Citation Nr: 18146865 Decision Date: 11/01/18 Archive Date: 11/01/18 DOCKET NO. 17-46 349 DATE: November 1, 2018 ORDER The previously denied claim of entitlement to service-connection for a back disorder is reopened. The previously denied claim of entitlement to service connection for residuals of a right eye injury is reopened. The previously denied claim of entitlement to service connection for a stomach disorder is reopened. The previously denied claim of entitlement to service connection for residuals of a mouth injury is reopened. Entitlement to an initial compensable evaluation for service-connected poikiloderma of Civatte is denied. Entitlement to a 10 percent evaluation for service-connected poikiloderma of Civatte is granted effective June 14, 2017. REMANDED Entitlement to service connection for a back disorder is remanded. Entitlement to service connection for residuals of a right eye injury is remanded. Entitlement to service connection for a stomach disorder is remanded. Entitlement to service connection for residuals of a mouth injury is remanded. Entitlement to an evaluation higher than 10 percent for service-connected tinea pedis and tinea manum is remanded. FINDINGS OF FACT 1. An October 1986 rating decision denied entitlement to service connection for a back disorder, residuals of a right eye injury, a stomach disorder, and residuals of a mouth injury. The Veteran did not appeal and did not submit new and material evidence within one year. 2. The evidence associated with the file after the October 1986 rating decision includes evidence that relates to an unestablished fact necessary to substantiate the claim, is neither cumulative nor redundant of evidence already of record, and raises a reasonable possibility of substantiating the claims of entitlement to service connection for a back disorder, residuals of a right eye injury, a stomach disorder, and residuals of a mouth injury. 3. Prior to June 14, 2017, service-connected poikiloderma of Civatte covered 2 percent of the total exposed skin areas, was not being treated with medication, and did not cause any scarring. 4. On and after June 14, 2017, service-connected poikiloderma of Civatte was estimated to cover 5 percent of the total body area, was not being treated with medication, and did not cause any scarring. CONCLUSIONS OF LAW 1. New and material evidence has been received sufficient to reopen a previously denied claim of entitlement to service connection for a back disorder, residuals of a right eye injury, a stomach disorder, and residuals of a mouth injury. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2018). 2. The criteria for entitlement to an initial compensable evaluation prior to June 14, 2017 for service-connected poikiloderma of Civatte have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.321, 4.118 Diagnostic Codes (DCs) 7800 – 7806 (2018); 83 Fed. Reg. 32, 592 (July 13, 2018). 3. On and after June 14, 2017, the criteria for a 10 percent evaluation for service-connected poikiloderma of Civatte are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.321, 4.118 DCs 7800 – 7806 (2018); 83 Fed. Reg. 32, 592 (July 13, 2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Army from August 1959 to August 1962. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from November 2016 and December 2016 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Milwaukee, Wisconsin. In April 2018, the Veteran testified at a hearing before the undersigned Veterans Law Judge and a transcript of the proceeding is of record. The Board finds that all requirements for hearing officers have been met. 38 C.F.R. § 3.103 (c)(2) (2018); Bryant v. Shinseki, 23 Vet. App. 488 (2010). The Veteran’s service treatment records (STRs) appear incomplete, but further efforts to obtain them are futile. The Veteran has reported that he received treatment for his eye and mouth while stationed in Germany, and those records are not included in the Veteran’s STRs. An October 2012 VA records request and December 2012 VA memorandum documented that some of the Veteran’s service records had been affected by a fire at the National Personnel Records Center and any missing records could not be reconstructed. The Board finds that VA has met its duty to assist the Veteran with obtaining his STRs. An October 2018 Board decision denied entitlement to service-connection for a skin disorder other than tinea pedis, tinea manum, or poikiloderma of Civatte. That decision referenced a March 2018 specialist’s opinion related to the Veteran’s skin disorders, but that opinion is not associated with the claims file. The 2018 Board decision explained that the specialist’s opinion only addressed the skin diseases other than the Veteran’s service-connected tinea pedis, tinea manum, or poikiloderma of Civatte. Thus, the March 2018 opinion is not relevant to the issues being decided on appeal, and the absence of the opinion from the claims file is not prejudicial to the Veteran in relation to this decision. Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist, nor are any other potential deficiencies apparent in the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). New and Material Evidence In general, decisions of the RO and the Board that are not appealed in the prescribed time period are final. 38 U.S.C. §§ 7104, 7105 (2012); 38 C.F.R. §§ 3.104, 20.1100, 20.1103 (2018). A finally disallowed claim, however, may be reopened when new and material evidence is presented or secured with respect to that claim. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2018). Regardless of the action taken by the RO, the Board must determine whether new and material evidence has been received subsequent to an unappealed RO denial. Jackson v. Principi, 265 F.3d 1366, 1369 (Fed. Cir. 2001). As part of this review, the Board considers evidence of record at the time of the previous final disallowance of the claim on any basis, including on the basis that there was no new and material evidence to reopen the claim, and evidence submitted since a prior final disallowance. Evans v. Brown, 9 Vet. App. 273, 285-86 (1996). New evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156 (2018). For purposes of reopening a claim, the credibility of newly submitted evidence is generally presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is low. Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). In determining whether this low threshold is met, VA should not limit its consideration to whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, to include by triggering the Secretary’s duty to assist or consideration of a new theory of entitlement. Shade, 24 Vet. App. at 117-18. Additionally, new and material evidence received prior to the expiration of the appeal period, or prior to the appellate decision if a timely appeal has been filed, will be considered as having been filed in connection with the claim which was pending at the beginning of the appeal period. 38 C.F.R. § 3.156(b). Furthermore, at any time after VA issues a decision on a claim, if VA receives or associates with the claims file relevant official service department records that existed but were not associated with the claims file when VA first decided the claim, VA will reconsider the claim, rather than requiring new and material evidence. 38 C.F.R. § 3.156(c)(1). To establish service connection, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service - the so-called nexus requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). 1. Whether new and material evidence has been received sufficient to reopen a previously denied claim of entitlement to service connection for a back disorder In an October 1986 rating decision, the RO denied service connection for back strain on the grounds that the in-service back strain was acute and transitory, and there was no evidence of continuity of back problems since separation. The Veteran did not appeal that decision nor submit new and material evidence within one year. No additional or relevant service department records were added following the October 1986 decision. The 1986 rating decision is thus final based on the evidence then of record. See 38 U.S.C. § 7105(c); 38 C.F.R. § 20.1103. Of record at the time of the 1986 rating decision were the Veteran’s STRs that showed complaints of backache in 1960 and 1961 with normal findings at separation, and private medical records showing treatment for back problems from 1983 to 1986. Evidence submitted after the 1986 decision includes the Veteran’s April 2018 hearing testimony that he first injured his back in service, and has continued to experience back symptoms and reinjuries since that time. The Board finds that new and material evidence has been presented. The 2018 hearing testimony is new because it was not previously submitted to VA. The evidence is material because it relates to unestablished facts necessary to establish the claim - evidence of a chronic back symptoms that began in service and continued thereafter. See 38 C.F.R. § 3.303(a); Shedden, 381 F.3d at 1167. Additionally, the evidence is neither cumulative nor redundant as that evidence was not of record at the time of the prior denial. See 38 C.F.R. § 3.156(a). Further, new evidence is to be presumed credible for purposes of deciding whether a previously denied claim may be reopened. Justus, 3 Vet. App. at 513. Moreover, when considering the new evidence in conjunction with the evidence already of record, combined with VA assistance including an examination, it raises a reasonable possibility of substantiating the claim. Shade, 24 Vet. App. at 117. Accordingly, for all of the above reasons, the Veteran’s claim of entitlement to service connection for a back disorder is reopened. 2. Whether new and material evidence has been received sufficient to reopen a previously denied claim of entitlement to service connection for residuals of a right eye injury The October 1986 rating also denied service connection for an eye injury because there was no evidence of an in-service eye injury. The Veteran did not appeal that decision nor submit new and material evidence within one year. No additional or relevant service department records were added following the October 1986 decision. The rating decision is thus final based on the evidence then of record. See 38 U.S.C. § 7105(c); 38 C.F.R. § 20.1103. Of record at the time of the 1986 rating decision were the Veteran’s STRs that were silent for any eye related problems or complaints, and private treatment records documenting a September 1983 work related eye injury. Evidence submitted after the 1986 decision includes the Veteran’s April 1990 statement where he described injuring his eye when he was stationed in Germany; a November 1991 statement from the Veteran explaining that the treatment records related to his eye were missing from his STRs; and May 2013 VA treatment records noting the Veteran had a history of a pine needle in his right eye in Germany in 1961, with reported symptoms of being bothered by bright sunlight. The Board finds that new and material evidence has been presented. The lay testimony and VA treatment records are considered new evidence because those records did not exist at the time of the October 1986 rating decision. The evidence is material because it relates to unestablished facts necessary to establish the claim - evidence of an in-service eye injury and continuity of eye symptoms since that time. See 38 C.F.R. § 3.303(a); Shedden, 381 F.3d at 1167. Additionally, the evidence is neither cumulative nor redundant as that evidence was not of record at the time of the prior denial. See 38 C.F.R. § 3.156(a). Further, new evidence is to be presumed credible for purposes of deciding whether a previously denied claim may be reopened. Justus, 3 Vet. App. at 513. Moreover, when considering the new evidence in conjunction with the evidence already of record, combined with VA assistance including an examination, it raises a reasonable possibility of substantiating the claim. Shade, 24 Vet. App. at 117. Accordingly, the Veteran’s claim of entitlement to service-connection for residuals of a right eye injury is reopened. 3. Whether new and material evidence has been received to reopen a previously denied claim of entitlement to service connection for a stomach disorder The October 1986 rating decision also denied service connection for a stomach disorder. The RO found that while the Veteran was treated for a stomach condition in service, it was acute and transitory and there was no evidence of a chronic stomach condition. The Veteran did not appeal that decision nor submit new and material evidence within one year. No additional or relevant service department records were added following the October 1986 decision. The rating decision is thus final based on the evidence then of record. See 38 U.S.C. § 7105(c); 38 C.F.R. § 20.1103. Of record at the time of the 1986 rating decision were the STRs showing complaints of abdominal pain in 1960 and 1961, with normal findings at separation, and private treatment records showing complaints of abdominal and epigastric pain in 1985 and 1986. Evidence submitted after the October 1986 decision includes May 2017 testimony from the Veteran that he was treated with antacids in service, and April 2018 hearing testimony that he was diagnosed with indigestion within two months of separation from service. The Board finds that new and material evidence has been presented. The evidence, including the 2017 and 2018 hearing testimony is new because it did not exist at the time of the prior rating decision. The evidence is material because it relates to unestablished facts necessary to establish the claim; specifically, evidence of treatment for indigestion in service and a diagnosis of indigestion shortly after separation. See 38 C.F.R. § 3.303(a); Shedden, 381 F.3d at 1167. Additionally, the evidence is neither cumulative nor redundant as that evidence was not of record at the time of the prior denial. See 38 C.F.R. § 3.156(a). Further, new evidence is to be presumed credible for purposes of deciding whether a previously denied claim may be reopened. Justus, 3 Vet. App. at 513. Moreover, when considering the new evidence in conjunction with the evidence already of record, combined with VA assistance in obtaining an adequate medical opinion, it raises a reasonable possibility of substantiating the claim. Shade, 24 Vet. App. at 117. Accordingly, the Veteran’s claim of entitlement to service connection for a stomach disorder is reopened. 4. Whether new and material evidence has been received to reopen a previously denied claim of entitlement to service connection for residuals of a mouth injury Last, in the October 1986 decision the RO denied service connection for a mouth injury because there was no evidence of a mouth injury in service. The Veteran did not appeal that decision nor submit new and material evidence within one year. No additional or relevant service department records were added following the October 1986 decision. The rating decision is thus final based on the evidence then of record. See 38 U.S.C. § 7105(c); 38 C.F.R. § 20.1103. Of record at the time of the 1986 rating decision were the Veteran’s STRs, including dental records, that were silent for a mouth injury but did note several dental procedures during the Veteran’s period of service. Evidence submitted after the October 1986 decision includes the Veteran’s April 2018 hearing testimony explaining that he was hit in the face in 1961 and bled around his tooth, that he later had teeth removed in service, and that he experienced dental and jaw problems since that time. The lay statements demonstrate an in-service mouth injury and reported continuity of dental and jaw symptoms since that time. The Board finds that new and material evidence has been presented. The April 2018 hearing testimony is new because it did not exist at the time of the 1986 decision. The evidence is material because it relates to unestablished facts necessary to establish the claim - evidence of an in-service mouth injury and ongoing symptoms. See 38 C.F.R. § 3.303(a); Shedden, 381 F.3d at 1167. Additionally, the evidence is neither cumulative nor redundant as that evidence was not of record at the time of the prior denial. See 38 C.F.R. § 3.156(a). Further, new evidence is to be presumed credible for purposes of deciding whether a previously denied claim may be reopened. Justus, 3 Vet. App. at 513. Moreover, when considering the new evidence in conjunction with the evidence already of record, combined with VA assistance including an examination, it raises a reasonable possibility of substantiating the claim. Shade, 24 Vet. App. at 117. Accordingly, Veteran’s claim of entitlement to service connection for residuals of a mouth injury is reopened. 5. Entitlement to an initial compensable evaluation for service-connected poikiloderma of Civatte. The Veteran seeks a higher rating for his service-connected poikiloderma of Civatte. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Schedule), found in 38 C.F.R. Part 4 (2018). The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1 (2018). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2018). When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3 (2018). In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2018). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran’s medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). Where entitlement to compensation has been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where an appeal is based on an initial rating for a disability, however, evidence contemporaneous with the claim and the initial rating decision are most probative of the degree of disability existing when the initial rating was assigned and should be the evidence “used to decide whether an original rating on appeal was erroneous.” Fenderson v. West, 12 Vet. App. 119, 126 (1999). In either case, if later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, staged ratings may be assigned for separate periods of time. Fenderson, 12 Vet. App. at 126; Hart v. Mansfield, 21 Vet. App. 505 (2007) (noting that staged ratings are appropriate whenever the factual findings show distinct time periods in which a disability exhibits symptoms that warrant different ratings). When adjudicating a claim for an increased initial evaluation, the relevant time period is from the date of the claim. Moore v. Nicholson, 21 Vet. App. 211, 215 (2007), rev’d in irrelevant part, Moore v. Shinseki, 555 F.3d 1369 (2009). Poikiloderma of Civatte is rated by analogy under 38 C.F.R. § 4.118 DC 7899-7806 for dermatitis. Under DC 7806, a 60 percent rating is assigned for dermatitis or eczema affecting more than 40 percent of the entire body or exposed areas, or when constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs is required during the past 12-month period. A 30 percent rating is assigned when dermatitis or eczema affect 20 to 40 percent of the entire body or exposed areas, or when systemic therapy such as corticosteroids or other immunosuppressive drugs are required for a total duration of 6 weeks or more during the past 12-month period, but not constantly. A 10 percent rating is assigned when dermatitis or eczema affects at least 5 percent but less than 20 percent of the entire body or exposed areas, or when intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs were required for a total duration of less than 6 weeks during the past 12-month period. A noncompensable rating is assigned when dermatitis or eczema affects less than 5 percent of the entire body or exposed areas, and when no more than topical therapy was required during the prior 12-month period. Prior to August 13, 2018 a topical corticosteroid could be considered either systemic therapy or topical therapy based on the factual circumstances of each case. Generally, topical is defined as pertaining to a particular surface area, as a topical anti-infective applied to a certain area of the skin and affecting only the area to which it is applied. Systemic pertains to or affects the body as a whole. See Dorland’s Illustrated Medical Dictionary 1865, 1940 (32d ed. 2012). Effective August 13, 2018, the regulations regarding skin disabilities were amended. After that date, the regulations provide that systemic therapy is treatment that is administered through any route (orally, injection, suppository, intranasally) other than the skin, and topical therapy is treatment that is administered through the skin. See 83 Fed. Reg. 32, 592 (July 13, 2018). Effective August 13, 2018, DC 7806 is to be evaluated under the General Rating Formula for the Skin. See 38 C.F.R. § 4.118. The General Rating Formula for the Skin assigns a 60 percent rating when characteristic lesions affect more than 40 percent of the entire body or exposed areas; or when constant or near-constant systemic therapy is required including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs required over the past 12-month period (hereinafter “systemic therapy.”) A 30 percent rating is assigned when characteristic lesions affect more than 20 to 40 percent of the entire body or exposed areas; or when systemic therapy is required for a total duration of 6 weeks or more but not constantly over the past 12-month period. A 10 percent rating is assigned when characteristic lesions affect at least 5 percent but less than 20 percent of the entire body or exposed areas, or when intermittent systemic therapy is required for a total duration of less than 6 weeks over the past 12-month period. A noncompensable evaluation is assigned when no more than topical therapy is required over the prior 12-month period and the characteristic lesions affect less than 5 percent of the total body or exposed areas. Or, the disorder may be rated according to DCs 7800 to 7805 depending on the predominant disability. The changes effective August 13, 2018 are applicable for the whole period of claims that were pending on August 13, 2018 if that yields a more favorable result to the Veteran. See 83 Fed. Reg. 32, 592 (July 13, 2018). Private treatment records from 2011 to 2014 fail to show any findings related to or treatment of poikiloderma of Civatte. Those records generally showed treatment for seborrheic keratosis, actinic damage, and pruritis that included biopsies and application of liquid nitrogen affected areas. See e.g. July 2011, August 2012, and June 2014 private treatment records. At a January 2014 VA dermatology appointment, the Veteran complained of several brown bumps on his bilateral posterior shoulders and on the central chest for which he used a cream, and scaling and bumps on his scalp. The diagnoses were seborrheic keratoses, angioma of the scalp, sebaceous hyperplasia, seborrheic dermatitis, and history of actinic damage without current lesions. The Veteran was given cream and a medicated shampoo for the identified disorders. An October 2014 VA dermatology note reported the Veteran had scars from benign biopsies and removals of growths, and the benign growths were assessed as seborrheic keratosis. A September 2014 VA scars examination documented the Veteran had scars from removal of an epidermal inclusion of the left cheek, a biopsied benign lentigo, actinic keratoses of the right cheek treated with liquid nitrogen, and from removal of seborrheic keratoses on the back and neck. No scars were attributed to poikiloderma of Civatte. The Veteran underwent another VA skin disease examination in March 2016, at which time the examiner noted prior diagnoses of seborrheic keratosis, folliculitis of the back, milia of the face, poikiloderma of Civatte, mild eczema, and seborrheic dermatitis. The Veteran used topical medications and cleansers to treat dermatitis of the face, seborrheic dermatitis, and folliculitis of the back. He did not take any medication for poikiloderma of Civatte. The poikiloderma of Civatte was mild, and located on the neck and chest. The examiner explained that poikiloderma of Civatte was a benign skin condition that consists of areas of hypopigmentation, hyperpigmentation, telangiectasias, and atrophy. The condition was most frequently seen on the chest or neck, characterized by a red colored pigment to the skin. The poikiloderma of Civatte covered 2 percent of the total exposed body surface area. In November 2016 correspondence the Veteran asserted that he had not been previously diagnosed with poikiloderma of Civatte, and denied having a red rash on neck or body. Instead, he asserted that his dermatitis and eczema had gotten worse, and that VA had failed to rate him for multiple scars. Most recently, the Veteran had a June 2017 VA skin examination. The examiner noted skin diagnoses of seborrheic dermatitis, poikiloderma of Civatte, tinea manum, tinea pedis, and pruritis. Poikiloderma of Civatte did not cause scarring or disfigurement of the head, face, or neck; and the Veteran did not use any medication to treat the condition. Poikiloderma of Civatte covered 3 to 5 percent of the body surface area. Based on the foregoing evidence, staged ratings are appropriate. Prior to June 14, 2017, the poikiloderma of Civatte covered 2 percent of the total exposed body area and was not treated with any medication. When characteristic lesions cover less than 5 percent of the total exposed body area and require no medication, a noncompensable rating is applied under DC 7806 both before and after the August 2018 regulation changes. See 38 C.F.R. § 4.118 DC 7899-7806; see 83 Fed. Reg. 32, 592 (July 13, 2018). On and after June 14, 2017, the poikiloderma of Civatte was assessed as covering an estimated 3 to 5 percent of the total body area. When characteristic lesions cover at least 5 percent of the total body area or total exposed areas, a 10 percent evaluation is assigned. The 2017 examiner estimated that the condition covered up to and including 5 percent of the total body area. Thus, on and after June 14, 2017, the date of the most recent VA examination, the criteria for a 10 percent evaluation have been met under DC 7806 under both the old and new regulations. Id. A higher rating is not warranted as the poikiloderma of Civatte has not been shown to have characteristic lesions covering at least 20 percent of the total body area or total exposed areas. To the extent the Veteran has reported using several topical creams and cleansers for alleged service-connected skin disorders, the evidence, including the lay testimony from November 2016, does not show that any medication or cleansers were used to treat the poikilderma of Civatte. In October 2018, the Board denied entitlement to service connection for a skin disorder other than tinea pedis, tinea manum, and poikiloderma of Civatte. As a result, although the Veteran argues that VA has failed to adequately rate him for other skin disorders, the appropriate remedy is to appeal the October 2018 Board decision. Because the evidence does not show that any medication has even been prescribed to treat the poikiloderma of Civatte, discussion of topical versus systemic therapy under the old and new skin rating regulations is not warranted. Last, a separate evaluation for scarring is not warranted as no scars have been attributed to the service-connected poikiloderma of Civatte. In conclusion, the criteria for an initial compensable evaluation for service-connected poikiloderma of Civatte have not been met. The criteria for entitlement to a 10 percent evaluation, but no higher, for the same condition on and after June 14, 2017 have been met. REASONS FOR REMAND 1. Entitlement to service connection for a back disorder This issue is remanded to secure a VA examination and opinion on the etiology of the Veteran’s claimed back disorder. VA’s duty to assist includes providing a medical examination when is necessary to make a decision on a claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). Such development is necessary if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim, but (1) contains competent evidence of diagnosed disability or recurrent symptoms of disability, (2) establishes that the Veteran suffered an event, injury or disease in service, or has a presumptive disease during the pertinent presumptive period, and (3) indicates that the claimed disability may be associated with the in-service event, injury, or disease, or with another service-connected disability. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006) (noting that the third element establishes a low threshold and requires only that the evidence “indicates” that there “may” be a nexus between the current disability or symptoms and active service, including equivocal or non-specific medical evidence or credible lay evidence of continuity of symptomatology). In this case, the Veteran’s STRs document in-service back aches in 1960 and 1961. A May 1978 VA treatment record notes a history of chronic back pain. Private and VA treatment records document current diagnoses of multilevel degenerative disc and joint disease of the lumbar spine. See February 1986 private treatment records; June 2011 private treatment record. The Veteran has also testified that he first experienced back pain in service, and that he had chronic back complaints since that time. See April 2018 hearing testimony. Because there is evidence of currently diagnosed disabilities, an in-service event, and an indication that the current disabilities may be associated with the in-service event, remand for a VA examination is required.   2. Entitlement to service connection for residuals of an eye injury This issue must also be remanded to obtain a VA examination and etiological opinion to fulfill VA’s duty to assist. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. at 83-86. In July 2017 correspondence, the Veteran wrote that he got a pine needle in his eye in service and wore an eye patch for a week. Since then, he reportedly had problems with his eye, had to wear dark sunglasses, had to use eye medications, and had to use reading glasses. VA treatment records from June 2017 document diagnoses of bilateral cataracts, pseudoexfoliation syndrome, and dry eye syndrome, as well as a history of pine needle to the right eye with no signs of visual significant scarring or injury. There is evidence of an in-service eye injury, current eye diagnoses, and testimony of continuity of eye symptoms since the in-service eye injury; but insufficient evidence to decide the claim. Thus, remand is required to secure an examination and opinion on the etiology of the Veteran’s claimed residuals of a right eye injury. 3. Entitlement to service connection for a stomach disorder This issue is remanded to obtain an adequate medical opinion that is based on an accurate factual premise. Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). A medical opinion based upon an inaccurate factual premise has no probative value. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). The Veteran underwent a VA esophageal conditions examination in June 2016, and the examiner reported that the currently diagnosed gastroesophageal reflux disorder (GERD) was not related to the Veteran’s period of service. The examiner explained that GERD was not diagnosed in service, and was instead diagnosed in 1993, some 30 years after separation from active duty service. The examiner further reported there was no evidence of a chronicity of symptoms since service. The Veteran also underwent a VA intestinal conditions examination in December 2016, at which time the examiner reported the Veteran did not have nor had ever been diagnosed with an intestinal condition. Unfortunately, the June and December 2016 VA examiners relied on an inaccurate reporting of the facts to support their etiological opinions. The Veteran has reported experiencing indigestion in service, being treated with antacids, and being diagnosed with indigestion 2 months after separation from service. See April 2018 hearing testimony. On his separation report of medical history in 1962, the Veteran reported gas and stomach trouble, and the examiner noted the Veteran had trouble with greasy foods. A May 1978 VA treatment record documented the Veteran complained of abdominal pain that went up to chest, and an upper gastrointestinal series showed a small, sliding-type hiatal hernia. January 1986 private treatment records include another gastrointestinal series that showed findings consistent with mild duodenitis, and September 1999 private treatment records document a diagnosis of irritable bowel syndrome with generalized anxiety. The evidence shows that the Veteran was diagnosed with stomach conditions prior to 1993, and had been diagnosed with an intestinal condition. Therefore, the factual premises of the 2016 VA opinions were incorrect. Also, the examiner failed to address the Veteran’s competent testimony of in-service symptoms, the evidence of continuing stomach problems at separation related to certain foods, and the testimony of continuity of stomach problems since separation. Dalton v. Nicholson, 21 Vet. App. 23, 39 (2007) (holding that the VA examiner’s opinion was inadequate where the examiner impermissibly ignored the appellant’s lay assertions that he had sustained a back injury during service). For these reasons, remand is necessary to obtain adequate addendum opinions. 4. Entitlement to service connection for residuals of a mouth injury This issue is also remanded to obtain a VA examination and etiological opinion. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. at 83-86.38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006). Initially, the Veteran reported that he had teeth removed in service due to infection. See October 1986 statement. In July 2017, the Veteran reported that he had 4 impacted teeth removed in service, and that he was given a partial bridge or denture that broke less than 2 years later. At the April 2018 hearing, the Veteran reported he injured his mouth when he was hit in the face with a trailer hitch, and that he bled around one of his teeth. He reported he was seen in the dental clinic and had a cracked tooth removed, and impacted wisdom teeth removed. He then reported he had ongoing jaw problems in addition to still missing the teeth. Based on the Veteran’s recent testimony, it is unclear whether he has current compensable residuals of the reported in-service dental trauma and the Board finds that an examination and opinion is necessary to adjudicate the claim. 5. Entitlement to an evaluation higher than 10 percent for service-connected tinea pedis and tinea manum This final issue is remanded to secure a VA examination to ascertain the current severity of the tinea pedis and tinea manum. VA's duty to assist includes obtaining evidence necessary to substantiate the claim, which may include a thorough and contemporaneous medical examination. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159; Green v. Derwinski, 1 Vet. App. 121, 124 (1991). The Veteran most recently underwent a VA skin disease examination in June 2017, at which time the examiner reported that tinea manum of the hands was not currently active. The examiner also reported that tinea pedis was not currently being treated with any medication. A March 2018 VA podiatry treatment record reported the Veteran was diagnosed with plantar fascial fibromatosis and given Polysorb shoe inserts. At the April 2018 hearing, the Veteran reported that he had increased thickening on the soles of his feet due to the service-connected tinea pedis and now required special shoe inserts. In October 2018, the Veteran wrote that he had current skin problems on his hands. The March 2018 VA treatment records, April 2018 hearing testimony, and October 2018 lay statement indicate a potential worsening in the Veteran’s service-connected tinea pedis and tinea manum, thus remand is required to obtain an examination assessing the current severity of the service-connected disorders. The matters are REMANDED for the following action: 1. Contact the appropriate VA Medical Center and obtain and associate with the claims file all outstanding records of treatment. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. The non-existence or unavailability of such records must be verified and this should be documented for the record. Required notice must be provided to the Veteran and his representative. 2. Contact the Veteran and afford him the opportunity to identify by name, address and dates of treatment or examination any relevant medical records. Subsequently, and after securing the proper authorizations where necessary, make arrangements to obtain all the records of treatment or examination from all the sources listed by the Veteran which are not already on file. All information obtained must be made part of the file. All attempts to secure this evidence must be documented in the claims file, and if, after making reasonable efforts to obtain named records, they are not able to be secured, provide the required notice and opportunity to respond to the Veteran and his representative. 3. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the etiology of his claimed back disorder. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. (a.) The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that a back disorder had onset in, or is otherwise related to, active military service. (b.) The examiner’s attention is directed to the following: 1) the Veteran’s 1960 and 1961 STRs noting back ache; 2) May and October 1973 VA treatment records documenting a history of chronic back pain with a diagnosis of myalgia; 3) a March 1983 private orthopedic surgery note from Dr. EC; February 1986 private hospital records and imaging studies; and 4) an October 1992 letter from Dr. TR. 4. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the etiology of his claimed right eye disorder other than refractory error. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. (a.) The examiner is requested to elicit testimony from the Veteran regarding his in-service right eye injury and symptoms. (b.) The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that any diagnosed eye disorder other than refractory error, and to include bilateral cataracts, pseudoexfoliation syndrome, and dry eye syndrome had onset in, or is otherwise related to, active military service. (c.) The examiner’s attention is directed to the following: 1) the Veteran’s competent lay testimony that he injured his right eye in service with a pine needle and was treated with an eye patch; 2) a December 1983 private treatment record documenting a work related right eye injury; 3) and June 2017 VA treatment records. 5. After any additional records are associated with the claims file, obtain an addendum opinion regarding the etiology of the claimed stomach disorder from a VA examiner. The entire claims file must be made available to and be reviewed by the examiner. If an examination is deemed necessary, it shall be provided. An explanation for all opinions expressed must be provided. (a.) The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that a stomach disorder had onset in, or is otherwise related to, active service. (b.) The examiner’s attention is directed to the following: 1) the STRs noting complaints of abdominal pain and the separation report of medical history documenting gas and stomach problems related to eating greasy foods; 2) May 1978 VA treatment records and studies showing a small, sliding-type hiatal hernia; 3) January 1986 private treatment records and studies showing findings compatible with mild duodenitis; 4) November 1993 private imaging studies showing an active duodenal ulcer and diagnosing GERD; 5) July 1999 private treatment records noting diagnoses of dyspepsia and gastritis; 6) a September 1999 private treatment record documenting a diagnosis of irritable bowel syndrome; and 7) the Veteran’s lay testimony that he first experienced stomach problems in service for which he was given antacids, and that he experienced chronic stomach symptoms since that time. 6. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the etiology of his residuals of a mouth or dental injury. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. (a.) The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that any dental pathology had onset in, or is otherwise related to, active military service. (b.) The examiner’s attention is directed to the following: 1) the Veteran’s lay testimony that he was hit in the face with a trailer hitch and bled from a tooth, had several teeth removed in service, and that he continued to have dental and jaw problems since service; 2) the Veteran’s entrance report of medical history noting severe tooth or gum problems; and 3) the Veteran’s dental STRs documenting several procedures. 7. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the severity of the service-connected tinea pedis and manum. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The relevant Disability Benefits Questionnaire must be utilized. K. MILLIKAN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. Smith, Associate Counsel