Citation Nr: 18140191 Decision Date: 10/02/18 Archive Date: 10/02/18 DOCKET NO. 13-00 556 DATE: October 2, 2018 REMANDED Entitlement to service connection for warts on the legs, to include as secondary to exposure to herbicide agents, is remanded. Entitlement to service connection for a skin condition of the arms and legs, to include as secondary to exposure to herbicide agents, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from July 1963 to January 1964. The Board notes that four claims have been certified to the Board and perfected for consideration and decision. In addition to the two claims on the title page, entitlement claims for service connection for cataracts and hyperthyroidism were certified to the Board on May 22, 2018. In July 2018, the Veteran withdrew his entitlement claim for service connection for cataracts. In August 2018, the Board remanded the Veteran’s entitlement claim for service connection for hypothyroidism for further development. Consequently, the Board will only address the Veteran’s two entitlement claims on the title page. Upon review of the record, the Board concludes that further evidentiary development is necessary. Although the Board sincerely regrets this delay and is appreciative of the Veteran’s service to his country, a remand is necessary to ensure VA provides the Veteran with appropriate assistance in developing his claim prior to final adjudication. The Veteran’s claims for entitlement to service connection for warts on the legs and a skin condition of the arms and legs, to include as secondary to exposure to herbicide agents, are remanded. In November 2010, the Veteran submitted his VA Form 21-526. Therein, the Veteran initiated his entitlement claim for service connection for the warts on his legs. In May 2012, the Veteran submitted his VA Form 21-526b. Therein, the Veteran initiated his entitlement claim for service connection for a bilateral arm condition. In December 2010, the Veteran’s service treatment records (STRs) were associated with his claims file. After careful and deliberate review, the Board found no mention of an in-service skin condition, diagnosis and/or treatment. In January 2012, the agency of original jurisdiction (AOJ) granted the Veteran’s service connection claims for diabetes mellitus, Type II and peripheral artery disease. The AOJ decision(s) were based on the presumptions that coincide with in-service exposure to an herbicide agent. The AOJ observed that fifteen (15) days of the Veteran’s active duty period were during known Agent Orange spraying at Fort Chaffee. Consequently, for this Board analysis, the Board finds that the Veteran endured exposure to an herbicide agent for VA compensation purposes. In January 2015, the Veteran supplied sworn testimony to the undersigned Veteran’s Law Judge (VLJ), via videoconference technology. At that time the Veteran testified that he began developing warts on his skin in 2012 or 2013. He also testified that two or three bumps would appear at a time, but they stopped appearing. The Veteran testified that, “I haven’t gotten any more.” Regarding the Veteran’s entitlement claim for a skin condition, he testified that, “maybe five years ago when I first noticed them real bad.” The Veteran testified that he had reported in-service herbicide agent exposure to medical providers; in response, the providers indicated that, “the sun is probably what caused it.” In January 2015, VA received the Veteran’s treatment notations from the a VA Medical Center (VAMC). Therein, on March 10, 2014, a general notation was generated by VA provider TDB. At time, TDB reported that, “Veteran calls clinic and wants to speak with someone in regards to the ‘warts’ on his legs. Veteran states for the last 2-3 moths he as ‘warts’ that coming up on his legs and thighs. He states they itch, but are not painful, small in size. Has notice that they appear and then a few days/weeks later they turn black and fall off. After areas turn black and fall off there are no signs of them being there, no open areas no bleeding noted from the site after they are gone.” In March 2015, the Veteran’s entitlement claims were before the Board for consideration. At that time, the undersigned Veteran’s Law Judge (VLJ) remanded the Veteran’s claims for a VA examination that addressed the nature and etiology of any currently endured skin conditions. In June 2015, the Veteran underwent a VA examination to address the nature and etiology of any currently endured skin conditions. At that time, Dr. JHT reported a diagnosis for Seborrheic Dermatitis. Dr. JHT noted that the date of onset of symptoms was in 2003. It was noted that the Veteran’s skin dermatitis was present on less than 5 percent of this total body area. Ultimately, Dr. JHT opined that, “the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness.” Within his supporting rationale, Dr. JHT observed that, “(t)here are no medical records that reveal . . . skin issues while on active duty.” In September 2017, the Board again considered the Veteran’s claims for entitlement to service connection for warts on the legs and a skin condition of the arms and legs, to include as secondary to exposure to herbicide agents. At that time, the undersigned VLJ determined that the June 2015 VA examination was not adequate to address the Veteran’s entitlement claims. The Board concluded that the examination was not adequate because the VA provider failed to consider whether the Veteran’s warts or skin condition of the arms and legs was secondary to in-service herbicide agent exposure. In the resultant remand directives, the Board requested two opinions: 1) a medically competent determination that considered the Veteran’s presumed in-service exposure to herbicide agents, and 2) a medically competent determination that considered causation from, or aggravation by, one the Veteran’s service-connected disabilities. In November 2017, the Veteran underwent a VA examination to determine the nature and etiology of any currently endured skin diseases. In the resultant examination report, Dr. LDB identified diagnoses for seborrheic keratosis and actinic keratosis. After an in-person examination of the Veteran, and review of his electronic claims file, Dr. LDB opined that, “(t)he condition claimed was less likely than not (less than 50% probability) incurred in or caused by the claimed in-service injury, event or illness.” For her supporting rationale, Dr. LDB opined that, “(t)he veteran's skin disorder is seborrheic keratosis and actinic keratosis. These conditions are not related to herbicide exposure. Review of the literature published in peer reviewed medical journals is negative for an association of either of these skin conditions and herbicide exposure to include Agent Orange exposure.” The Board acknowledges that Dr. LDB adequately addressed the first query proposed in the September 2017 remand directives. However, the Board finds that Dr. LDB’s overall report in inadequate because she did not address whether the Veteran’s skin conditions are due to, or aggravated by, one of his service-connected disabilities. The VA’s duty to assist also includes providing a medical examination and/or obtaining a medical opinion when necessary to make a decision on the claim, as defined by law. See 38 U.S.C. § 5103A; 38 C.F.R. §§ 3.159 (c)(4), 3.326(a); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). The VA examination and/or opinion must be adequate to decide the claim. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the November 2017 VA examination report is inadequate, because the query relating to secondary service connection was not answered. Consequently, these matters are REMANDED to the AOJ for the following action: 1. Obtain an opinion as to the nature and etiology of his leg warts. The VA examination must also address the etiology of any currently endured skin condition, to include Seborrheic Keratosis and Actinic Keratosis. The Veteran’s claims folder must be reviewed by the examiner in conjunction with the examination. The examiner is asked to: Provide an opinion as to whether it is at least as likely as not (i.e., probability of 50 percent or greater) that any current skin disorder, to include Seborrheic Keratosis or Actinic Keratosis, is either due to, or aggravated by, one of the Veteran’s service-connected disabilities to include diabetes mellitus and/or peripheral artery disease of the lower extremities. Governing regulations provide that service connection is permissible on a secondary basis if a claimed disability is proximately due, the result of, or aggravated by a service-connected disability. See 38 C.F.R. § 3.310. The term aggravation is defined as a chronic and permanent worsening of the underlying condition beyond its natural progression versus just a temporary or intermittent flare-up of symptoms. If the examiner determines there has been aggravation, he or she should try and quantify the amount of additional disability the Veteran had, above and beyond that he had prior to the aggravation. It should be noted that the Veteran, is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a clinical basis to support or doubt the lay history provided by the Veteran, the examiner should provide a fully reasoned explanation. Explanations for all opinions must be provided. While providing the requested rationale, the examiner is asked to cite to the pertinent evidence of record, including clinical records and the Veteran’s statements regarding the onset of his skin condition(s). DAVID L. WIGHT Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD RLBJ, Associate Counsel