Citation Nr: 1749335 Decision Date: 11/01/17 Archive Date: 11/13/17 DOCKET NO. 09-11 599 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for a dental disorder, claimed as gum issues and teeth falling out, to include as due to herbicide exposure, for VA compensation purposes. 2. Entitlement to service connection for melanoma of the face, scalp, back, and chest, to include as due to herbicide exposure. 3. Entitlement to service connection for a chronic disability manifested by numbness in the legs to include peripheral neuropathy and to include as due to herbicide exposure. 4. Entitlement to service connection for a back disorder. 5. Entitlement to service connection for a right knee disorder. 6. Whether new and material evidence has been received to reopen a claim for service connection for a skin rash as due to herbicide exposure. 7. Entitlement to service connection for allergic rhinitis, to include as due to herbicide exposure. 8. Entitlement to service connection for attention deficit disorder, to include as due to herbicide exposure and secondary to service-connected PTSD. 9. Entitlement to service connection for actinic keratoses, to include as due to herbicide exposure. 10. Entitlement to an initial rating in excess of 50 percent for posttraumatic stress disorder (PTSD) prior to January 15, 2015. 11. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) prior to January 15, 2015. REPRESENTATION Appellant represented by: Jeany Mark, Attorney ATTORNEY FOR THE BOARD N. T. Werner, Counsel INTRODUCTION The Veteran had active duty service from September 1967 to January 1970, to include service in the Republic of Vietnam from April 1969 to January 1970. This matter comes to the Board of Veterans' Appeals (Board) from decisions issued in January 2007, April 2009, June 2009, November 2009, and November 2012 by the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. In a June 2014, the Veteran withdrew his earlier Board hearing request. Therefore, the Board finds that it can adjudicate the appeal without holding a hearing. 38 C.F.R. § 20.704(e) (2016). In August 2014, the Board remanded the above issues for additional development. In a May 2015 rating decision, the RO granted the Veteran a 100 percent rating for his PTSD, effective January 15, 2015. As such, the Board has identified the PTSD and TDIU as stated on the title page. In August 2017 the Veteran's attorney waived AOJ consideration of the additional evidence that was added to the claims file since the issuance of the May 2015 supplemental statement of the case. Therefore, the Board finds that a remand for AOJ review of this evidence is not needed before adjudicating the appeal. See 38 C.F.R. § 20.1304 (2016). In a July 1982 rating decision, the RO denied service connection for a rash. The Board finds that he has submitted new and material evidence to reopen this claim. The Veteran's claims of service connection for a skin rash; the claims of service connection for allergic rhinitis, for an attention deficit disorder, and actinic keratoses; the claim for an initial rating in excess of 50 percent for PTSD prior to January 15, 2015; and the claim for a TDIU prior to January 15, 2015, are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDINGS OF FACT 1. The Veteran does not have a dental disability for which service connection may be granted for VA compensation purposes. 2. The preponderance of the evidence shows that the Veteran has not been diagnosed with melanoma of the face, scalp, back, and/or chest at any time during the pendency of the appeal. 3. The preponderance of the evidence shows that a chronic disability manifested by numbness in the legs, diagnosed as radiculopathy, was not present in service or until many years thereafter and it is not related to service or to an incident of service origin nor was it caused or aggravated by a service-connected disability. 4. The preponderance of the evidence shows that a back disorder was not present in service or until many years thereafter and it is not related to service or to an incident of service origin. 5. The preponderance of the evidence shows that a right knee disorder was not present in service or until many years thereafter and it is not related to service or to an incident of service origin. CONCLUSIONS OF LAW 1. The criteria for service connection for a dental disability for VA compensation purposes have not been met. 38 U.S.C.A. §§ 1110, 1712, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.306, 3.310, 3.381, 4.150 (2016). 2. Melanoma of the face, scalp, back, and chest was not incurred in or aggravated by military service. 38 U.S.C.A. §§ 1101, 1110, 1131, 1112, 1113, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2016). 3. A chronic disability manifested by numbness in the legs, diagnosed as radiculopathy, was not incurred in or aggravated by military service and it was not caused or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1101, 1110, 1131, 1112, 1113, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.310 (2016). 4. A back disorder was not incurred in or aggravated by military service. 38 U.S.C.A. §§ 1101, 1110, 1131, 1112, 1113, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2016). 5. A right knee disorder was not incurred in or aggravated by military service. 38 U.S.C.A. §§ 1101, 1110, 1131, 1112, 1113, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran asserts, in substance, that he has a dental disorder manifested by gum issues and teeth falling out, melanoma of the face, scalp, back, and chest, a chronic disability manifested by numbness in the legs, a back disorder, and a right knee disorder due to military service. See Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). As to the dental disorder manifested by gum issues and teeth falling out, melanoma of the face, scalp, back, and chest, and a chronic disability manifested by numbness in the legs he also claims they are due to herbicide exposure. Id. As to the back and right knee disorders, he maintains that they were caused by a documented motor vehicle accident while serving in the Republic of Vietnam. Id. Service connection is warranted where the evidence shows that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. In addition, service connection may also be granted on the basis of a post-service initial diagnosis of a disease, where the physician relates the current condition to the period of service. 38 C.F.R. § 3.303(d). Other specifically enumerated disorders, including arthritis, will be presumed to have been incurred in service if they manifested to a compensable degree within the first year following separation from active duty. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. In this regard, in order to establish service connection for the claimed disorders, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). As to herbicide exposure, VA laws and regulations provide that a Veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the Vietnam war (i.e., January 9, 1962, to May 7, 1975), shall be presumed to have been exposed to an herbicide agent, unless there is affirmative evidence to the contrary. 38 U.S.C.A. § 1116(a)(3); 38 C.F.R. § 3.307(a)(6)(iii). 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 served in the Republic of Vietnam during the Vietnam war period. 38 C.F.R. § 3.307. For these Vietnam Veterans, diseases associated with exposure to certain herbicide agents will be presumed to have been incurred in service even though there is no evidence of that disease during the period of service at issue. 38 U.S.C.A. § 1116; 38 C.F.R. §§ 3.307, 3.309. The availability of presumptive service connection for a disability based on exposure to herbicides does not preclude a Veteran from establishing service connection with proof of direct causation. Stefl v. Nicholson, 21 Vet. App. 120 (2007); see also Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). As to compensation for dental disabilities, VA's controlling regulations provide that service connection is not warranted for periodontal disease but instead only for bone loss through trauma or disease such as osteomyelitis. See 38 C.F.R. § 4.150, Note (2016) ("these ratings apply only to bone loss through trauma or disease such as osteomyelitis, and not to the loss of the alveolar process as a result of periodontal disease, since such loss is not considered disabling."); VAOPGCPREC 5-97; 62 Fed. Reg. 15,566 (1997); see also 38 C.F.R. § 3.306(b)(1) (The usual effects of surgery performed to ameliorate a condition incurred before service, including poorly functioning parts, will not be considered service connected unless the disease or injury is otherwise aggravated by service.); Nielson v. Shinseki, 607 F.3d 802 (Fed. Cir. 2010) (holding that service trauma is defined as an injury or wound produced by an external physical force during a service member's performance of military duties and does not include intended results of proper medical treatment provided by the military). Further, treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, and periodontal disease are not considered disabling for VA disability compensation purposes; such conditions will be considered service connected solely for the purpose of establishing eligibility for outpatient dental treatment. See 38 U.S.C.A. § 1712 (West 2014); 38 C.F.R. § 3.381. Service connection may also be granted where disability is proximately due to or the result of already service-connected disability. 38 C.F.R. § 3.310. Compensation is also payable when service-connected disability has aggravated a non-service-connected disorder. Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). The requirement of a current disability is "satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim." See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under the laws administered by VA. VA shall consider all information and medical and lay evidence of record. Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Board is charged with the duty to assess the credibility and weight given to evidence. Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). Indeed, the Court has declared that in adjudicating a claim, the Board has the responsibility to do so. Bryan v. West, 13 Vet. App. 482, 488-89 (2000). In doing so, the Board is free to favor one medical opinion over another, provided it offers an adequate basis for doing so. Owens v. Brown, 7 Vet. App. 429, 433 (1995). a. Dental Disorder Although the service treatment records document dental treatment, the Veteran does not assert and the record does not show that he sustained a dental trauma while on active duty. See 38 C.F.R. § 4.150, Note; Nielson. Likewise, not only is the record negative for the diagnosis of a dental disease such as osteomyelitis but the January 2015 VA dental examiner opined that he did not have such a diagnosis and the Board finds that the Veteran is not competent or credible to provide such a diagnosis because its diagnosis is a complex medical question and he does not have the required medical training. Therefore, the Board finds that the Veteran has not been diagnosed with a dental disability for which service connection for VA compensation purposes may be granted. Accordingly, the Board finds that the claim of service connection for a dental disability for VA compensation purposes on direct and secondary bases must be denied as a matter of law. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). b. Melanoma A condition precedent for establishing service connection on a direct, presumptive, and secondary basis is the presence of a current disability. In this regard, the Veteran's service treatment records and post-service records are negative for a diagnosis of melanoma. In fact, when examined by VA in January 2015 for the express purpose of ascertaining if he had this disease it was opined that he did not. See Colvin. Moreover, while the Veteran is competent to report on what he sees and feels, including having observable symptoms of melanoma, the Board finds that he is not qualified to diagnose melanoma because he does not have the required medical training. See Davidson. The Board finds that the most probative evidence of record shows that the Veteran did not have a diagnosis of melanoma of the face, scalp, back, and/or chest, at any time during the pendency of his appeal. Accordingly, because a condition precedent for establishing service connection for a claimed disability is the diagnosis of the disability at any time during the pendency of the appeal and this Veteran does not have such a diagnosis, the Board must conclude that entitlement to service connection for melanoma of the face, scalp, back, and chest, must be denied on a direct, presumptive, and secondary basis because the weight of the evidence is against the claim. See 38 U.S.C.A. §§ 1110, 1116; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310; McClain. c. Back, Right Knee, and Leg Disorders Initially, the Board notes that the post-service record documents the Veteran's complaints and treatment for low back pain diagnosed as increased lumbar lordosis (see May 1975 X-ray), spondylosis (see December 1999 and February 1982 low back X-rays), defect at L5-S1 (see February 2002 low back X-ray), degenerative disc disease (see September 2007 VA X-ray), and lumbar stenosis (see December 2007 VA treatment record). The post-service record also documents the Veteran's complaints and treatment for right knee pain diagnosed as a complex tear of the body of the posterior horn of the medial meniscus (see September 2002 VA right lower extremity Magnetic Resonance Imaging (MRI)) and anterior cruciate ligament deficiency status post July 2003 arthroscopy (see July 2003 operation report). As to the leg pain and numbness, the post-service record shows that the Veteran being diagnosed with radiculopathy (see December 2007 VA treatment records). The record does not show the Veteran being diagnosed with peripheral neuropathy despite the Veteran being afforded a VA nerves examination in January 2015 for the express purpose of obtaining a diagnosis. See McClain. As to service incurrence under 38 C.F.R. § 3.303(a), the Veteran's service records show that he served in the Republic of Vietnam during the Vietnam era. Moreover, an October 1969 service treatment record reported that the Veteran fell out of a moving Jeep. A December 1969 coccyx X-ray also stated that the Veteran had fallen out of a Jeep "onto his butt." Furthermore, the Board finds that the Veteran is competent to report on having observable symptoms of back, right knee, and leg problems since this documented fall because these symptoms come to him via his own senses. See Davidson. Similarly, the Board finds the August 2009 statement from S. Smith, who reported that he had served with the Veteran, is competent to report that he drove the Jeep the Veteran feel from and following the fall the Veteran complained of back and knee pain/injuries because these observations also come to him via his senses. Id. However, the October 1969 service treatment record following the fall from the Jeep was negative for a back, right knee, and/or a leg injury. In this regard, the record specifically reported that his injury and treatment were related to "scraps" and cuts on his right hand. Likewise, a subsequent December 1969 coccyx X-ray did not reveal any fracture. Moreover, the subsequent service treatment records, including the January 1970 separation examination, are negative for a back, right knee, and/or leg injury or a diagnosed disorder. In fact, when examined in January 1970 the Veteran did not report a history of back, right knee, or leg problems and the examiner specifically opined that his spine, lower extremities, and neurological system examinations were normal. See Colvin. Furthermore, the Board finds that the Veteran is not competent to diagnose the disorders because these are complex medical questions and he does not have the required medical expertise. See Davidson. Given the above, the Board finds the most probative evidence to be the service treatment records, including the October 1969 service treatment record following the fall from the Jeep, December 1969 coccyx X-ray, and January 1970 separation examination, that do not show the Veteran had a back, right knee, and/or leg disability while on active duty. See Owens. Thus, the Board finds that service connection for a back disability, a right knee disability, and a chronic disability manifested by numbness in the legs based on in-service incurrence. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). As to the presumptions found at 38 C.F.R. § 3.309(a), the record does not show the Veteran being diagnosed with arthritis in the back, right knee, or either leg in his first post-service year, if ever. Accordingly, the Board finds that entitlement to service connection for back disability, a right knee disability, and a chronic disability manifested by numbness in the legs must be denied on a presumptive basis. See 38 U.S.C.A. §§ 1112, 1113, 1110; 38 C.F.R. §§ 3.303, 3.307, 3.309. As to the presumptions found at 38 C.F.R. § 3.309(e), the record does not show the Veteran being diagnosed with any of the specifically enumerated disease processes listed under this regulation. Accordingly, the Board finds that entitlement to service connection for a back disability, a right knee disability, and a chronic disability manifested by numbness in the legs must be denied on a presumptive basis. See 38 U.S.C.A. § 1116; 38 C.F.R. §§ 3.303, 3.307, 3.309. As for service connection for a back disability, a right knee disability, and a chronic disability manifested by numbness in the legs based on continued symptoms since service, the Board finds that the length of time between the Veteran's separation from of service in 1970 and his first complaints, diagnoses, or treatment for a back disorder in 1975 (see low back X-ray dated in May 1975), a right knee disorder in 2002 (see MRI dated in September 2002), and the chronic disability manifested by numbness in the legs (i.e., radiculopathy) in 2007 (see VA treatment records and MRI dated in December 2007) years later to be evidence against his claims. In this regard, the Board acknowledges that the service treatment records document a fall from a Jeep and the Veteran is competent to give evidence about what he sees and feels and others are competent to give evidence about what they see. See Davidson. However, upon review of the record the Board finds that any lay accounts from the Veteran, his representative, and others that the claimant has had these disabilities since service are not credible. In this regard, these lay claims are contrary to what is found in the service records, including the October 1969 service treatment record following the fall from the Jeep, December 1969 coccyx X-ray, and January 1970 separation examination. Likewise, these lay claims are contrary to what is found in the post-service treatment records, including the May 1975 orthopedic examination and June 1975 hospitalization summary, which do not show him being diagnosed with any of the disorders until years after service. In these circumstances, given the service treatment records, including the October 1969 service treatment record following the fall from the Jeep, December 1969 coccyx X-ray, and January 1970 separation examination that do not diagnose either disability in-service and the post-service records, including the May 1975 orthopedic examination and June 1975 hospitalization summary, as well as the treatment records, which do not report a history or diagnosis any of the disabilities until years after service than any claims by the Veteran and other lay persons to the contrary. Thus, the Board finds that service connection for a back disability, a right knee disability, and a chronic disability manifested by numbness in the legs based on recurrent problems since service must be denied. 38 U.S.C.A. § 1110. As for service connection for a back disability, a right knee disability, and a chronic disability manifested by numbness in the legs based on their initial documentation after service under 38 C.F.R. § 3.303(d), the Board notes that in February 2014 Dr. Aliya Al indicated that it was more likely than not that the Veteran's residuals of a right knee injury and a back injury with radiculopathy were secondary to his fall out of a Jeep while in service. However, because this opinion does not contain a rationale the Board does not find it probative. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (a medical opinion that contains only data and conclusions is not entitled to any weight). On the other hand, at the post-remand January 2015 VA examination which was scheduled for the express purpose of ascertaining if the Veteran's back disability, right knee disability, and a chronic disability manifested by numbness in the legs where due to his military service to include the documented fall from a jeep the examiner after a review of the record on appeal and examination of the Veteran opined that they were not. The Board finds the VA examiner's opinion the most probative evidence of record because it contains a rationale supported by citation to evidence found in the record. See Owens. As to any lay claims from the Veteran and others that his back, right knee, and leg disorders were caused by his military service, the Board finds that diagnosing musculoskeletal and neurological disabilities requires special medical training that these lay persons do not have and therefore the presence of the disabilities is a determination "medical in nature" and not capable of lay observation. See Davidson. Accordingly, since laypersons are not capable of opining on matters requiring medical knowledge, the Board finds that the lay opinions that these disabilities were caused by service is not competent evidence. Jandreau. Therefore, the Board finds that the most probative evidence of record shows that the Veteran's back disability, right knee disability, and chronic disability manifested by numbness in the legs were not caused by his military service, including his documented Jeep accident while in the Republic of Vietnam, and service connection is not warranted based on the initial