Citation Nr: 18149068 Decision Date: 11/08/18 Archive Date: 11/08/18 DOCKET NO. 16-27 826 DATE: November 8, 2018 ORDER New and material evidence has not been submitted to reopen a claim for service connection for irritable bowel syndrome, to include as secondary to service-connected posttraumatic stress disorder (PTSD) or medications prescribed for service-connected disabilities. New and material evidence has been submitted to reopen a claim for service connection for skin cancer, to include as secondary to in-service sun exposure and herbicide agent exposure is granted. New and material evidence has not been submitted to reopen a claim for service connection for residuals of a right foot bone chip fracture, to include as secondary to service-connected diabetes mellitus, type II, residuals of a right ankle sprain, or left chronic ligamentous strain of the medial ankle joint. Entitlement to service connection for a right knee disability, to include as secondary to service-connected residuals of a right ankle sprain is denied. Entitlement to service connection for a bilateral eye disability, to include as secondary to service-connected diabetes mellitus, type II with erectile dysfunction is denied. Entitlement to service connection for an esophageal disability, to include gastroesophageal reflux disease, to include as secondary to service-connected PTSD or any medications prescribed for service-connected disabilities is denied. REMANDED Entitlement to a compensable disability rating for a left foot hairline bone chip fracture is remanded. Entitlement to a disability rating in excess of 30 percent for PTSD is remanded. Entitlement to service connection for a left knee disability, to include as secondary to left foot hairline bone chip fracture, residuals of a right ankle sprain, and left chronic ligamentous strain of the medial ankle joint is remanded. Entitlement to service connection for a skin disability, to include skin cancer, chloracne, and actinic keratosis, to include as secondary to in-service sun exposure and conceded herbicide agent exposure is remanded. Entitlement to service connection for an equilibrium disability, to include vertigo, to include as secondary to service-connected bilateral hearing loss or tinnitus is remanded. Entitlement to service connection for hypertension, to include as secondary to service-connected PTSD, diabetes mellitus, type II, or any medications prescribed for service-connected disabilities is denied. FINDINGS OF FACT 1. A December 2002 rating decision denied service connection for irritable bowel syndrome. The Veteran was notified of this decision and of his appellate rights by letter dated December 17, 2002. 2. The Veteran did not submit a notice of disagreement within one year of the mailing of notice of the December 2002 rating decision, and no new and material evidence was obtained or received by VA within this one-year time period. 3. Additional evidence received since the December 2002 rating decision is either cumulative or redundant of the evidence previously of record, and does not raise a reasonable possibility of substantiating the claim for service connection for irritable bowel syndrome. 4. A December 2006 rating decision denied service connection for skin cancer. The Veteran was notified of this decision and of his appellate rights by letter dated December 22, 2006. 5. The Veteran did not submit a notice of disagreement within one year of the mailing of notice of the December 2006 rating decision, and no new and material evidence was obtained or received by VA within this one-year time period. 6. Additional evidence received since the December 2006 rating decision is neither cumulative nor redundant of the evidence previously of record, and raises a reasonable possibility of substantiating the claim for service connection for skin cancer. 7. A March 2003 Board decision denied service connection for residuals of a right foot bone chip fracture. 8. The Veteran did not appeal the March 2003 Board decision or request reconsideration of that decision. 9. Additional evidence received since the March 2003 Board decision is either cumulative or redundant of the evidence previously of record, and does not raise a reasonable possibility of substantiating the claim for service connection for a right foot bone chip fracture. 10. The competent evidence of record is against finding that the Veteran has a right knee disability due to service-connected residuals of a right ankle sprain. 11. The Veteran’s bilateral eye disability is neither proximately due to nor aggravated beyond their natural progression by his service-connected diabetes mellitus, type II with erectile dysfunction. 12. The Veteran’s gastroesophageal reflux disease is neither proximately due to nor aggravated beyond their natural progression by his service-connected PTSD or any medications prescribed for service-connected disabilities. CONCLUSIONS OF LAW 1. The December 2002 rating decision is final with regard to the claim for service connection for irritable bowel syndrome. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. 2. New and material evidence has not been submitted to reopen the claim for service connection for irritable bowel syndrome. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. 3. The December 2006 rating decision is final with regard to the claim for service connection for skin cancer. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. 4. New and material evidence has been submitted to reopen the claim for service connection for skin cancer. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. 5. The March 2003 Board decision is final with regard to the claim for service connection for residuals of a right foot bone chip fracture. 38 U.S.C. § 7104; 38 C.F.R. § 20.1100. 6. New and material evidence has not been submitted to reopen the claim for service connection for residuals of a right foot bone chip fracture. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. 7. The criteria for service connection for a right knee disability are not met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.310(a). 8. The criteria for service connection for bilateral eye disability are not met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.310(a). 9. The criteria for service connection for gastroesophageal reflux disease are not met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.310(a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1969 to September 1970. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from multiple rating decisions. Although VA has reopened the claim for service connection for irritable bowel syndrome and right foot bone chip fracture and declined to reopen the claim for service connection for skin cancer, the Board must determine of its own accord whether new and material evidence is of record to reopen these claims before it may consider them on the merits. Jackson v. Principi, 265 F. 3d 1366 (Fed. Cir. 2001). The Veteran submitted a claim for service connection for a skin condition in September 2015. VA has made separate determinations that the Veteran is not entitled to service connection for skin cancer and for chloracne. Additionally, as is discussed in detail below, the Board has determined that the new and material evidence has been submitted to reopen the Veteran’s claim for service connection for skin cancer. However, what constitutes a claim is not limited by a lay veteran’s assertion of his condition in the application, but must be construed based on the reasonable expectations of the non-expert claimant and the evidence developed in processing the claim. Clemons v. Shinseki, 23 Vet. App. 1, 4-5 (2009). The record raises the issue of service connection for a skin disability, to include skin cancer, chloracne, and actinic keratosis. The Veteran also submitted a claim for service connection for vertigo, but the record raises the issue of service connection for an equilibrium disability, to include vertigo. Therefore, the Board has recharacterized the issues more broadly. New and Material Evidence A determination on a claim by the agency of original jurisdiction of which the claimant is properly notified is final if no notice of disagreement (NOD) is filed within the prescribed time period, or an appeal is not perfected pursuant to 38 C.F.R. § 20.302. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103; see 38 C.F.R. §§ 20.200, 20.201, 20.302 (setting forth requirements and timeframe for initiating and perfecting an appeal). In order to reopen a previously and finally disallowed claim, new and material evidence must be submitted by the claimant or secured by VA with respect to that claim since the last final denial, regardless of the basis for that denial. See 38 U.S.C. § 5108; Evans v. Brown, 9 Vet. App. 273, 282-83 (1996) (holding that § 5108 requires a review of all evidence submitted by or on behalf of a claimant since the last final denial on any basis to determine whether a claim must be reopened). VA regulation defines “new and material evidence” as follows. “New evidence” means evidence not previously submitted to agency decision makers, and “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. 38 C.F.R. § 3.156(a), Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). In order to warrant reopening, the new evidence must neither be 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. Id.; see Shade, 24 Vet. App. at 117 (holding that there is a “low threshold” for reopening). For the purpose of establishing whether new and material evidence has been submitted, the credibility of the evidence is to be presumed, unless it is inherently false or untrue or, if it is in the nature of a statement or other assertion, it is beyond the competence of the person making the assertion. Duran v. Brown, 7 Vet. App. 216, 220 (1994); Justus v. Principi, 3 Vet. App. 510, 513 (1992). If new and material evidence is received within one year after the date of mailing of an RO decision, it prevents that decision from becoming final and 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); Young v. Shinseki, 22 Vet. App. 461, 466 (2009) (holding that new and material evidence received within one year of an RO decision prevents that decision from becoming final); 38 C.F.R. § 3.400(q) (providing that, as to new and material evidence received within appeal period, “effective date will be as though the former decision had not been rendered”). 1. New and material evidence has not been submitted to reopen a claim for service connection for irritable bowel syndrome, to include as secondary to service-connected PTSD or medications prescribed for service-connected disabilities. Service connection for irritable bowel syndrome was originally denied in a December 2002 rating decision. The Veteran was notified of this decision and of his appellate rights by letter dated December 17, 2002. He did not appeal. See 38 C.F.R. §§ 20.200, 20.201, 20.302. Further, no new and material evidence was received within one year of the date of mailing of the rating decision. See 38 C.F.R. § 3.156(b). Accordingly, the December 2002 rating decision is final with regard to this claim. See 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. The Veteran submitted a petition to reopen the service connection claim for irritable bowel syndrome in September 2015. The Veteran’s claims folder does not reveal any evidence that relates to an unestablished fact necessary to support the claim, namely a current disability, an in-service injury, disease, or event, or evidence of a link between a current disability and an in-service injury, disease, or event. Of note, the March 2016 VA Intestinal Conditions Examination noted that the Veteran does not have and has never been diagnosed with an intestinal condition. Thus, the Board finds the evidence is not new and material. See 38 C.F.R. § 3.156(a); see also 38 C.F.R. § 3.303; Shade, 24 Vet. App. at 122. Therefore, the claim is not reopened. 2. New and material evidence has been submitted to reopen a claim for service connection for skin cancer, to include as secondary to in-service sun exposure and herbicide agent exposure. Service connection for skin cancer was originally denied in a December 2006 rating decision. The Veteran was notified of this decision and of his appellate rights by letter dated December 22, 2006. He did not appeal. See 38 C.F.R. §§ 20.200, 20.201, 20.302. Further, no new and material evidence was received within one year of the date of mailing of the rating decision. See 38 C.F.R. § 3.156(b). Accordingly, the December 2006 rating decision is final with regard to this claim. See 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. The Veteran submitted a petition to reopen the service connection claim for a skin cancer in September 2015. Since the last rating decision, the Veteran submitted a summary of a study from Medical News Today that showed that Veterans exposed to herbicide agents had a statistically significant higher rate of non-melanoma invasive skin cancer. The Board notes that VA has conceded the Veteran was exposed to herbicide agents during the Vietnam Era. The evidence submitted by the Veteran relates to an unestablished fact necessary to support the claim, namely a link between a current disability and an in-service injury, disease, or event. Thus, the Board finds the evidence is both new and material. See 38 C.F.R. § 3.156(a); see also 38 C.F.R. § 3.303; Shade, 24 Vet. App. at 122. Therefore, the claim is reopened. 3. New and material evidence has not been submitted to reopen a claim for service connection for residuals of a right foot bone chip fracture, to include as secondary to service-connected diabetes mellitus, type II, residuals of a right ankle sprain, or left chronic ligamentous strain of the medial ankle joint. Service connection for residuals of a right foot bone chip fracture was originally denied in a March 2003 Board decision. The Veteran did not appeal or request reconsideration of that decision. Accordingly, the March 2003 Board decision is final with regard to this claim. See 38 U.S.C. § 7104; 38 C.F.R. § 20.1100. The Veteran submitted a petition to reopen the service connection claim for residuals of a right foot bone chip fracture in September 2015. The Veteran did not submit and the Veteran’s claims folder does not reveal any competent evidence that relates to an unestablished fact necessary to support the claim, namely a current disability, an in-service injury, disease, or event, or evidence of a link between a current disability and an in-service injury, disease, or event. Thus, the Board finds the evidence obtained since the March 2003 Board decision is not new or material. See 38 C.F.R. § 3.156(a); see also 38 C.F.R. § 3.303; Shade, 24 Vet. App. at 122. Therefore, the claim is not reopened. Service Connection Service connection means that a Veteran has a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge when the evidence shows that the disease was incurred in service. 38 C.F.R. § 3.303(d). Entitlement to service connection is established when the following elements are satisfied: (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship or “medical nexus” between the current disability and the disease or injury incurred or aggravated during service. Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); see 38 C.F.R. § 3.303(a). Service connection may also be established on a secondary basis for a disability which is proximately due to, or the result of, a service-connected disease or injury. 38 C.F.R. § 3.310(a). Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the of the nonservice-connected disease, will be service-connected. § 3.310(b). Secondary service connection under § 3.310 entails “any additional impairment of earning capacity resulting from an already service-connected condition, regardless of whether or not the additional impairment is itself a separate disease or injury caused by the service-connected condition.” Allen v. Brown, 7 Vet. App. 439, 448 (1995). Accordingly, in order to establish entitlement to service connection on a secondary basis, the evidence must show: (1) that a current disability exists; and (2) that the current disability was either: (a) caused by; or (b) aggravated by a service-connected disability. Id. A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence on any issue material to the claim. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102 (providing, in pertinent part, that reasonable doubt will be resolved in favor of the claimant). When the evidence supports the claim, or is in relative equipoise, the claim will be granted. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); see also Wise v. Shinseki, 26 Vet. App. 517, 532 (2014). If the preponderance of the evidence weighs against the claim, it must be denied. See id.; Alemany v. Brown, 9 Vet. App. 518, 519 (1996). 4. Entitlement to service connection for a right knee disability, to include as secondary to service-connected residuals of a right ankle sprain is denied. The Veteran maintains that his current right knee disability is related to his service-connected residuals of a right ankle sprain. The question for the Board is whether the Veteran has a current right knee disability that is proximately due to or the result of, or is aggravated beyond its natural progress by his service-connected residuals of a right ankle sprain. The Board concludes that, while the Veteran has a current diagnosis of a right knee strain, the competent evidence of record is against finding that the Veteran’s right knee strain is proximately due to or the result of, or aggravated beyond its natural progression by his service-connected residuals of a right ankle sprain. 38 U.S.C. §§ 1110; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). The December 2015 VA examiner opined that the Veteran’s right knee strain is instead a natural progression of disease with age. The rationale was that there was no valid medical reasoning to support a conclusion that the Veteran’s right knee strain is caused or aggravated by his service-connected residuals of a right ankle sprain. The Board notes there is no conflicting evidence in terms of VA treatment records, private treatment records, or private medical opinions regarding the nexus of the Veteran’s right knee strain. In determining the probative value to be assigned to a medical opinion, the Board must consider three factors: whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case; whether the medical expert provided a fully articulated opinion; and whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the s file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (“[A] medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions.”). In this case, the examiner was aware of the Veteran’s medical history, provided a fully articulated opinion, and also furnished a reasoned analysis. The Board therefore attaches significant probative value to this opinion, and the most probative value in this case, as it is well reasoned, detailed, consistent with other evidence of record, and included an access to the accurate background of the Veteran. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (Factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion). The Board has considered the Veteran’s own opinion; however, as a lay person in the field of medicine, the Veteran does not have the training or expertise in medical matters and this issue involves a medical determination that is too complex to be made based on lay observation alone. See Jandreau v. Nicholson, 492 F. 3d 1372, 1376-77 (Fed. Cir. 2007) (observing that a layperson can be competent to identify conditions that are simple, such as a broken leg, but is not competent to identify more complex conditions such as a form of cancer); Barr v. Nicholson, 21 Vet. App. 303, 309 (2007) (holding that lay testimony is competent as to matters capable of lay observation, but not with respect to determinations that are “medical in nature”); Layno v. Brown, 6 Vet. App. 465, 469-71 (1994) (holding that in order for testimony to be probative of any fact, the witness must be competent to testify as to the facts under consideration, and that lay testimony is not competent to prove that which would require specialized knowledge, training, or medical expertise). Thus, the Veteran’s opinion is outweighed by the findings to the contrary by the VA examiner, a medical professional who considered the pertinent evidence of record and found against such a relationship. See id.; see also King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012) (affirming the Court’s conclusion that the Board did not improperly discount the weight of a lay opinion in finding a medical expert’s opinion more probative on the issue of medical causation). In sum, the preponderance of the evidence weighs against entitlement to service connection for a right knee disability. Consequently, the benefit-of-the-doubt rule does not apply and service connection for a right knee disability is denied. See 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3; Gilbert, 1 Vet. App. at 55. 5. Entitlement to service connection for a bilateral eye disability, to include as secondary to service-connected diabetes mellitus, type II with erectile dysfunction is denied. The Veteran provides that a bilateral eye disability is related to his service-connected diabetes mellitus, type II with erectile dysfunction. The question for the Board is whether the Veteran has a current bilateral eye disability that is proximately due to or the result of, or is aggravated beyond its natural progress by his service-connected diabetes mellitus, type ii with erectile dysfunction. The Board concludes that, while the Veteran has a current diagnosis of nuclear sclerotic cataracts, right eye corneal scar, and status post right eye LASIK surgery, the preponderance of the evidence is against finding that the Veteran’s above eye disabilities are proximately due to or the result of, or aggravated beyond its natural progression by his service-connected diabetes mellitus, type II with erectile dysfunction. 38 U.S.C. §§ 1110; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). The November 2015 VA examiner opined that the Veteran’s nuclear sclerotic cataracts are instead related to his age. The examiner explained that diabetic cataracts are primarily cortical or subscapular and the Veteran has no significant cortical or subscapular cataracts. The examiner also opined that while diabetes can accelerate the progression of age-related nuclear sclerotic cataracts, the Veteran’s nuclear sclerotic changes are at the expected level for his age. The examiner provided that the Veteran’s right eye corneal scar is peripheral, not visually significant, and not related to diabetes. The Board notes there is no conflicting evidence in terms of VA treatment records, private treatment records, or private medical opinions regarding the nexus of the Veteran’s bilateral eye disability. In determining the weight assigned to the evidence, the Board also looks at factors such as the health care provider’s knowledge and skill in analyzing the medical data. See Black v. Brown, 10 Vet. App. 279, 284 (1997). The Board finds that the VA examiner’s opinion based on medical expertise outweighs the Veteran’s own opinion. In sum, the preponderance of the evidence weighs against entitlement to service connection for a bilateral eye disability. Consequently, the benefit-of-the-doubt rule does not apply and service connection for a bilateral eye disability is denied. See 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3; Gilbert, 1 Vet. App. at 55. 6. Entitlement to service connection for an esophageal disability, to include gastroesophageal reflux disease, to include as secondary to service-connected PTSD or any medications prescribed for service-connected disabilities is denied. The Veteran maintains that his gastroesophageal reflux disease is due to his service-connected PTSD or any medications prescribed for service-connected disabilities. The question for the Board is whether the Veteran’s gastroesophageal reflux disease is proximately due to or the result of, or is aggravated beyond its natural progress by his service-connected PTSD or any medications prescribed for service-connected disabilities. The Board concludes that, while the Veteran has a current diagnosis of gastroesophageal reflux disease, the competent evidence of record is against finding that the Veteran’s gastroesophageal reflux disease is proximately due to or the result of, or aggravated beyond its natural progression by service-connected disability. 38 U.S.C. §§ 1110, 1131; Allen, 7 Vet. App. at 439; 38 C.F.R. § 3.310(a). The December 2015 VA examiner opined that the Veteran’s gastroesophageal reflux disease is not due to his service-connected PTSD as he has risk factors and lifestyle factors, such as diet, that cause his gastroesophageal reflux disease and PTSD does not cause specific mechanical or structural changes in the gastrointestinal tract. Further, the examiner opined that there is no evidence of a link between the Veteran’s gastroesophageal reflux disease and the prescriptions and therapeutic treatment for any service-connected disability. The examiner again provided that the Veteran’s gastroesophageal reflux disease most likely has a relationship with lifestyle factors, intake, and body habits. Inasmuch as the VA opinion clearly was based upon both examination of the Veteran and consideration of his documented medical history and statements, and because the rationale underlying the opinion is reasonable and consistent with the evidence of record, this opinion constitutes the most probative evidence. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993). While the Veteran believes his gastroesophageal reflux disease is due to his service-connected PTSD and medications prescribed for service-connected disabilities, he is not competent to provide a nexus opinion in this case. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body and the interpretation of complicated diagnostic medical testing]. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the December 2015 VA examiner’s findings and opinions. In sum, the preponderance of the evidence weighs against entitlement to service connection for gastroesophageal reflux disease. Consequently, the benefit-of-the-doubt rule does not apply and service connection for gastroesophageal reflux disease is denied. See 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3; Gilbert, 1 Vet. App. at 55. REASONS FOR REMAND 1. Entitlement to a compensable disability rating for a left foot hairline bone chip fracture is remanded. The December 2015 VA Foot Conditions Examination is inadequate. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate); D’Aries v. Peake, 22 Vet. App. 97, 104 (2008) (holding that an examination must be based on consideration of the claimant’s medical history and must describe the disability in sufficient detail so that the Board’s evaluation of the disability will be a fully informed one). As discussed below, the VA examiner did not obtain required information concerning the severity, frequency, and duration of flare-ups to his left foot, as well as precipitating and alleviating factors prior to providing an estimate concerning the additional loss of range of motion during a flare-up. Regarding the claim for a higher rating for the Veteran’s left foot hairline bone chip fracture, a new VA examination must be provided to comply with Sharp v. Shulkin, 29 Vet. App. 26 (2017). VA examiners are required to obtain information from the Veteran as to the severity, frequency, and duration of flare-ups, as well as precipitating and alleviating factors, and the extent of functional impairment. Sharp, 29 Vet. App. at 32. VA examiners are also required to estimate the additional loss of range of motion during a flare-up based on all procurable information from the record, as well as the Veteran’s own statements. Id. at 34-35. If an estimate cannot be provided without resort to speculation, it must be clear whether this is due to a lack of knowledge among the medical community at large, or insufficient knowledge of the specific examiner. Id. at 36. In this case, the December 2015 examination report indicates that the Veteran experiences flare-ups with activity and has difficulty on uneven surfaces, but does not provide all of the necessary information regarding flare-ups. Specifically, the examination report does not advise of the severity, frequency, duration, precipitating, or alleviating factors of the flare-ups. The examiner also did not estimate additional functional loss based on the Veteran’s statements describing the flare-ups, or why the available information in the file was not sufficient to permit such an estimate. Should the new VA examination be conducted while the Veteran is not experiencing a flare-up of his left foot, the estimation of additional loss of range of motion during a flare-up must be made after obtaining information concerning the severity, frequency, and duration of flare-ups, as well as precipitating and alleviating factors. 2. Entitlement to a disability rating in excess of 30 percent for PTSD is remanded. The Veteran was last afforded a VA PTSD Examination in November 2015. The Veteran’s attorney submitted a written statement in September 2016, that provided that the Veteran isolates himself and retired from employment because he does not want to be around other people. That level of functional impairment and isolation was not indicated on the November 2015 examination report. Considering that the Veteran’s last examination occurred almost three years ago and the evidence that his disability picture has changed, the Board finds that the current evidence of record does not adequately reveal the present state of the Veteran’s service-connected PTSD. See Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991) (where the record does not adequately reveal the current state of the claimant’s disability, a VA examination must be conducted); see also Caffrey v. Brown, 6 Vet. App. 377, 381 (1994) (wherein the Court determined the Board should have ordered a contemporaneous examination of the Veteran because a 23-month old exam was too remote in time to adequately support the decision in an appeal for an increased rating); Palczewski v. Nicholson, 21 Vet. App. 174, 181-82 (2007), citing Caluza v. Brown, 7 Vet. App. 498, 505-06 (1998) (“Where the record does not adequately reveal the current state of the claimant’s disability…the fulfillment of the statutory duty to assist requires a thorough and contemporaneous medical examination.”); see also Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); VAOPGCPREC 11-95 (1995). 3. Entitlement to service connection for a left knee disability, to include as secondary to left foot hairline bone chip fracture, residuals of a right ankle sprain, and left chronic ligamentous strain of the medial ankle joint is remanded. The Veteran maintains that he has a left knee disability that is related to his service-connected ankle and foot disabilities. While the May 2016 Statement of the Case (SOC) states that the December 2015 VA Knee and Lower Leg Conditions Examination provided no diagnosis for the Veteran’s left knee, it does not appear that the Veteran’s left knee has been examined. Additionally, there was no medical opinion concerning the nexus provided. VA will provide a medical examination or obtain a medical opinion if the evidence indicates the existence of a current disability or persistent or recurrent symptoms of a disability that may be associated with an event, injury, or disease in service, but the record does not contain sufficient medical evidence to decide the claim. 38 U.S.C. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4)(i); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The threshold for determining whether the evidence “indicates” that there “may” be a nexus between a current disability and an in-service event, injury, or disease is a low one. McLendon, 20 Vet. App. at 83. That threshold having been met, a VA examination and opinion must be provided to make an informed decision on the Veteran’s claim for service connection for a left knee disability. Because there is at least an indication that the Veteran’s current left knee disability may be related to his active duty service, a VA examination and opinion must be provided to make an informed decision on this claim. See McLendon, 20 Vet. App. at 83; see also Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (the Board is not competent to substitute its own opinion for that of a medical expert). 4. Entitlement to service connection for a skin disability, to include skin cancer, chloracne, and actinic keratosis, to include as secondary to in-service sun exposure and herbicide agent exposure is remanded. As noted above, the Board reopened the Veteran’s claim for service connection for skin cancer and recharacterized the Veteran’s claim more broadly. The Veteran has not been afforded a VA examination concerning this disability. The Veteran maintains that in-service sun exposure and conceded herbicide agent exposure caused his skin cancer. The Veteran submitted a summary of a study from Medical News Today that showed that Veterans exposed to herbicide agents had a statistically significant higher rate of non-melanoma invasive skin cancer. A VA treatment record from June 2016 showed the Veteran has a diagnosis of actinic keratosis at that time. Because there is at least an indication that the Veteran’s skin disability may be related to his active duty service, a VA examination and opinion must be provided to make an informed decision on this claim. See McLendon, 20 Vet. App. at 83; see also Colvin, 1 Vet. App. at 175. 5. Entitlement to service connection for an equilibrium disability, to include vertigo, to include as secondary to service-connected bilateral hearing loss or tinnitus is remanded. The Veteran was afforded an Ear Conditions VA Examination in December 2015. The medical opinion provided by the VA examiner that found the Veteran’s vertigo unrelated to his active service is inadequate. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate); D’Aries v. Peake, 22 Vet. App. 97, 104 (2008) (holding that an examination must be based on consideration of the claimant’s medical history and must describe the disability in sufficient detail so that the Board’s evaluation of the disability will be a fully informed one). The December 2015 medical opinion concluded that the Veteran’s symptoms are classic for benign paroxysmal positional vertigo versus orthostatic hypotension, which is likely exacerbated by his anti-hypertensive medication. The examiner concluded that there is no evidence to support a chronic disability related to the Veteran’s inner ears as a source of his claimed dizziness or vertigo. However, in the medical opinion, the examiner did not comment on a December 2015 private clinical vestibular/balance evaluation that indicated that the Veteran’s chief complaint is dizziness that began over 20 years ago and that he has a medical history that is significant for a head injury in 1970. The medical opinion also does not directly discuss the potential link between the Veteran’s vertigo and his service-connected bilateral hearing loss or tinnitus. Further, in an April 2016 written statement, the Veteran’s attorney reported that the Veteran lost consciousness during active service and continues to suffer from vertigo on occasion. The Veteran must be afforded a new VA examination to consider other equilibrium disabilities and a new medical opinion must be obtained to consider this information. 6. Entitlement to service connection for hypertension, to include as secondary to service-connected PTSD, diabetes mellitus, type II, or any medications prescribed for service-connected disabilities is denied. The Veteran was afforded a Hypertension VA Examination in December 2015. The medical opinion provided by the VA examiner that found the Veteran’s hypertension unrelated to his active service is inadequate. See Barr, 21 Vet. App. at 312; D’Aries, 22 Vet. App. at 104. The December 2015 medical opinion concluded that whether the Veteran’s PTSD, diabetes mellitus, type II, or any medication prescribed for service-connected disabilities aggravated the Veteran’s hypertension could not be determined because there is a host of medical comorbidities that play into his hypertension. The Board finds this rationale is inadequate in determining whether the Veteran’s hypertension is linked to his active service. See Wilson v. Derwinski, 2 Vet. App. 614 (1992) (The Board is free to assess medical evidence and is not obligated to accept a physician’s opinion. The medical opinion does not indicate whether any comorbidities that contribute to his hypertension are service-connected. Because the Board is unable to make an informed decision on the Veteran’s claim due to the inadequate medical opinion, an addendum opinion must be obtained. The matters are REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records for the period from October 2017 to the present. 2. Ask the Veteran to complete a VA Form 21-4142 for physicians and/or facilities adequately identified by the Veteran. Make two requests for the authorized records from physicians and/or facilities adequately identified by the Veteran, unless it is clear after the first request that a second request would be futile. 3. Schedule the Veteran for an examination of the current severity of his left foot bone chip fracture. (a.) The examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. (b.) To the extent possible, the examiner should identify any symptoms and functional impairments due to left foot bone chip fracture alone and discuss the effect of the Veteran’s left foot bone chip fracture on any occupational functioning and activities of daily living. (c.) If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). All examination findings, along with the complete rationale for all opinions expressed, must be set forth in the examination report. 4. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected PTSD. (a.) The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. (b.) The examiner must attempt to elicit information regarding the severity, frequency, and duration of symptoms. (c.) To the extent possible, the examiner should identify any symptoms and social and occupational impairment due to his PTSD alone. All examination findings, along with the complete rationale for all opinions expressed, must be set forth in the examination report. 5. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any left knee disability. (a.) Identify all current left knee disabilities. (b.) The examiner must opine whether any current left knee disability is at least as likely as not related to an in-service injury, event, or disease. (c.) The examiner must also opine whether any current left knee disability is at least as likely as not: (1) proximately due to the Veteran’s service-connected left foot hairline bone chip fracture, residuals of a right ankle sprain, or left chronic ligamentous strain of the medial ankle joint; or (2) aggravated beyond its natural progression by the Veteran’s service-connected left foot hairline bone chip fracture, residuals of a right ankle sprain, or left chronic ligamentous strain of the medial ankle joint. All examination findings, along with the complete rationale for all opinions expressed, must be set forth in the examination report. 6. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any current skin disability, to include skin cancer, chloracne, and actinic keratosis. (a.) Identify all current skin disabilities. (b.) The examiner must opine whether any current skin disability is at least as likely as not related to an in-service injury, event, or disease, including in-service sun exposure. (c.) The examiner must also opine whether any current skin disability is at least as likely as not related to in-service herbicide agent exposure. The examiner must discuss the Medical News Today article that showed that Veterans exposed to herbicide agents had a statistically significant higher rate of non-melanoma invasive skin cancer All examination findings, along with the complete rationale for all opinions expressed, must be set forth in the examination report. 7. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any equilibrium disability. (a.) The examiner must identify all current equilibrium disabilities. (b.) The examiner must opine whether any equilibrium disability is at least as likely as not related to an in-service injury, event, or disease, including a reported in-service injury where the Veteran lost consciousness. (c.) The examiner must also opine whether any equilibrium disability is at least as likely as not (1) proximately due to the Veteran’s service-connected bilateral hearing loss or tinnitus, or (2) aggravated beyond its natural progression by the Veteran’s service-connected bilateral hearing loss or tinnitus. All examination findings, along with the complete rationale for all opinions expressed, must be set forth in the examination report. 8. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s hypertension is at least as likely as not: (a.) Proximately due to the Veteran’s service-connected PTSD, diabetes mellitus, type II, or any medications prescribed for service-connected disabilities; or (b.) Aggravated beyond its natural progression by the Veteran’s service-connected connected PTSD, diabetes mellitus, type II, or any medications prescribed for service-connected disabilities. All examination findings, along with the complete rationale for all opinions expressed, must be set forth in the examination report. J.CONNOLLY Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. Mussey, Associate Counsel