Citation Nr: 18142406 Decision Date: 10/15/18 Archive Date: 10/15/18 DOCKET NO. 17-38 390 DATE: October 15, 2018 REMANDED Entitlement to service connection for allergic rhinitis is remanded. Entitlement to service connection for chronic obstructive pulmonary disease is remanded. Entitlement to service connection for Peyronie’s disease is remanded. Entitlement to service connection for benign hypertrophy of the prostate is remanded. Entitlement to service connection for skin cancer is remanded. Entitlement to service connection for a skin disorder, to include actinic keratosis and seborrheic dermatitis/keratosis, is remanded. REFERRED In September 2017, the Veteran submitted a claim of entitlement to service connection for coronary artery disease. As this issue has not yet been adjudicated, it is referred to the agency of original jurisdiction for adjudication.   REASONS FOR REMAND The Veteran served on active duty from December 1963 to December 1966, including service in the Republic of Vietnam. The Veteran argues that the claimed disorders were caused by his exposure to herbicide agents in Vietnam. Certain diseases may be presumed to have been incurred in service when a Veteran has been exposed, or may be presumed to have been exposed, to herbicide agents, such as Agent Orange, in service. 38 U.S.C. § 1116(a); 38 C.F.R. §§ 3.307(a)(6), 3.307(d)(1), 3.309(e). In this case, the Veteran served in the Republic of Vietnam, and it is presumed that he was exposed to herbicide agents. The disabilities at issue, however, are not diseases that have been found to be associated with herbicide agent exposure. Id. Even though the Veteran’s claimed disorders do not qualify for the presumption of being caused by herbicide agent exposure, service connection may be established by showing that a disorder resulting in disability was in fact causally linked to such exposure. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). The Veteran has asserted that he believes that his claimed disabilities were caused by exposure to Agent Orange in service. Given the absence of any medical opinions on these issues, the Board finds that examination and medical opinion addressing these theories of potential etiology by an appropriate physician would be helpful in resolving the claim for service connection. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159; McLendon v. Nicholson, 20 Vet. App. 79 (2006). Regarding the claim of entitlement to service connection for Peyronie’s disease, the Board finds that an opinion is needed to address whether this disorder, a disease characterized by fibrous scar tissue in the penis, is related to his inservice episodes of urethritis and gonorrhea. The Veteran’s service treatment records show that he was treated for acute urethritis due to gonococcus in January 1966. In April and May 1966, he was treated for red rashes on the glans, penile lesions, and discharge. His December 1966 separation examination notes that he was treated twice for venereal disease, and tests indicate that he had tested positive for gonorrhea. The Veteran’s VA treatment records show that he was diagnosed with Peyronie’s disease and underwent penile implant surgery in May 2001. In the years following his surgery, the implant and disorder was noted to be stable. Throughout 2016 and 2017, the Veteran was treated for recurrent pseudomonas urinary tract infections, and had recurring complaints of discharge, discomfort, and urinary leakage. The Board therefore finds that while the Veteran’s Peyronie’s disease was surgically treated in 2001, it is possible that he is having continued urinary problems which are secondary to this disorder, and a medical opinion should be obtained addressing whether it is as likely as not related to his urethritis and gonorrhea in service. The Veteran has also submitted claims of entitlement to service connection for a skin disorder, to include actinic keratosis, seborrheic keratosis, and skin cancer. His service treatment records show multiple complaints relating to skin infections in service. In May 1964, the Veteran was treated for pruritus ani. In April 1966, the Veteran had several red areas around his glans which appeared to be balanitis. In May and September 1966, the Veteran was treated for a heat rash. In October 1966, the Veteran was treated for dermatitis. The Veteran wrote on his December 1966 Report of Medical History that he had occasional boils on the back and neck. The Veteran’s VA treatment records show that he has been prescribed creams for treatment of rosacea. In June 2005, the Veteran had multiple skin lesions on his left arm and right hand, and two benign lesions were surgically removed. The Veteran has subsequently had additional skin lesions removed. In January 2007, the Veteran reported having a pruritic rash in sun-exposed areas of the skin, including the back and inner legs, since Vietnam. A July 2007 evaluation noted that the Veteran had a sun damaged face with rosacea, and small papules on the cheeks and forehead. In February 2009, the Veteran was diagnosed with seborrheic dermatitis, and in February 2010, a removed skin lesion was biopsied, and he was diagnosed with actinic keratosis with hyperkeratosis. In December 2015, the Veteran had an additional skin lesion biopsy, and was diagnosed with actinic keratosis. At a May 2016 VA skin examination, the Veteran was found to have lesions on his arms and head. He was diagnosed with actinic keratosis and seborrheic keratosis. The examiner also noted that a skin lesion removed eight months earlier was diagnosed as squamous cell carcinoma, with no residuals. The Board finds that a medical opinion is needed to address whether any inservice skin disorder indicated the onset of a chronic skin disorder or whether his current skin problems are related to those disorders or to exposure to herbicide agents in service. The Board also requests clarification as to whether the Veteran actually has a current diagnosis of squamous cell carcinoma, to include residuals thereof, which is not documented in his VA treatment records since the Veteran submitted his claim in 2015. Although the May 2016 VA examiner noted that the Veteran had been found to have squamous cell carcinoma eight months earlier, VA treatment records only show that a biopsy performed in June 2012 found keratosis and squamous cell carcinoma with early invasion. The examiner should also address whether the Veteran has had skin cancer at any time during the pendency of the claim and whether it is related to service, including exposure to herbicide agents. The Veteran has also submitted treatment records from St. Mary’s Medical Center and from Thomas Memorial Hospital. As VA has not yet requested the Veteran’s complete private medical treatment records, an attempt should be made to obtain these records prior to further adjudication. The matters are REMANDED for the following action: 1. Obtain all available records from the VA Medical Center in Huntington, West Virginia since October 2017. If any such records cannot be located, specifically document the attempts that were made to locate them, and explain in writing why further attempts to locate or obtain any government records would be futile. Then: (a) notify the claimant of the specific records that it is unable to obtain; (b) explain the efforts VA has made to obtain that evidence; and (c) describe any further action it will take with respect to the claims. The claimant must then be given an opportunity to respond. 2. Request that the Veteran submit a completed release form (VA Form 21-4142) authorizing VA to secure any relevant private treatment records from St. Mary’s Medical Center and from Thomas Memorial Hospital, as well as any additional private records of treatment for skin cancer or other skin disorder. The Veteran should be advised that he can also submit those records himself. If the Veteran provides a completed release form, then request the identified treatment records. At least two efforts should be made to obtain these records, and the Veteran and his representative should be notified of any unsuccessful efforts. 3. Thereafter, schedule the Veteran for a VA genitourinary examination with a physician to address the nature and etiology of any diagnosed Peyronie’s disease and benign hypertrophy of the prostate. The physician must be provided access to all files in Veteran’s VBMS and Virtual VA/Legacy files, and the physician must specify in the report that these files have been reviewed. Following a review of the files, the reviewing physician is to address the following: Does the Veteran have any current symptoms or residuals associated with his prior diagnosis and surgery for Peyronie’s disease? Are the Veteran’s current problems of recurrent pseudomonas urinary tract infections related to his Peyronie’s disease or 2001 penile implant surgery? Is it at least as likely as not (is there a 50/50 chance) that Peyronie’s disease had its onset during or was otherwise related to the appellant’s active duty service, including his exposure to Agent Orange and other herbicide agents while serving in Vietnam? Please specifically discuss the Veteran’s 1966 in-service treatment for urethritis and gonorrhea. Is it at least as likely as not that benign prostatic hypertrophy had its onset during or was otherwise related to service, including due to exposure to Agent Orange and other herbicide agents while serving in Vietnam? A complete and fully explanatory rationale must be provided for any opinion offered. If any opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge, i.e., no one could respond given medical science and the known facts, or by a deficiency in the record or the examiner, i.e., additional facts are required, or the examiner does not have the needed knowledge or training. 4. After completing directives one and two schedule the Veteran for a VA skin diseases examination to address the nature and etiology of any skin disorder, including skin cancer, actinic keratosis, and seborrheic keratosis. The examiner must be provided access to all files in Veteran’s VBMS and Virtual VA/Legacy files, and must specify in the report that these files have been reviewed. Following a review of the files, please address the following: What are the Veteran’s current diagnoses pertaining to the skin? Please discuss VA treatment records showing diagnoses of rosacea, seborrheic dermatitis/keratosis, and actinic hyperkeratosis. Does the Veteran have, or has he had at any time since 2015, a diagnosis of squamous cell carcinoma? Please specifically address the May 2016 skin examination which noted that the Veteran had a squamous cell carcinoma removed eight months earlier and whether the squamous cell carcinoma removed in 2012 has left any residuals. For each and every skin diagnosis noted in the record since 2015, is it at least as likely as not (is there a 50/50 chance) that the disorder had its onset during or was otherwise related to his service, including his exposure to Agent Orange and other herbicide agents while serving in Vietnam? Please specifically discuss the Veteran’s assertions that he has had a pruritic rash since serving in Vietnam and the service treatment records showing treatment for pruritus ani, red rash around the glans, heat rash and dermatitis on the upper body, and the December 1966 Report of Medical History indicating occasional boils on the back and neck. A complete and fully explanatory rationale must be provided for any opinion offered. If any opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge, i.e., no one could respond given medical science and the known facts, or by a deficiency in the record or the examiner, i.e., additional facts are required, or the examiner does not have the needed knowledge or training. 5. After completing directives one and two schedule the Veteran for a VA respiratory examination to address the nature and etiology of any current pulmonary disorder, including chronic obstructive pulmonary disease, and allergic rhinitis. The examiner must be provided access to all files in Veteran’s VBMS and Virtual VA/Legacy files, and must specify in the report that these files have been reviewed. Following a review of the files, please address the following: What are the Veteran’s current respiratory or sinus diagnoses? Please discuss the VA treatment records showing diagnoses of chronic obstructive pulmonary disease and allergic rhinitis. For each and every respiratory and sinus disorder diagnosed at any time since 2015, is it at least as likely as not (is there a 50/50 chance) that the disorder had its onset during or was otherwise related to his service, including his exposure to Agent Orange and other herbicide agents while serving in Vietnam? A complete and fully explanatory rationale must be provided for any opinion offered. If any opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge, i.e., no one could respond given medical science and the known facts, or by a deficiency in the record or the examiner, i.e., additional facts are required, or the examiner does not have the needed DEREK R. BROWN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Mary E. Rude, Counsel