documentation of the disabilities after service. See 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(d). As for service connection for a chronic disability manifested by numbness in the legs based on secondary service connection under 38 C.F.R. § 3.310, the January 2015 examiner opined that the Veteran's radiculopathy was due to his non service-connected low back disability and this medical opinion is not contradicted by any other medical evidence of record. See Colvin. Moreover, the Board finds that any lay claims to the contrary from the Veteran and others lack probative value because they do not have the required medical taring. See Davidson. Therefore, the Board finds that the most probative evidence of record shows that the Veteran's chronic disability manifested by numbness in the legs was not caused or aggravated by a service connected disability and service connection is not warranted on a secondary bases See 38 U.S.C.A. § 1110; 38 C.F.R. § 3.310. In reaching the above conclusions the Board also considered the doctrine of reasonable doubt. 38 U.S.C.A. § 5107(b). However, as the preponderance of the evidence of record is against the claims, the Board finds that this doctrine is not for application. See also, e.g., Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001); Gilbert. ORDER Service connection for a dental disability for VA compensation purposes is denied. Service connection for melanoma of the face, scalp, back, and chest is denied. Service connection for a back disorder is denied. Service connection for a right knee disorder is denied. Service connection for a chronic disability manifested by numbness in the legs to include peripheral neuropathy is denied. REMAND As to the Veteran's skin rash claim, the Board finds the January 2015 examination inadequate and that another VA examination is necessary to adjudicate the claim. As to the claim of service connection for allergic rhinitis, the Board finds that the January 2015 VA skin examination is inadequate because the examiner did not provide an opinion as to direct causation. See Stefl; Combee. Therefore, the Board finds that a remand to obtain an adequate etiology opinion is required. See 38 U.S.C.A. § 5103A(d) (West 2014); Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). As to the claim of service connection for an attention deficit disorder, treatment records document the Veteran's complaints and/or treatment for attention deficit-hyperactive disorder (ADHD) (see, e.g., VA treatment records dated in October 2000, April 2003, July 2003, October 2003, December 2003, and June 2004). Moreover, in February 2014 Dr. Aliya Al, after citing to a medical article, opined that there is relationship between organophosphate exposure and ADHD development in children and therefore there is a similar relationship between the Veteran's Agent Orange exposure in the Republic of Vietnam and his ADHD. However, from the existing record is it unclear as to whether there was a clinically significant level of organophosphate in Agent Orange. From the existing record, it is also not clear if organophosphate exposure from Agent Orange would have the same cause and effect relationship as seen in the article cited by Dr. Al because the Veteran was an adult (the record shows that the Veteran was almost 23 years old by the time he first arrived in the Republic of Vietnam in April 1969), as opposed to a child, when he had the exposure. Lastly, the Board notes that the record does not contain a medical opinion as to whether the Veteran's service connected PTSD caused or aggravated his ADHD despite the medical literature the Veteran filed with VA in December 2013 that supports such a link. Therefore, the Board finds that a remand for a VA examination to obtain answers to these questions is needed. See 38 U.S.C.A. § 5103A(d). As to the claim of service connection for actinic keratosis, post-service VA treatment records document the Veteran's treatment for actinic keratosis on the posterior head. See, e.g., VA treatment records dated in September 2005, October 2004, July 2006, February 2014, and August 2014. Moreover, given the Veteran's documented Vietnam service, it is presumed that he had herbicide exposure. However, the January 2015 VA skin examiner did not provide an opinion as to the relationship between the Veteran's post-service actinic keratosis and service, including his presumptive herbicide exposure. Moreover, the Board finds that Dr. Aliya Al's February 2014 favorable etiology opinion lacks probative value because it relied on an inaccurate medical history (i.e., service treatment records documented the Veteran's treatment for actinic keratosis with tetracycline for nine months while on active duty). See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (a medical opinion based on an inaccurate factual premise is not probative). Thus, the Board finds that a remand for a VA examination to obtain an etiology opinion is needed. See 38 U.S.C.A. § 5103A(d); Barr. As to the claim for an initial rating in excess of 50 percent for PTSD prior to January 15, 2015, a remand is required because the Veteran was not provided an supplemental statement of the case (SSOC) that addressed the development undertaken as to this issue while it was in remand status. See 38 C.F.R. § 19.31 (2016) (a supplemental statement of the case will be furnished to the veteran when additional pertinent evidence is received after a statement of the case has been issued). On remand, the Board reiterates that the record reflects that the Veteran was afforded a VA psychiatric examination in January 2009. The Board finds that an additional examination is necessary as the Veteran alleged significantly worsening symptoms since his last VA examination. Specifically, he has reported experiencing suicidal ideations. See Bankhead v. Shulkin, 29 Vet. App. 10 (2017). As to the claim for a TDIU prior to January 15, 2015, the Board finds that a remand is required because adjudication of this issue is inextricably intertwined with the above development. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that where a claim is inextricably intertwined with another claim, the claims must be adjudicated together in order to enter a final decision on the matter). Accordingly, these issues are REMANDED to the AOJ for the following actions: 1. After obtaining authorizations from the Veteran, associate with the claims file any outstanding private treatment records. 2. Associate with the claims file the Veteran's post January 2016 VA treatment records from the Charleston VA Medical Center. 3. Notify the Veteran that he may submit lay statements from himself and from other individuals who have first-hand knowledge of any in-service problems with allergic rhinitis, for an attention deficit disorder, and/or actinic keratoses and any continued problems since that time as well as have first-hand knowledge of the problems caused by his PTSD prior to January 15, 2015, to include problems it caused with employment. The Veteran should be provided an appropriate amount of time to submit this lay evidence. 4. Schedule the Veteran for an allergic rhinitis VA examination. The claims file should be made available to the examiner. After a review of the claims file and an examination of the Veteran, the examiner should opine as to whether it is at least as likely as not that allergic rhinitis is related to or had its onset in service to include as a result of the Veteran's presumptive exposure to herbicides due to his documented service in Vietnam. In providing the requested opinions, the examiner should not rely on the fact that VA regulations do not list allergic rhinitis as a disability presumptively caused by herbicide exposure. The examination report must include a complete rationale for all opinions expressed. 5. Schedule the Veteran for an attention deficit disorder VA examination. The claims file should be made available to the examiner. After a review of the claims file and an examination of the Veteran, the examiner should provide answers to the following questions: (a) Since the record does not show the Veteran's diagnosis and treatment for ADHD since 2004, does he currently have a diagnosis or did he ever have during the pendency of the appeal a diagnosis of an attention deficit disorder? (b) If he had or currently has a diagnosis of an attention deficit disorder, is it at least as likely as not that it is related to or had its onset in service to include as a result of the Veteran's presumptive exposure to herbicides due to his documented service in Vietnam? In providing this opinion, the examiner should discuss and comment on Dr. Al's February 2014 opinion. Specifically, the examiner should provide opinions as to (i) whether Agent Orange had high levels of organophosphate and (ii) whether exposure to high levels of organophosphate by a man who was almost 23 when he arrived in the Republic of Vietnam is more likely than not to cause or aggravate ADHD taking into account the medical article cited to by Dr. Al which, in substance, found a relationship between ADHD in children and the child's exposure to organophosphate. (c) If he had or currently has a diagnosis of an attention deficit disorder, is it at least as likely as not it was caused by his service-connected PTSD? (d) If he had or currently has a diagnosis of an attention deficit disorder, is it at least as likely as not that it was aggravated by his service-connected PTSD? In providing the requested opinions, the examiner should consider and comment on the medical literature the Veteran filed with VA in December 2013 that supports a link between PTSD and ADHD. In providing the requested opinions, the examiner should not rely on the fact that VA regulations do not list attention deficit disorder as a disability presumptively caused by herbicide exposure. The examination report must include a complete rationale for all opinions expressed. 6. Schedule the Veteran for skin rash and for actinic keratosis VA examination. The claims file should be made available to the examiner. After a review of the claims file and an examination of the Veteran, the examiner should opine as to whether it at least as likely as not that skin rash and/or actinic keratosis is related to or had its onset in service to include as a result of his presumptive exposure to herbicides due to his documented service in Vietnam. In providing this opinion, the examiner should discuss and comment on the February 2014 opinion. The examination report must include a complete rationale for all opinions expressed. 7. Then adjudicate the claims. If any benefit sought on appeal is not granted in full, furnish the Veteran and his representative a SSOC. The Veteran and his representative should be given an appropriate opportunity for response before returning the appeal to the Board. 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). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board 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). ______________________________________________ STEVEN D. REISS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs