an inaccurate factual premise has no probative value"). On the other the hand, the September 2013 fibromyalgia DBQ provided a diagnosis of fibromyalgia. This diagnosis was provided by a private doctor that reportedly had treated the Veteran since 2001. There does not appear to be any reason to question the competency of Dr. A. and the Board therefore finds that the September 2013 fibromyalgia DBQ provides probative evidence as to crucial issue of whether the Veteran has had fibromyalgia during the appeal period. In review of the evidence of record, the Board finds that the evidence is at least in equipoise as to whether the Veteran has had fibromyalgia during the appeal period. Resolving any reasonable doubt in the Veteran's favor, the Board finds that the Veteran has had fibromyalgia during the appeal period. As the Veteran is a Persian Gulf War Veteran who has had fibromyalgia during the appeal period, fibromyalgia is presumed to have been incurred as a result of the Veteran's active service in the Southwest Asia theater of operations during the Persian Gulf War. 38 U.S.C.A. §§ 1110, 1117 (West 2014); 38 C.F.R. §§ 3.303, 3.317 (2017). Entitlement to service connection for fibromyalgia is therefore warranted and to this extent the Veteran's claim is granted. ORDER Entitlement to service connection for fibromyalgia is granted. REMAND Skin Disability On the Veteran's July 2011 formal claim, he listed a disability of Gulf War Syndrome and stated "regarding the Gulf Sympt[]o[m]s, I have experienced and am being treated for...skin rashes." The Veteran was afforded a VA examination in March 2012 and a Skin Diseases DBQ was completed. A diagnosis was noted of dermatitis or eczema, with a date of diagnosis noted of 10-15 years ago. Under the remarks section, the DBQ stated "[a]ppears to have mild eczema. While he was treated for itching during service, I can not determine if related to service without resorting to speculation." The reference to treatment for itching in service may have been in reference to a March 1981 service treatment record (STR) that noted a complaint of a rash on the right leg and noted an assessment of dry skin dermatitis. A July 2012 Deferred Rating decision stated that "[t]he examiner provided a nexus opinion, but did not provide an opinion if it could be related to hazardous materials." A July 2012 VA opinion was subsequently obtained. The opinion stated as follows: The rash on the right leg is noted in 1981...The entry was vague and non-descript. His recent [VA] examination mentions eczema, 10-15 y[ea]rs duration. Whether this rash is due to Gulf War is completely unknown and would be speculative at best to determine exact etiology. Whether this is due to a specific exposure event in the Gulf is unknown. E[cz]ema is a diagnos[]able illness. In review, the March 2012 and July 2012 VA opinions are, essentially, inconclusive opinions. The Court has stated that "[a]n examiner's conclusion that a diagnosis or etiology opinion is not possible without resort to speculation is a medical conclusion just as much as a firm diagnosis or a conclusive opinion." See Jones v. Shinseki, 23 Vet. App. 382 (2010). The Court went on to state that "before the Board can rely on an examiner's conclusion that an etiology opinion would be speculative, the examiner must explain the basis for such an opinion or the basis must otherwise be apparent in the Board's review of the evidence" and that VA: must ensure that any medical opinion, including one that states no conclusion can be reached without resorting to speculation, is "based on sufficient facts or data." See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302 (2009). Therefore, it must be clear, from either the examiner's statements or the Board decision, that the examiner has indeed considered "all procurable and assembled data," by obtaining all tests and records that might reasonably illuminate the medical analysis. See Daves v. Nicholson, 21 Vet.App. 46 (2007)]. When the record leaves this issue in doubt, it is the Board's duty to remand for further development. Subsequent to the March 2012 and July 2012 VA opinions, private medical records were obtained in June 2013 from Dr. C. of the Dermatology Care Center. Such records included treatment notes and biopsy testing results. For example, a March 2013 letter from Dr. C. to Dr. A. stated that the Veteran's diagnosis was "Psoriasiform Dermatitis With Dermal Fibrosis [and] Spongiotic Dermatitis With Extravasated Erythrocytes" and Dr. C. wrote in hand "most likely repressed eczema." As these additional private dermatological records were obtained subsequent to the March 2012 and July 2012 VA opinions, it is clear that the medical professionals that provided those opinions did not consider "'all procurable and assembled data'... that might reasonably illuminate the medical analysis." See Jones v. Shinseki, 23 Vet. App. 382 (2010). Moreover, the Board finds that the March 2012 VA opinion did not explain the basis for the inconclusive opinion provided and the July 2012 VA opinion, while comparatively more detailed than the March 2012 VA opinion, similarly did not sufficiently explain the basis for the inconclusive opinion provided. Accordingly, the Board finds that remand is required for a new VA examination and opinion, as outlined further in the remand directives below, in which the examiner has the opportunity to consider the private dermatological records from Dr. C. and which sufficiently explains the basis for any conclusions reached. CAD As noted, the Veteran was afforded a VA examination in May 2012 and a Heart Conditions DBQ was completed. A diagnosis was noted of CAD, with a date of diagnosis noted of November 2009. It was noted that the Veteran "had a cholesterol level of greater than 400 for more than twenty years." In regards to the etiology of the Veteran's CAD, the DBQ noted "most likely due to chronically elevated cholesterol levels." Beyond this statement, no opinion was provided (or otherwise obtained by VA) as to direct service connection with respect to the Veteran's CAD claim. Also of record is a September 2013 Heart Conditions DBQ completed by Dr. S., a private doctor. A diagnosis was noted of CAD, with a date of diagnosis noted of November 2009. In regards to the etiology of the Veteran's CAD, the DBQ noted "unknown - [r]isk factors include hyperlipidemia [and] [t]obacco use." In the Veteran's November 2012 NOD, he referenced examinations conducted in March 1988 and May 1991 during his active service that noted his cholesterol levels. He referenced being told that his cholesterol of 201 was "high" at the March 1988 examination and that the cholesterol level "had risen to 215" at the May 1991 examination. The