Citation Nr: 1806356 Decision Date: 02/01/18 Archive Date: 02/14/18 DOCKET NO. 10-40 963 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUES 1. Whether new and material evidence has been received to reopen the claim of entitlement to service connection for hypertension due to exposure to environmental hazards. 2. Whether new and material evidence has been received to reopen the claim of entitlement to service connection for diabetes mellitus, type II, due to exposure to environmental hazards. 3. Whether new and material evidence has been received to reopen the claim of entitlement to service connection for skin disease, to include basal cell carcinoma and lichenoid keratosis, due to exposure to environmental hazards. 4. Entitlement to service connection for skin disease, to include basal cell carcinoma and lichenoid keratosis, due to exposure to environmental hazards. 5. Entitlement to service connection for a left foot condition, to include a left foot cavus deformity, including as secondary to the service-connected residuals, fracture of first phalanx, right little toe with cavovarus foot. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD C. Taylor, Associate Counsel INTRODUCTION The Veteran served on active duty from April 1962 to August 1966. This matter comes before the Board of Veterans' Appeals (Board) on appeal from May 2009 and April 2014 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Chicago, Illinois. Notices of Disagreement (NODs) were filed in July 2009 and July 2014. Statements of the Case (SOCs) were issued in September 2010 and May 2017. Substantive appeals (VA Form-9s) were filed in October 2010 and May 2017. In August 2017, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge (VLJ). The transcript of the hearing is of record. The Board reviewed the Veteran's electronic claims file which includes records in Virtual VA and Veterans Benefits Management System (VBMS) databases prior to rendering its decision. The issue of entitlement to service connection for a skin disease, to include basal cell carcinoma and lichenoid keratosis, due to environmental exposure, including Agent Orange exposure, and entitlement to service connection for a left foot condition, to include a left foot cavus deformity including as secondary to service-connected residuals, fracture of first phalanx, right little toe with cavovarus foot are addressed in the REMAND portion of the decision below and is REMANDED to the AOJ. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (2012). FINDINGS OF FACT 1. The Veteran's appeal to reopen the claim of entitlement to service connection for hypertension was denied in an August 2005 Board decision. 2. Evidence received since the August 2005 Board decision is either cumulative or redundant, and does not relate to an unestablished fact necessary to establish the claim, or raise a reasonable possibility of substantiating the claim of entitlement to service connection for hypertension. 3. The Veteran's claim of entitlement to service connection for diabetes mellitus, type II, was denied in an October 2001 rating decision; the Veteran did not appeal, and no new and material evidence was received within one year of the determination. 4. Evidence received since the October 2001 rating decision is either cumulative or redundant, and does not relate to an unestablished fact necessary to establish the claim, or raise a reasonable possibility of substantiating the claim of entitlement to service connection for diabetes. 5. The Veteran's claim of entitlement to service connection for a skin condition was denied in an October 2001 rating decision; the Veteran did not appeal, and no new and material evidence was received within one year of the determination. 6. Evidence received since the October 2001 rating decision is neither cumulative nor redundant of the prior evidence, and it raises a reasonable possibility of substantiating the claim of entitlement to service connection for a skin condition. CONCLUSIONS OF LAW 1. The August 2005 Board decision denied reopening the claim of entitlement to service connection for hypertension; and no new and material evidence has been received to reopen this matter. 38 U.S.C. §§ 5108, 7104 (2012); 38 C.F.R. §§ 3.104, 3.156, 20.1100 (2017). 2. The October 2001 rating decision denied entitlement to service connection for diabetes mellitus, type II, is final; and no new and material evidence has been received to reopen this matter. 38 U.S.C. §§ 5108, 7105(c) (2012); 38 C.F.R. §§ 3.104, 3.156, 20.302, 20.1103 (2017). 3. The October 2001 rating decision denied entitlement to service connection for a skin condition is final; however, new and material evidence has been received to reopen this matter. 