Citation Nr: 18158440 Decision Date: 12/14/18 Archive Date: 12/14/18 DOCKET NO. 17-01 635 DATE: December 14, 2018 REMANDED Entitlement to service connection for obstructive sleep apnea is remanded. Entitlement to service connection for migraine headaches is remanded. Entitlement to a rating in excess of 0 percent for pseudofolliculitis barbae is remanded. REASONS FOR REMAND The Veteran had active duty service from January 1985 to January 2005 This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a November 2012 and April 2013 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). 1. Entitlement to an initial rating in excess of 0 percent for pseudofolliculitis barbae is remanded. The Veteran contends that he is entitled to a rating in excess of 0 percent for pseudofolliculitis barbae. In an October 2012 VA examination, the examiner indicated that the affected area was less than 5 percent of the body, and that the Veteran used cortisone on a “constant/near constant” basis. Under Diagnostic Code 7806, a 10 percent rating is warranted where the skin disability covers at least 5 percent, but less than 20 percent of the entire body, or at least 5 percent, but less than 20 percent of the exposed areas affected, or, intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs were required for a total duration of less than six weeks during the past 12 month period. A 30 percent rating is assigned when the skin disability affects 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas, or by systemic therapy being required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A 60 percent rating is assigned when the skin disability affects more than 40 percent of the entire body or more than 40 percent of exposed areas, or by constant or near-constant systemic therapy being required during the past 12-month period. 38 C.F.R. § 4.118. Systemic therapy for Diagnostic Code 7806 purposes is not limited to corticosteroids or immunosuppressive drugs, and the Board must consider whether any particular treatment is “like” a corticosteroid or other immunosuppressive drug to determine whether that treatment is a systemic therapy. Warren v. McDonald, 28 Vet. App. 194 (2016). In the October 2012 VA examination, there was no indication as to whether or not the use of cortisone was “like” a corticosteroid or other immunosuppressive drugs to be considered systemic therapy given the frequency of use by the Veteran. The Veteran has not had a VA examination since October 2012. The Board finds that a more current VA examination is necessary for not only determining the current severity of the Veteran’s condition, but to also assess if the over the counter cortisone can be classified as “systemic therapy” for rating purposes. 2. Entitlement to service connection for obstructive sleep apnea (OSA) is remanded. 3. Entitlement to service connection for migraine headaches is remanded. The Veteran contends that he is entitled to service connection for OSA and migraine headaches, as the alleged disabilities are the result of an in-service motor vehicle accident (MVA). The Veteran asserts that after a head injury in the MVA he began to experience migraine headaches. The Veteran also alleges that head injuries can cause OSA. The service medical records show that the Veteran struck his head in a MVA in July 2000. The Veteran has not received a VA examination for the purpose of determining if OSA and migraine headaches are service-connected or related to that incident during service. VA must provide the Veteran with an examination where 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 symptoms of disability, (2) establishes an in-service event, injury or disease, or the presence of a presumptive disease during the pertinent 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. McLendon v. Nicholson, 20 Vet. App. 79 (2006). Due to the in-service documentation of a MVA and head injury, the Board finds that a VA examination is necessary to determine the etiology of the claimed disabilities. The matters are REMANDED for the following action: 1. Secure all outstanding VA medical records. If any 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. If records are unable to be obtained (a) notify the claimant of the specific records that VA 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 claim. The claimant must then be given an opportunity to respond. 2. Schedule the Veteran for a VA skin examination to determine the current severity and manifestations of pseudofolliculitis barbae. The examiner must review the claims file and must note that review in the report. All indicated tests should be conducted. All pertinent symptomatology and findings must be reported in detail. If possible, the VA examination should be scheduled during an active stage of the disability. If it is not possible to schedule the Veteran for a VA examination during an active stage, the examiner’s report should include documentation of the symptoms of the Veteran’s skin disability based on his description of his symptoms during an active stage. The examiner should provide the following: (a.) Describe the areas of the body affected by the skin disability, to include the percentage of the entire body affected, and the percentage of exposed areas affected. (b.) Note whether the Veteran has been prescribed any systemic therapy, such as corticosteroids or other immunosuppressive drugs, and the period of time prescribed during a twelve-month period. If the Veteran is using topical treatment, in this case cortisone treatment or any other topical or systemic treatment prescribed, the examiner should note whether the topical treatment operates by affecting the body as a whole in treating a veteran’s skin condition and whether that specific treatment is “like” a corticosteroid or other immunosuppressive drug (c.) Specify whether the Veteran has any functional impairment associated with the skin disability, to include any impact of the disability on the Veteran’s ability to obtain and retain substantially gainful employment. 3. Schedule the Veteran for a VA examination conducted by a medical doctor to determine the nature and etiology of any migraine headache disability. The examiner must review the claims file and note that review in the report. All indicated tests and studies should be accomplished and the findings reported in detail. The examiner should opine as to whether it is as likely as not (50 percent or greater probability) that any migraine headache disability had its onset during active service, manifested within one year following separation from service, or otherwise originated during active service, to include as a result of a motor vehicle accident during service. If the examiner determines that the migraine headache disability is not the result of active service, and another etiology can be determined, the examiner should provide an opinion as to what likely caused the migraine headache disability, taking into account the Veteran’s full post-service work and medical history. The examiner should discuss the Veteran’s lay statements regarding the history and continuity of symptomatology. The examiner should provide a complete rationale for all conclusions. 4. Schedule the Veteran for a VA examination conducted by a medical doctor to determine the nature and etiology of any sleep apnea disability. The examiner must review the claims file and note that review in the report. All indicated tests and studies should be accomplished and the findings reported in detail. The examiner should opine as to whether it is as likely as not (50 percent or greater probability) that any sleep apnea disability had its onset during active service or otherwise originated during active service, to include as the result of a head injury from a motor vehicle accident during active service. If the examiner determines that sleep apnea is not the result of active service, and another etiology can be determined, the examiner should provide an opinion as to what likely caused the sleep apnea disability, taking into account the Veteran’s full post-service work and medical history. The examiner should discuss the Veteran’s lay statements regarding the history and continuity of symptomatology. The examiner should provide a complete rationale for all conclusions. Harvey P. Roberts Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K. D. Cross, Associate Counsel