Veteran referenced post-service having a stent placed in his heart and that "[s]ince this has occurred I have found out what to eat and exercise to keep my cholesterol under 120." He further stated that "[if] I had this information when first found that I had high cholesterol in 1988 and again in 1991 while I was in [active service] this could possibly have been avoided, and the damage not done to my heart." The Veteran's statement appears to be asserting that his in-service cholesterol levels "damaged" his heart. The Board notes that the Veteran's STRs included a March 1988 examination report that noted a cholesterol level of 201 and referenced cholesterol counseling and handout. Also, a May 1991 examination report noted a cholesterol level of 215 and an accompanying laboratory result printout noted that the desirable range of cholesterol was less than 200, that between 200 and 239 was borderline and that above 240 was high. As noted, the May 2012 Heart Conditions DBQ referenced an etiology of CAD as "most likely due to chronically elevated cholesterol levels" and the September 2013 Heart Conditions DBQ referenced an etiology of CAD as "unknown - [r]isk factors include hyperlipidemia." Based on the Veteran's assertion that his in-service cholesterol levels "damaged" his heart and the May 2012 and September 2013 Heart Conditions DBQs that either related the Veteran's CAD to elevated cholesterol levels or noted a risk factor of hyperlipidemia, the Board finds that remand is required for a VA opinion that addresses the Veteran's contention and the issue of direct service connection, as outlined further in the remand directives below. In addition, on the Veteran's July 2011 formal claim, he listed a disability of Gulf War Syndrome and stated "regarding the Gulf Sympt[]o[m]s, I have experienced and am being treated for...cardiovascular symptoms." This statement can be taken as a contention that the Veteran's current heart disability is related to his active service in the Southwest Asia theater of operations. The Board notes that of record are multiple VA exam requests and many of these requests included a document titled "Notice to VA Examiners VA Considers this Veteran Exposed to High Levels of Particulate Matter." The document stated that "[o]nce inhaled, 10-micron sized particles or smaller can affect the heart...and cause serious health effects." Based on this document, the opinion on remand will also be asked to consider the Veteran's active service in the Southwest Asia theater of operations during the Persian Gulf War. All Claims On the September 2013 VA Form 21-526EZ, which the listed a disability of fibromyalgia, the Veteran listed that he received VA treatment from December 2011 to August 2013. The VA treatment records of record are dated from March 2012 to November 2013. As such, while on remand, all outstanding VA treatment records must be obtained, to specifically include any records available prior to March 2012 and from November 2013. Also, the Veteran appears to obtain a significant amount of his medical care from non-VA providers. The Veteran is informed that on remand he may provide any outstanding relevant private treatment records or may submit a release for such providers to allow VA to attempt to obtain outstanding relevant records. Accordingly, the case is REMANDED for the following action: 1. Obtain all outstanding VA treatment records. This specifically includes any records available prior to March 2012 and from November 2013. 2. Afford the Veteran a VA examination with respect to his claim for entitlement to service connection for a skin disability. The examiner must provide an opinion addressing the following: Whether it is at least as likely as not (i.e., probability of 50 percent or greater) that any skin disability present at any point during the appeal period had its onset during active service or is related to any in-service disease, event, or injury, to include the Veteran's service in the Southwest Asia theater of operations during the Persian Gulf War. While review of the entire claims folder is required, attention is invited to the Veteran's lay statements regarding his skin, to include his November 2012 NOD (stating in regards to eczema that "I had this while in military service and it has grown worse and more pronounced since I have returned from Desert St[or]m/Shield") and an October 2014 statement (stating that "eczema claimed as skin rash did result from the exposure to burn pits from the Gulf...and has had continuous issues since leaving the Gulf" and "eczema[] did manifest within one year" [presumably of separation from active service]). For all opinions provided, the examiner must include the underlying reasons for any conclusions reached. 3. Obtain a VA opinion with respect to the Veteran's claim for entitlement to service connection for coronary artery disease (CAD). If the medical professional determines that additional examination of the Veteran is necessary to provide an adequate opinion, such examination must be scheduled. The medical professional must provide an opinion addressing the following: Whether it is at least as likely as not (i.e., probability of 50 percent or greater) that CAD had its onset during active service or is related to any in-service disease, event, or injury, to include the Veteran's service in the Southwest Asia theater of operations during the Persian Gulf War. While review of the entire claims folder is required, attention is invited to the Veteran's assertion that his in-service cholesterol levels "damaged" his heart and the May 2012 and September 2013 Heart Conditions DBQs that either related the Veteran's CAD to elevated cholesterol levels or noted a risk factor of hyperlipidemia. Additional attention is invited to the multiple VA examination requests that included a document titled "Notice to VA Examiners VA Considers this Veteran Exposed to High Levels of Particulate Matter," which stated that "[o]nce inhaled, 10-micron sized particles or smaller can affect the heart...and cause serious health effects." These issues are discussed further in the body of the remand above. For all opinions provided, the medical professional must include the underlying reasons for any conclusions reached. 4. After completing the requested actions, readjudicate the claims in light of all pertinent evidence. If the benefits sought remain denied, furnish to the Veteran and his representative a Supplemental Statement of the Case. The Veteran has the right to submit additional evidence and argument on the 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 2014). ______________________________________________ J.W. FRANCIS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs