Citation Nr: 1754917 Decision Date: 11/30/17 Archive Date: 12/07/17 DOCKET NO. 12-22 528 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Diego, California THE ISSUES 1. Entitlement to service connection for skin cancers of the ears, including as due to herbicide exposure. 2. Entitlement to service connection for chloracne of the back, including as due to herbicide exposure. 3. Entitlement to a rating in excess of 60 percent for ischemic heart disease prior to January 28, 2016. 4. Entitlement to an effective date earlier than April 9, 2013 for the award of service connection for ischemic heart disease. REPRESENTATION Appellant represented by: John M. Baird, Attorney ATTORNEY FOR THE BOARD K. Hughes, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from May 1967 to April 1970, including service in the Republic of Vietnam.. These matters are before the Board of Veterans' Appeals (Board) on appeal from rating decisions issued by the San Diego, California Regional Office/Agency of Original Jurisdiction (RO/AOJ) in February 2010 (which in pertinent part denied service connection for skin cancers, chloracne, and pterygium) and July 2013 (which awarded service connection for IHD, rated 60 percent, effective April 9, 2013). In his August 2012 substantive appeal, the Veteran requested a Travel Board hearing at the RO; however, in a November 2014 correspondence, he withdrew his hearing request. In a July 2015 decision, the Board denied an effective date prior to April 9, 2013, for the award of service connection for ischemic heart disease. The Veteran appealed that decision to the Court. In February 2017, the Court issued an order that vacated the July 2015 Board decision and remanded the matter for readjudication consistent with the instructions outlined in the January 2017 Joint Motion for Partial Remand by the parties. The July 2015 Board decision also remanded the matters of an increased rating for ischemic heart disease and service connection for skin cancers of the ears, chloracne of the back and pterygium in both eyes for additional development. The additional development ordered in the July 2015 Board remand has been completed and the claims have been re-certified to the Board. An interim April 2016 rating decision granted an increased 100 percent rating for ischemic heart disease from January 28, 2016. As the staged rating prior to January 28, 2016 provides for less than the maximum schedular rating available for ischemic heart disease and the Veteran has not expressed satisfaction with the rating, the matter of an evaluation in excess of 60 percent for ischemic heart disease prior to January 28, 2016 remains in appellate status. AB v. Brown, 6 Vet. App. 35 (1993). [The interim April 2016 rating decision also granted service connection for pterygium in both eyes. As this represents a complete grant of the Veteran's claim of service connection for pterygium in both eyes, this issue is no longer on appeal before the Board. See generally Grantham v. Brown, 114 F.3d 116 (Fed. Cir. 1997); Barrera v. Gober, 122 F.3d 1030 (Fed. Cir. 1997).] The matters of an increased rating for ischemic heart disease and service connection for skin cancers of the ears and chloracne of the back are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDINGS OF FACT 1. The Veteran's claim of service connection for ischemic heart disease was received by VA on February 17, 2012; no formal or informal claim of service connection for a heart disability was received prior to that date. 2. The date of receipt of the claim of entitlement to service connection for a heart disorder is later than the date entitlement arose. CONCLUSION OF LAW The criteria for an effective date of February 17, 2011 for the award of service connection for ischemic heart disease have been met. 38 U.S.C. § 5110, 5107 (West 2014); 38 C.F.R. § 3.1(p), 3.102, 3.114, 3.151, 3.155, 3.400, 3.816 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSION Initially, it is noted that the Board has thoroughly reviewed all the evidence in the record. Although the Board has an obligation to provide adequate reasons and bases supporting its decision, there is no requirement that the Board discuss every piece of evidence in the record. The Board will summarize the relevant evidence, as deemed appropriate, and the Board's analysis will focus on what the evidence shows, or fails to show, as to the claim. See Gonzalez v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case with all reasonable doubt to be resolved in favor of the claimant; however, the reasonable doubt rule is not a means for reconciling actual conflict or a contradiction in the evidence. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The Veteran claims the effective date assigned for the grant of service connection for ischemic heart disease is incorrect and should be earlier than the effective date (April 9, 2013) assigned. Generally, the effective date of an award of a claim is the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400. Unless otherwise provided, the effective date of compensation will be fixed in accordance with the facts found, but will not be earlier than the date of the application therefore. 38 U.S.C. § 5100(a). If a claim for disability compensation is received within one year after separation from service, the effective date of entitlement is the day following separation or the date entitlement arose. 38 U.S.C. § 5110(b)(1); 38 C.F.R. § 3.400(b)(2). Prior to March 24, 2015, VA recognized formal and informal claims. [Effective March 24, 2015, VA amended its rules as to what constitutes a claim for benefits; claims are now required to be submitted on a specific claim form, prescribed by the Secretary, and available online or at the local RO.] A claim is a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit. 38 C.F.R. § 3.1(p). A formal claim is the use of the appropriate designated VA form to seek specific benefits. 38 C.F.R. § 3.151(a). Any communication or action indicating an intent to apply for VA benefits from a claimant or representative may be considered an informal claim. Such an informal claim must identify the benefit sought. 38 C.F.R. § 3.155(a). VA is required to identify and act on informal claims for benefits. 38 U.S.C. § 5110(b)(3); 38 C.F.R. §§ 3.1(p), 3.155(a). However, VA is not required to anticipate any potential claim for a particular benefit where no intention to raise it was expressed. See Brannon v. West, 12 Vet. App. 32, 35 (1998) (holding that before VA can adjudicate a claim for benefits, "the claimant must submit a written document identifying the benefit and expressing some intent to seek it"). See also Talbert v. Brown, 7 Vet. App. 352, 356-57 (1995). The essential elements for any claim, whether formal or informal, are: (1) an intent to apply for benefits; (2) an identification of the benefits sought; and (3) a communication in writing. Brokowski v. Shinseki, 23 Vet. App. 79, 84 (2009); see also MacPhee v. Nicholson, 459 F.3d 1323, 1326-27 (Fed. Cir. 2006) (holding that the plain language of the regulations requires a claimant to have intent to file a claim for VA benefits). A pending claim is an application, formal or informal, which has not been finally adjudicated. 38 C.F.R. § 3.160(c); Adams v. Shinseki, 568 F.3d. 956, 960 (Fed. Cir. 2009). A finally adjudicated claim is defined as "an application, formal or informal, which has been allowed or disallowed by an agency of original jurisdiction." 38 C.F.R. § 3.160(d). Such an action becomes "final" by the expiration of one year after the date of notice of an award or disallowance, or by denial on appellate review, whichever is the earliest. Id. The pending claims doctrine provides that a claim remains pending in the adjudication process - even for years - if VA fails to act on it. Norris v. West, 12 Vet. App. 413, 422 (1999). The Court has confirmed that raising a pending claim theory in connection with a challenge to the effective-date decision is procedurally proper. Ingram v. Nicholson, 21 Vet. App. 232, 249, 255 (2007) (recent Federal Circuit cases have not overruled the pending claim doctrine articulated in Norris); Myers v. Principi, 16 Vet. App. 228, 236 (2002) (since VA failed to issue a statement of the case (SOC) after a valid NOD was filed, the original claim was still pending and is relevant to determining the effective date of a service connection award); McGrath v. Gober, 14 Vet. App. 28, 35 (2000) (a claim that has not been finally adjudicated remains pending for purposes of determining the effective date for that disability). Upon receipt of an informal claim for which a formal claim has not already been filed, an application for VA benefits (VA Form 21-526) must be forwarded to the claimant for execution. If received within one year after the date it was sent to the claimant, that signed application will be considered filed as of the date of receipt of the informal claim. 38 C.F.R. § 3.155; Norris v. West, 12 Vet. App. 413 (1999). Where compensation is awarded pursuant to a liberalizing law or a liberalizing VA issue, the effective date of the increase shall be fixed in accordance with facts found, but shall not be earlier than the effective date of the act or administrative issue. 38 U.S.C. § 5110(g); 38 C.F.R. § 3.114(a). See also McCay v. Brown, 9 Vet. App. 183, 187 (1996) ("plain language of section 5110(g) prohibits a retroactive award prior to the effective date of the legislation"), aff'd, 106 F.3d 1577 (Fed. Cir. 1997). If a claim is reviewed on the initiative of VA within one year from the effective date of the law or VA issue, or at the request of a claimant received within one year from that date, benefits may be authorized from the effective date of the law or VA issue. 38 C.F.R. § 3.114(a)(1). However, if a claim is reviewed on the initiative of VA more than one year after the effective date of the law or VA issue, benefits may be authorized for a period of one year prior to the date of administrative determination of entitlement. 38 C.F.R. § 3.114(a)(2). If a claim is reviewed at the request of the claimant more than one year after the effective date of the law or VA issue, benefits may be authorized for a period of one year prior to the date of receipt of such request. 38 C.F.R. § 3.114(a)(3). In order to be eligible for a retroactive award, the claimant must show that all eligibility criteria for the benefits existed at the time of the effective date of the law or administrative issue and continuously thereafter. 38 C.F.R. § 3.114(a). Ordinarily, under the above provisions for liberalizing laws, awards based on presumptive service connection established under the Agent Orange Act of 1991 can be made effective no earlier than the date VA issued the regulation authorizing the presumption. Id. The covered herbicide diseases are listed in 38 C.F.R. § 3.309(e). See 38 C.F.R. § 3.816 (b)(2). Effective August 31, 2010, ischemic heart disease was added to the list of disorders for which service connection may be granted on a presumptive basis for veterans exposed to Agent Orange during service. Ischemic heart disease includes, but is 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). The term ischemic heart disease does not include hypertension or peripheral manifestations of arteriosclerosis such as peripheral vascular disease or stroke, or any other condition that does not qualify within the generally accepted medical definition of ischemic heart disease. See 38 C.F.R. § 3.309(e), Note 3; 75 Fed. Reg. 53202. However, with respect to earlier effective date claims for service connection for diseases presumed to be caused by herbicide or Agent Orange exposure, VA has promulgated special rules to implement orders of a United States District Court in the class action of Nehmer v. United States Department of Veteran's Affairs. 38 C.F.R. § 3.816. See Nehmer v. U.S. Veterans Admin., 32 F. Supp. 1404 (N.D. Cal. 1989) (Nehmer I); Nehmer v. U.S. Veterans Admin., 32 F. Supp. 2d 1175 (N.D. Cal 1999) (Nehmer II); Nehmer v. Veterans Admin. of the Gov't of the U. S., 284 F.3d 1158 (9th Cir. 2002) (Nehmer III); Nehmer v. U.S. Veterans Admin., 494 F.3d. 846 (2007) (Nehmer IV). The regulation, 38 C.F.R. § 3.816, defines Nehmer class members and sets forth effective date rules for Vietnam veterans that currently have a "covered herbicide disease," or have died from a "covered herbicide disease." In short, the Nehmer litigation has created an exception to the generally applicable effective date rules contained in 38 U.S.C. § 5110(g) and 38 C.F.R. § 3.114. In pertinent part, a "Nehmer class member" is defined as a Vietnam veteran who has a covered herbicide disease. 38 C.F.R. § 3.816(b)(1)(i). According to 38 C.F.R. § 3.816(b)(2), a "covered herbicide disease" includes a disease for which the Secretary of Veterans Affairs has established a presumption of service connection before October 1, 2002 pursuant to the Agent Orange Act of 1991. As noted above, ischemic heart disease, to include coronary artery disease, was not added to the list of presumptive disabilities until August 31, 2010. See 75 Fed. Reg. 53,202 (August 31, 2010). Notwithstanding the language of 38 C.F.R. § 3.816, however, notice accompanying the issuance of the final August 31, 2010 rule specifically notes the Nehmer provisions apply to the newly covered diseases, to include ischemic heart disease. Id.; see also Garza v. Shinseki, 480 Fed. App. 984, 987 (Fed. Cir. 2012) (specifically associating ischemic heart disease with Nehmer despite the language of 38 C.F.R. § 3.816). The Nehmer regulation provides for situations where the effective date can be earlier than the date of the liberalizing law, assuming a "Nehmer class member" has been granted compensation from a covered herbicide disease. Either (1) VA denied compensation for the same covered herbicide disease in a decision issued between September 25, 1985 and May 3, 1989; or (2) the class member's claim for disability compensation for the covered herbicide disease was either pending before VA on May 3, 1989, or was received by VA between May 3, 1989 and the effective date of the statute or regulations establishing a presumption of service connection for the covered disease (here August 31, 2010). In these situations, the effective date of the award will be the later of the date such claim was received by VA or the date the disability arose. 38 C.F.R. § 3.816(c)(1), (c)(2). A prior decision will be construed as having denied compensation for the same disease if the prior decision denied compensation for a disease that reasonably may be construed as the same covered herbicide disease for which compensation has been awarded. Minor differences in the terminology used in the prior decision will not preclude a finding, based on the record at the time of the prior decision, that the prior decision denied compensation for the same covered herbicide disease. 38 C.F.R. § 3.816(c)(1). A claim will be considered a claim for compensation for a particular covered herbicide disease if: (i) The claimant's application and other supporting statements and submissions may reasonably be viewed, under the standards ordinarily governing compensation claims, as indicating an intent to apply for compensation for the covered herbicide disability; or (ii) VA issued a decision on the claim, between May 3, 1989, and the effective date of the statute or regulation establishing a presumption of service connection for the covered herbicide disease (August 31, 2010), in which VA denied compensation for a disease that reasonably may be construed as the same covered herbicide disease for which compensation has been awarded. 38 C.F.R. § 3.816(c)(2)(i), (ii). As to 38 C.F.R. § 3.816(c)(3), if the class member's claim was received within one year of his or her separation from service, the effective date of the award shall be the day following the date of the class member's separation from active service. If the requirements of paragraph (c)(1) or (c)(2) listed above are not met, the effective date of the award shall be determined in accordance with liberalizing law and general effective date provisions of 38 C.F.R. §§ 3.114 and 3.400. See 38 C.F.R. § 3.816(c)(4). In this case, the record reflects that the Veteran served in Vietnam, and he was granted presumptive service connection for ischemic heart disease based on his presumed exposure to herbicides in Vietnam. As such, he is a Nehmer class member. Initially, the Board notes that the Veteran was separated from military service in April 1970. He did not raise a claim of entitlement to service connection for a heart disorder within a year of his discharge. Thus, an effective date of the day following his separation is not warranted. Review of the record shows that in October 1980, the Veteran reported intermittent chest pains, off and on for months. There was no exertional chest pain, substernal chest pain, pleuritic chest pain, associated nausea or vomiting, diaphoresis or shortness of breath. The impressions included chest pain probably secondary to dyspepsia or anxiety; the Veteran was advised to take an antacid for his chest pain. On July 1981 Agent Orange examination, chest X-ray was normal. Subsequent private treatment records show complaints of recurrent chest pain. A June 25, 1982 letter notified the Veteran that he was a part of the Agent Orange registry and was on the mailing list to receive Agent Orange information. On November 2003 treatment, the Veteran was noted to have no cardiac risk factors, no high blood pressure, no family history, and no hypercholesterolemia; he reported having chest pain since the previous November. He reported having intermittent discomfort of the left arm, shoulder and chest for three years; the pain was not exertional, and he denied any other symptoms including shortness of breath, nausea, vomiting, or palpitations. An EKG was negative apart from a left anterior fascicular block which was known. Chest X-ray was negative. The assessment was atypical chest pain. Private treatment records include a January 2007 report noting that the Veteran had a transient ischemic attack (TIA). It is also noted that TIA usually occurs in persons with atherosclerosis or "hardening of the arteries." In a March 17, 2008 VA Form 21-4138, Statement in Support of Claim, in pertinent part, the Veteran claimed service connection for skin rash on the ears from exposure to Agent Orange. On August 2008 VA Agent Orange examination, the Veteran's heart was clinically normal and he reported no complaints of chest pain. On his February 2009 VA Form 21-526, Veteran's Application for Compensation and/or Pension (formal claim), the Veteran's claim included skin cancer on ears and rashes due to Agent Orange Exposure. A claim for heart disease was not listed among the claimed disabilities. A February 2010 rating decision, which included the denial of service connection for skin cancers of the ears, chloracne on the back, rectal polyps and a throat condition as a result of exposure to herbicides, did not include a denial of service connection for a heart disorder. There are no prior rating decisions. On February 17, 2012, VA received the Veteran's initial claim of service connection for ischemic heart disease. He reported that he had "gone into emergency a few times with the heart condition noted above, since [he] was out of Vietnam." On March 2012 VA treatment, the Veteran reported having chronic pain in the left upper chest for many years. He reported that he had seen a private cardiologist in the recent past and had a stress test which was normal. He reported the pain worsened with certain movements. He denied any pressure-like sensation. The assessments included atypical chest pain, most likely musculoskeletal. A new exercise stress test was normal. On May 2012 treatment, the Veteran was noted to have a 20 year history of recurrent episodes of chest pain radiating to the left arm; extensive cardiac workup had been normal. In an August 2012 VA Form 21-4138, Statement in Support of Claim, the Veteran expressed his desire to file a claim of service connection for ischemic heart disease. He reported that he has had a heart condition since he left Vietnam but he did not know what it was. A March 2013 report of chest X-ray in connection with the Veteran's complaint of acute onset of chest pain includes a finding of moderate tortuosity of the descending thoracic aorta with arteriosclerosis. An April 9, 2013, coronary CT angiogram showed atherosclerosis with no significant luminal narrowing, moderate coronary calcification, minimal thoracic aorta calcification, and enlarged ascending aorta; in view of the coronary atherosclerosis, aggressive management of coronary risk factors was recommended. An April 2013 VA examination report includes a diagnosis of ischemic heart disease status post old inferior wall myocardial infarction, diagnosed in 1970. He also reported that he had been treated for a myocardial infarction at Riverside Community Hospital on March 9, 2013. On a May 2013 Ischemic Heart Disease (IHD) Disability Benefits Questionnaire (DBQ), C. Chen, M.D. noted the Veteran's August 11, 2009 diagnosis of chest pain and his April 9, 2013 diagnosis of coronary artery disease. On another May 2013 IHD DBQ, L. Couture, M.D., noted the Veteran's August 11, 2009 diagnosis of chest pain and his April 9, 2013 diagnosis of coronary artery disease. A July 2013 rating decision granted service connection for ischemic heart disease rated 60 percent effective April 9, 2013, the date entitlement arose based on a diagnosis of ischemic heart disease. In an August 2013 IHD DBQ, C. Chen, M.D. noted diagnoses of CAD since April 9, 2013 and chest pain since October 7, 1980. Dr. Chen also noted that the Veteran had been seen multiple times from October 7, 1980 for chest pain without an established diagnosis of CAD/IHD until April 9, 2013 and previous testing was negative for CAD. In an August 2014 IHD DBQ, Dr. Couture noted diagnoses of CAD and fatigue in April 2013 and angina in about 1980. The record reflects VA received the Veteran's initial claim of service connection for ischemic heart disease on February 17, 2012. Notably, although the Appellant's Brief and Written Brief Presentation indicate that the Veteran "contacted VA in 1995, trying to submit a claim for service connection for herbicide exposure," there is no record of a 1995 communication from the Veteran regarding his desire to file a claim for VA benefits (and the only reference to the 1995 communication is a January 15, 2010 letter from the Veteran, noted in the Written Brief Presentation, page 4) and there is no evidence of an informal or formal claim of service connection for a heart disorder prior to February 17, 2012 (and the earliest date of any claim for service connection from the Veteran is the March 5, 2008, VA Form 21-4138, Statement in Support of Claim, for service connection for skin rash on the ears from exposure to Agent Orange, noted above). Therefore, the Board finds that the Veteran's earliest date of claim for service connection for a heart disorder is February 17, 2012. The Nehmer provisions do not provide relief for the Veteran as there was no claim pending for service connection prior to May 3, 1989, in between May 3, 1989 and August 31, 2010, and no decision in between May 3, 1989 and August 31, 2010. In addition, the Veteran did not file his claim for service connection within one year of the effective date of the liberalizing law. The Board will thus determine whether the date of entitlement arose before or after the Veteran's February 17, 2012, claim. Under 38 C.F.R. § 3.309(e), ischemic heart disease is noted to include, but not be limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including CAD (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina. Review of the record shows that the Veteran has a long history of complaints of recurrent chest pain (since October 1980), the April 2013 VA examination report includes a diagnosis of ischemic heart disease status post old inferior wall myocardial infarction diagnosed in 1970 and the August 2014 DBQ notes that he has a current diagnosis of angina, which was diagnosed in 1980. In light of this evidence, as argued by the Veteran's attorney, his heart disease may have been manifest as early as 1970; thus, the date entitlement arose may be earlier than the date VA received the Veteran's original service connection claim on February 17, 2012. However, the mere fact that he was treated for chest pain symptoms which were subsequently diagnosed as heart disease (angina, coronary artery disease and/or ischemic heart disease) prior to his application for benefits does not constitute a claim of service connection for that disability. Because the first claim for service connection for a heart condition was received on February 17, 2012, the effective date regulations for herbicide-exposed Veterans claiming service connection for herbicide-related disabilities prior to the date that the presumption was established are not applicable, as no claim was pending or previously denied for a heart condition prior to February 17, 2012 - the date of receipt of the Veteran's initial service connection claim. 38 C.F.R. § 3.816 (2017). As the Veteran's claim of service connection for ischemic heart disease was received on February 17, 2012 and pertinent law and regulations permit the assignment of an effective date for a period of one year prior to the date of receipt of the request for review or the date of the claim, an earlier effective date of February 17, 2011, for the grant of service connection for the Veteran's heart disease is warranted. See 38 U.S.C. § 5110(g); 38 C.F.R. §§ 3.114, 3.400(p), 3.816. Specifically, although the Veteran's ischemic heart disease arose prior to the date of the claim, the grant of service connection was based upon liberalizing legislation regarding herbicide exposure. As noted above, the effective date of this liberalizing legislation is August 31, 2010. The Veteran did not apply for service connection within one year of the effective date of this liberalizing legislation; thus, the earliest date that may be awarded is February 17, 2011, one year prior to receipt of the Veteran's claim of service connection for ischemic heart disease. As such, the appeal is granted to this extent. It is argued in the Written Brief Presentation on behalf of the Veteran that an earlier effective date of March 17, 2008 is warranted for the grant of service connection for ischemic heart disease because the Veteran filed a claim of service connection due to his herbicide exposure in Vietnam which was received on this date and the record is replete with the Veteran's history of angina at the time of this earlier claim. However, as also acknowledged in the Written Brief Presentation, the "March 17, 2008 claim did not explicitly identify IHD, but did name other ailments" that the Veteran believed should be service-connected. Further, as a presumption of service connection for ischemic heart disease due to herbicide exposure is effective August 31, 2010; a claim of service connection for heart disease cannot be liberally implied in the March 17, 2008 claim, despite the medical evidence of chest pain (angina) noted at that time. Resolving all reasonable doubt in the Veteran's favor, the Board finds that an effective date of February 17, 2011 is warranted for the grant of service connection for ischemic heart disease. ORDER An effective date of February 17, 2011, but no earlier, for entitlement to service connection for ischemic heart disease is granted, subject to the laws and regulations governing the payment of monetary benefits. REMAND While further delay is regrettable, the Board finds that additional development is required prior to adjudicating the Veteran's remaining claims. The claims of service connection for skin cancers of the ears and chloracne of the back were remanded in August 2015 for action which has not been satisfactorily accomplished. The December 2015 VA examination reports provide diagnoses of skin cancer (basal cell carcinoma) of the right ear and inclusion cysts and intradermal nevus of the back and include the opinions that these disorders are unrelated to service, including the Veteran's presumed exposure to herbicides therein, essentially because "[c]hloracne or other acneform disease consistent with chloracne is the only skin condition that has been associated with herbicide exposure" (the Veteran's skin cancer (basal cell carcinoma) of the right ear and inclusion cysts and intradermal nevus of the back are not on the list of Agent Orange exposure presumptive diseases). However, the examiner failed to provide an adequate explanation as to why the Veteran's skin disorders of the ears and back are not otherwise related to his presumed in-service Agent Orange exposure. The explanation for such a nexus opinion should contain more explanatory information than merely that the diagnosed disorder is or is not on the list of diseases presumptive to Agent Orange exposure. Logical medical reasons for why the examiner feels that there is or is not a relationship to in-service Agent Orange exposure should be delineated in detail. Accordingly, this matter must be remanded, once again, for an addendum opinion. Regarding the matter of an increased rating for ischemic heart disease prior to January 28, 2016, as the decision above has granted an earlier effective date of February 17, 2011, for entitlement to service connection for ischemic heart disease, adjudication of the increased rating claim is deferred pending implementation of the earlier effective date of service connection. On remand, complete updated VA and private treatment records should also be obtained. Accordingly, the case is REMANDED for the following action: 1. The AOJ should undertake appropriate development to obtain any outstanding records pertinent to the Veteran's claim, to include updated VA treatment records. 2. After completion of item 1, above, the AOJ must contact the VA examiner who examined the Veteran in December 2015 in connection with his claims of service connection for skin cancers of the ears and chloracne of the back and request that he provide a supplemental medical opinion. [If that provider is unavailable, the record should be forwarded to another appropriate examiner for review and the opinion sought. If another examination is needed for the opinion sought, it should be arranged.] After review of the claims file, the examiner should respond to the following: (a) Is it at least as likely as not (50 percent or higher degree of probability) that the Veteran's skin cancer (basal cell carcinoma) of the right ear is related to service, to include presumed Agent Orange exposure therein? The explanation for any nexus opinion should be more than merely that the diagnosed disorder is or is not on the list of diseases presumptive to Agent Orange exposure. (b) Is it at least as likely as not (50 percent or higher degree of probability) that the currently diagnosed inclusion cysts and intradermal nevus of the back is related to presumed in-service Agent Orange exposure? The explanation for any nexus opinion should be more than merely that the diagnosed disorder is or is not on the list of diseases presumptive to Agent Orange exposure. In providing the requested opinions, in addition to reviewing the Veteran's claims file, the examiner should consider as necessary the January 1970 Report of Medical History of service separation which shows that the Veteran reported a history of skin disease, July 1981 VA Agent Orange examination report noting rash on upper extremities and neck, August 1984 VA dermatology consultation report noting a 5-6 year history of skin itching, January 2012 statement from C. Wolnisty, M.D. (noting the Veteran's history of skin problems and history of Agent Orange exposure) and the Veteran's competent assertions of experiencing skin problems since his military service in Vietnam. See, e.g., May 2009 letter from Veteran and March 2010 VA Form 21-4138, Statement in Support of Claim (notice of disagreement). The examiner should answer questions (a) and (b) separately, to help ensure that each is fully, clearly, and adequately answered, and should furnish detailed reasons for each opinion, specifically discussing the relevant evidence and medical principles, to the extent appropriate. 3. Thereafter, the AOJ should review the record and readjudicate the claims remaining on appeal (increased rating for ischemic heart disease after implementing the grant of an earlier effective date to February 17, 2011, for service connection for ischemic heart disease). If any decision remains unfavorable, the AOJ should issue an appropriate supplemental statement of the case, afford the Veteran and his attorney opportunity to respond, and return the case to the Board. 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 for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (West 2014). ______________________________________________ M.C. GRAHAM Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs