Citation Nr: 18160862 Decision Date: 12/28/18 Archive Date: 12/27/18 DOCKET NO. 14-05 574 DATE: December 28, 2018 REMANDED Whether new and material evidence has been received in order to reopen a claim of entitlement to service connection for a back disorder is remanded. Whether new and material evidence has been received in order to reopen a claim of entitlement to service connection for a left knee disorder, previously claimed as left leg disorder, is remanded. Whether new and material evidence has been received in order to reopen a claim of entitlement to service connection for a bilateral foot disorder is remanded. Entitlement to service connection for a skin disorder, to include pediculosis pubis, is remanded. Entitlement to service connection for cold injury residuals in the upper thigh area, is remanded. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), depressive disorder, and anxiety disorder not otherwise specified (NOS), is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1980 to April 1983. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a rating decision issued in August 2011 by a Department of Veterans Affairs (VA) Regional Office (RO). The Board notes that, following the issuance of the December 2013 statement of the case pertinent to the Veteran’s the instant claims, additional evidence, to include a lay statement from the Veteran, has been associated with the record. While the Veteran has not waived Agency of Original Jurisdiction (AOJ) consideration of such evidence, the AOJ will have an opportunity to consider it in the readjudication of the claim on remand. The Veteran’s claim of service connection for pediculosis pubis has been recharacterized to include all skin disorders reasonably raised by the record. Clemons v. Shinseki, 23 Vet. App. 1 (2009). 1. Back disorder. 2. Cold injury residuals to upper thigh. 3. Left knee disorder. 4. Bilateral foot disorder. 5. Skin Disorder/Pediculosis pubis. 6. An acquired psychiatric disorder. As an initial matter, with regard to the Veteran’s claims, the Board finds that a remand is necessary in order to obtain potentially outstanding records. In this regard, the record reflects that the Veteran may be in receipt of disability benefits from the Social Security Administration (SSA) and/or the State of Missouri. In this regard, an October 2015 statement from the Veteran indicates that he was receiving disability from the state for knee pain, low back pain, depression, frost bitten feet and thigh, and pediculosis pubis. Moreover, June 2013 VA treatment records indicate that the Veteran reported that he received social security income as a main source of income. Consequently, as such records may be relevant to the instant claim, a remand is necessary in order to obtain any determination pertinent to the Veteran’s claim for SSA benefits and/or disability from the State of Missouri, as well as any medical records relied upon concerning that claim. Murincsak v. Derwinski, 2 Vet. App. 363 (1992) (where VA has actual notice of the existence of records held by SSA which appear relevant to a pending claim, VA has a duty to assist by requesting those records from SSA). Accordingly, on remand, the Veteran’s complete SSA records and/or state determinations, including all administrative decision(s) on his application for disability benefits and all underlying medical records, should be obtained on remand. With regard to the Veteran’s claim for service connection for pediculosis pubis, the Veteran was afforded a VA examination in November 2013. At such time, the examiner noted February 2013 diagnoses of tinea corporis and tinea cruris, and a January 1983 diagnosis of pediculosis pubis, which the examiner noted as non-recurrent. The examiner further noted the Veteran’s reports that believed his current disorders are related to his in-service groin rash. The Veteran also reported that there had been no diagnosis or treatment for pediculosis pubis since 1983 and there was improvement in the rash, but he still experienced itching. Therefore, the examiner concluded that it was less likely than not that currently diagnosed tinea corpora and tinea pedis were related to the in-service episode of pediculosis pubis. As rationale, the examiner explained that the Veteran’s service treatment records (STRs) showed only a parasitic infection and no other visits for any diagnosed tinea yeast/fungal infections. The examiner continued that, later medical records contained no mention of recurrent pediculosis, and tinea infections treated in 2013 are unrelated and caused by a different organism. However, it appears that the November 2013 VA examiner’s opinion was based on the inaccurate factual premise that the Veteran’s STRs contained no other visits for any diagnosed tinea yeast/fungal infections. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis). In this regard, the Veteran’s STRs reveal that in June 1981 he had a rash in the groin area, with a possible yeast infection. Additionally, in August 1981, he the examiner assessed jock itch. Post-service VA treatment records show that, in September 1987, the Veteran reported jock itch for the past few weeks and he was assessed with tinea pedis, tinea versicolor, and tinea cruris. Additionally, in February 1998, he reported groin itching and was diagnosed with tinea cruris and tinea pedis. Moreover, in July 2001, he complained of an itchy rash in the groin area. He also stated that he had the problem for about 20 years. Thus, an addendum opinion addressing direct service connection must be obtained. With regard to the Veteran’s claim for service connection for an acquired psychiatric disorder, to include PTSD, depressive disorder, and anxiety disorder NOS, the Veteran contends that such disorder is directly related to his military service. Specifically, in a June and July 2011 statement from the Veteran, he stated that, while he was stationed in Fort Riley, Kansas, he was infected with a case of “giant crabs” and his acquired psychiatric disorder was due to such infestation. In this regard, he contends that since that day, he scratches excessively in the groin area, which has resulted in him bleeding. Moreover, he fears that one day it will be cancer and even though the crabs are not there, his mind says they are still present, thus, he continues to scratch in the area. In this regard, the Veteran’s STRs are silent as to any complaints, treatment, or diagnoses referable to an acquired psychiatric disorder. However, his STRs indicated that he was infected with crabs in January 1983. Moreover, his post-service treatment records indicate that he has been diagnosed with an acquired psychiatric disorder, including depressive disorder and anxiety disorder NOS. Accordingly, the Board finds that the low threshold of the McLendon standard has been met in this instance, and that a remand is necessary to afford the Veteran a VA examination and opinion to determine the nature and etiology of his acquired psychiatric disorder. See McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). With regard to the Veteran’s remaining claims of new and material evidence and service connection for frostbite residuals to the upper thigh, as indicated above, an attempt to obtain outstanding records is necessary. The matters are REMANDED for the following action: 1. Any determination pertinent to the Veteran’s claim for SSA benefits and/or disability insurance from the State of Missouri, as well as any medical records relied upon concerning that claim, should be obtained from SSA and associated with the claims file. All reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A (b)(2) and 38 C.F.R. § 3.159 (e). 2. Request any outstanding VA treatment records from VAMC in St. Louis, Missouri, since December 2013. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159 (e). 3. After all outstanding records have been obtained, return the record to the VA examiner who conducted the November 2013 examinations. The record and a copy of this Remand must be made available to the examiner. If the November 2013 VA examiner is not available, the record should be provided to an appropriate medical professional so as to render the requested opinion. The need for an additional examination of the Veteran is left to the discretion of the examiner selected to write the opinion. Following a review of the record, the examiner is requested to address the below inquiry: (A) Is it at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s skin disorder had its onset in, or is otherwise related to, his military service, to include his June 1981 in-service complaints of a rash in the groin area, with a possible yeast infection, and his August 1981 assessment of jock itch. The examiner should also consider the Veteran’s post-service VA treatment records. In this regard, in September 1987, he was assessed with tinea pedis, tinea versicolor, and tinea cruris, and, in February 1998, he was diagnosed with tinea cruris and tinea pedis. In July 2001, he complained of an itchy rash in the groin area for the past 20 years. 4. Schedule the Veteran for a VA examination to determine the nature and etiology of his acquired psychiatric disorder. The record, to include a copy of this Remand must be made available to and be reviewed by the examiner. Any indicated evaluations, studies, and tests should be conducted. Following a review of the record, the examiner should address the following inquiries: (A) Identify all of the Veteran’s acquired psychiatric disorders present at any time since April 2011, or in close proximity thereto, to include depressive disorder and anxiety disorder NOS, as evidenced by his treatment records. (B) Please indicate whether the alleged fear the Veteran experienced due to his infestation with “giant crabs” during service would satisfy the DSM-5’s criteria of a traumatic event for the purposes of rendering a diagnosis of PTSD. (C) If so, is it at least as likely as not that that the Veteran has a diagnosis of PTSD based on his alleged fear the Veteran experienced due to his infestation with “giant crabs” during service? (D) For each currently diagnosed acquired psychiatric disorder other than PTSD, including depressive disorder and anxiety disorder NOS, the examiner should offer an opinion as to whether it is at least as likely as not (probability of 50 percent or greater) that any such disorder had its onset in service or is related to the Veteran’s military service? (Continued on the next page)   In offering any opinion, the examiner must consider the full record, to include the Veteran’s lay statements regarding the incurrence of his claimed acquired psychiatric disorder and the recurrence of symptoms. The rationale for any opinion offered should be provided. TRACIE N. WESNER Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Brennae L. Brooks, Associate Counsel