38 U.S.C. §§ 5108, 7105(c) (2012); 38 C.F.R. §§ 3.104, 3.156, 20.302, 20.1103 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist In letters dated February 2009 and May 2013, VA notified the Veteran of the evidence required to substantiate his claim. The Veteran was informed of the evidence VA would attempt to obtain and of the evidence that the Veteran was responsible for providing. See Veterans Claims Assistance Act of 2000 (VCAA), 38 U.S.C.A. § 5103, 5103A; see also Quartuccio v. Principi, 16 Vet. App. 183 (2002); Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In a May 2017 substantive appeal (VA Form-9) statement, the Veteran asserted that the May 2017 VA examination was inadequate because the examiner was a "nurse practitioner who did not do a thorough examination" and that "due to the complexity of [his] claim . . . a podiatrist [was] the only physician" who should examine his feet. VA has a duty to assist the veteran in the development of claims. This duty includes providing an examination when necessary. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159, 3.327. Here, regarding the service connection claim for a left foot condition, the record indicates that the Veteran participated in a VA examination in May 2017, the results of which have been included in the claims file for review. The examination involved a review of the Veteran's medical records; a thorough, in-person examination of the Veteran; and the VA examiner provided a medical opinion based on the above. The Board observes that the examiner is a qualified medical professional who has the training, knowledge, and expertise on which she relied to conduct the May 2017 examination, form her medical opinion, and provide a rationale for her clinical assessment. Most importantly, the Veteran has not expressed any specific issue(s) or deficiencies with the May 2017 examination, other than his belief that the nurse practitioner was not qualified to conduct the examination. Again, the Board finds the VA medical professional qualified to conduct the Veteran's examination; and therefore, the Board finds the VA examiner and examination adequate for rating purposes. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). II. New and Material Evidence Generally, a claim which has been denied in a Board decision or an unappealed rating decision may not thereafter be reopened and allowed. 38 U.S.C. §§ 7104(b), 7105(c) (2012). An exception to this rule is 38 U.S.C. § 5108, which provides that if a claim of entitlement to service connection has been previously denied and that decision became final, the claim can be reopened and reconsidered only if new and material evidence is presented with respect to that claim. 38 U.S.C. § 5108. 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(a). VA must review all of the evidence submitted since the last final rating decision in order to determine whether the claim may be reopened. See Hickson v. West, 12 Vet. App. 247, 251 (1999). For the limited purpose of determining whether new and material evidence has been submitted, the credibility of the newly submitted evidence is presumed. See Justus v. Prinicipi, 3 Vet. App. 510, 513 (1992); see also Kutscherousky v. West, 12 Vet. App. 369, 371 (1999) (per curium) (holding that the "presumption of credibility" doctrine continues to be precedent). The presumption is rebuttable when the evidentiary assertion is inherently incredible or when the fact asserted is beyond the competence of the person making the assertion. King v. Brown, 5 Vet. App. 19, 21 (1993). Hypertension In a final, unappealed July 1998 rating decision, the RO denied the Veteran's claim of entitlement to service connection for hypertension, finding that the Veteran's hypertension was not incurred in, or caused by his service. In an October 2001 rating decision, the RO denied the issue of entitlement to reopen the Veteran's claim for hypertension. In an August 2005 decision, the Board denied the Veteran's appeal to reopen the claim for entitlement to service connection for hypertension. The Board determined that the newly associated evidence such as private treatment records spanning from December 1999-March 2001, one blood pressure reading from a July 2001 report of VA examination for diabetes, a lay statement dated in June 2002, correspondence from the Veteran and his congressional representative from January 1995 to March 2005, and statements from the Veteran and his representative, were merely cumulative of evidence that was considered at the time of the last final rating decision dated July 1998. The Board found that the evidence was neither new nor material for purposes of reopening the claim. The Board notified the Veteran of his appellate rights, but the Veteran did not file an appeal of the Board decision to the United States Court of Appeals for Veterans Claims (Court); and reconsideration, either by the Veteran or by the Board, was neither requested nor ordered with respect to the August 2005 Board decision. See 38 U.S.C. §§ 511(a), 7103, 7104(a) (2012); 38 C.F.R. § 20.1100 (2005, 2011). Accordingly, the claim may now be considered on the merits only if new and material evidence has been received since the time of the prior adjudication. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). The Veteran filed a request to reopen the claim for entitlement to service connection for hypertension in April 2007; and, by a May 2009 rating decision, the RO declined to reopen the claim. As such, the Board must decide the threshold issue of whether the Veteran submitted evidence that is new and material before addressing the merits of the claim. See Jackson v. Principi, 265 F. 3d 1366 (Fed. Cir. 2001); Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996). The relevant evidence added to the record since the August 2005 Board decision (last final denial) includes the a June 2002 statement from K.C., an employee, who worked at Southern Illinois Clinic, where the Veteran claims he was treated for hypertension after service and Veteran's August 2017 testimony. K.C. alleged that she worked at the Southern Illinois clinic from 1967-1972 and that the Veteran was treated for hypertension during that time. The Veteran testified that he was treated for hypertension in 1967, within the one year presumptive period after discharge from service, and that he is currently being treated for hypertension. The Veteran also claimed that K.C. was a nurse at Southern Illinois Clinic who could corroborate his contention that he was treated for hypertension within one year of separation. The Veteran's testimony is new, in that the hearing transcript was not previously associated with the claims file. However, because the evidence on file at the time of the August 2005 Board decision had already established that the Veteran claimed that his diagnosed hypertension incurred in service and that he was treated for hypertension within a year after separation, this evidence is not new. Additionally, the June 2002 statement from K.C. was previously associated with the claims file and considered by the Board in its August 2005 decision, the evidence is not new. K.C.'s statement does not provide recorded blood pressure readings for the Veteran such that it could be determined by those readings that the Veteran's alleged treatment for hypertension would indicate that the condition was manifest to a compensable degree within the presumptive period. As such, both K.C.'s June 2002 statement and the Veteran's lay assertions are cumulative and redundant of evidence previously considered with regard to the claim of service connection for hypertension. Such cumulative evidence does not meet the regulatory definition of new and material evidence under 38 C.F.R. § 3.156(a), and the claim of service connection for hypertension may not be reopened. Diabetes Mellitus, Type II With regard to the service connection claim for diabetes, the claim was originally denied by an October 2001 rating decision because the RO determined that the condition was not shown to be incurred in or aggravated by military service. An examination was provided in July 2001 and the examiner opined that the Veteran's diabetes could not be linked to his service. The RO notified the Veteran of its decision, and of his appellate rights, but the Veteran did not initiate an appeal of the rating decision within one year, nor was any new and material evidence received within a year. 38 C.F.R. § 3.156(b). As a result, the October 2001 rating decision became final. 38 U.S.C. §§ 7105; 38 C.F.R. §§ 3.156, 20.200, 20.201, 20.302, 20.1103. The Veteran filed a request to reopen the claim for entitlement to service connection for diabetes in April 2007; and, by a May 2009 rating decision, the RO declined to reopen the claim. The Veteran testified that his currently diagnosed diabetes is a result of his exposure to environmental hazards. Dr. C.Y. opined that the Veteran's diabetes is due to the Veteran being overweight and that exposure to Agent Orange and other chemicals during service could cause diabetes. The private treatment records indicated that the Veteran was treated for diabetes from March 2008-July 2009. The Board finds that the Veteran's testimony is new, in that the hearing transcript was not previously associated with the claims file. However, because the evidence on file at the time of the October 2001 rating decision had already established that the Veteran's diabetes was not attributable to service or that the Veteran had not provided sufficient evidence of his exposure to environmental hazards, including Agent Orange, this evidence is not new. Dr. C. Y.'s statement attributing the Veteran's diabetes to his weight does not establish that the Veteran's diabetes is attributable to his service, but merely provides a non-service related etiology of the Veteran's diabetes and then speculates as to an in-service origin. The Veteran's testimony and Dr. C. Y.'s medical opinion are cumulative, that is, supporting evidence of previously considered evidence, namely previous contentions that the Veteran was exposed to environmental hazards in service without providing sufficient evidence of exposure to environmental hazards, and are therefore, not new and material. Again, such cumulative evidence does not meet the regulatory definition of new and material under 38 C.F.R. § 3.156 (a), and the claim for service connection for diabetes mellitus is not reopened. Accordingly, the Board determines that the additional evidence received since the August 2005 Board decision and the October 2001 rating decision regarding the service connection claims from hypertension and diabetes mellitus, type II is not "new" as it is cumulative and redundant of the facts previously established by the record and thus provides no basis to reopen the claims of service connection for diabetes and hypertension. See 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). Skin Condition With regard to the claim of service connection for a skin condition, the claim was originally denied by an October 2001 rating decision because the RO determined that the condition was not shown to be incurred in or aggravated by military service. An examination was provided in July 2001 and the examiner opined that the Veteran's skin condition could not be linked to his service. The RO notified the Veteran of its decision, and of his appellate rights, but the Veteran did not initiate an appeal of the rating decision within one year, nor was any new and material evidence received within a year. 38 C.F.R. § 3.156(b). As a result, the October 2001 rating decision became final. 38 U.S.C. §§ 7105; 38 C.F.R. §§ 3.156, 20.200, 20.201, 20.302, 20.1103. The Veteran filed a request to reopen the claim for entitlement to service connection for a skin condition in April 2007; and, by a May 2009 rating decision, the RO declined to reopen the claim. As such, the Board must decide the threshold issue of whether the Veteran submitted evidence that is new and material before addressing the merits of the claim. See Jackson v. Principi, 265 F. 3d 1366 (Fed. Cir. 2001); Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996) The relevant evidence added to the record since the October 2001 rating decision (last final denial) includes private medical records dated April 1992 and November 1995, and from March 2008-July 2009, letters dated December 2011 and January 2012 from Dr. C. Y., the Veteran's private physician, the Veteran's October 2015 Statement in Support of Claim and his August 2017 testimony. The evidence submitted regarding the Veteran's service connection claim for a skin condition is new and material. During the August 2017 hearing, the Veteran testified that he worked as a barber during service and that he was exposed to hair follicles that caused his skin condition. The Veteran also testified that his military occupational specialty (MOS) as Automotive Mechanic exposed him to fuel and engine oil that caused his skin condition. Presuming its credibility, this evidence is new as it was not previously submitted and/or considered by agency decision-makers and is material as it provides a more detailed description of the facts and circumstances of the Veteran's service that relates to the unestablished fact regarding a causative factor for the Veteran's skin condition. As such, the evidence is new and material and sufficient to reopen the claim of service connection for a skin condition. 38 C.F.R. § 3.156(a). ORDER As new and material evidence has not been received, the claim of entitlement to service connection for hypertension is not reopened and the appeal is denied. As new and material evidence has not been received, the claim of entitlement to service connection for diabetes mellitus, type II, is not reopened and the appeal is denied. As new and material evidence has been received, the claim of entitlement to service connection for a skin condition, to include basal cell carcinoma and lichenoid keratosis, due to environmental exposure, including Agent Orange exposure is granted to this extent. REMAND Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the appealed issues of entitlement to service connection for a skin condition, to include basal cell carcinoma and lichenoid keratosis, due to environmental exposure, including Agent Orange exposure, and entitlement to service connection for a left foot condition, to include left foot cavus deformity, as secondary to the service-connected residuals, fracture of first phalanx, right little toe with cavovarus foot. Skin Condition The Veteran contends that his current skin condition is a result of environmental exposures, which he now describes as hair follicles and fuel and engine oil, during service. The existence of a present disability is established through the Veteran's medical treatment records and examination reports produced during the course of his appeal. These records contain a diagnosis of a skin condition variously diagnosed as basal cell carcinoma, lichenoid keratosis, and superficial perivascular and interstitial dermatitis, mixed. As noted above, the Veteran testified that he worked as a barber during service and that he was exposed to hair follicles. The Veteran also testified that his military occupational specialty (MOS) as Automotive Mechanic exposed him to fuel and engine oil. In this regard, the service record does tend to support that the Veteran performed the duties of both a barber and an automotive mechanic during service, the duties and types of exposure of which the Veteran has described would be consistent the circumstances of his service. 38 U.S.C. § 1154(a) (2012). Resolving all reasonable doubt in the Veteran's favor, the Board finds that the record evidence is sufficient to support an in-service element, i.e., exposure to hair follicles and fuel and engine oil. However, the remaining inquiry is whether the record evidence is sufficient to support the incurrence of a skin condition in service or as a result of service. A July 1990 private treatment record indicated that the Veteran sustained 1st and 2nd degree burns on his abdomen and right thigh. The Veteran reported that he spilled hot coffee on his abdomen and right thigh. Private treatment records indicated that the Veteran was diagnosed with basal cell carcinoma in April 1992 and lichenoid keratosis in November 1995. A January 2001 VA examination reported indicated that the Veteran reported that while in Jordan for training, a chemical was placed on his arm and caused a rash to develop. Skin examination revealed brown pigmentation on the Veteran's lower extremities, with a darker brown pigmentation on the lateral left lower leg. The Veteran stated that the pigmentation was from a rash that he has had for several years. The Veteran described the rash as chronic and itchy. The Veteran reported that treatments have not cleared-up the rash, but it did alleviate the itching. The examiner did not observe any open sores/lesions An August 2014 VA treatment note indicated that the Veteran underwent a punch biopsy of the right arm. The Veteran was diagnosed with superficial perivascular and interstitial dermatitis, mixed. During the August 2017 hearing, the Veteran testified that he worked as barber aboard several naval ships and was exposed to hair follicles, oftentimes from individuals whom the Veteran described as having "dirty and/or matted" hair. The Veteran contends that the "dust from the hair caused [his] skin condition." The Veteran also testified that he handled, and therefore was exposed to, environmental hazards, such as fuel and motor oil because of his MOS. The Veteran testified that he was an S1 driver and that he drove military vehicles in in areas that may have been sprayed with pesticides and other chemicals all of which exposed him to environmental hazards and resulted in his skin condition. A review of the treatment records and the Veteran's statements indicated that he continued treatment for a skin condition since July 1990. The Veteran contends that he has continued treatment for a skin condition since separation. The Veteran has not been afforded a VA examination in connection with his claim. VA has a duty to provide a VA examination when the record lacks evidence to decide the Veteran's claim and there is evidence of: 1) a current disability; 2) an in-service event, injury, or disease; and 3) some indication that the claimed disability may be associated with the established event, injury, or disease. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). In this case, there is evidence of a current disability and evidence that the disability may be related to service, but the medical evidence is insufficient to decide the claim. Therefore, an examination is warranted under McLendon. Left Foot Disability The Veteran contends that his left foot condition can be attributed to his service-connected residuals, fracture of first phalanx, right little toe with cavovarus foot. The existence of a present disability is established through the Veteran's medical treatment records and examination reports produced during the course of his appeal. These records contain a diagnosis of a left foot condition, variously diagnosed as left foot fracture; paronychia, left great toe; pes cavus; and metatarsalgia. The service treatment records revealed no abnormalities attributed to a left foot condition or related symptoms. However, the remaining inquiry is whether the evidence is sufficient to support the incurrence of, or aggravation of, a left foot condition, including as secondary to the Veteran's service-connected residuals, fracture of first phalanx, right little toe with cavovarus foot. The Veteran fractured his left foot in July 2003. The Veteran was diagnosed with left great toe fungus in April 2006. An April 2008 VA treatment note indicated that the Veteran was diagnosed with paronychia, left great toe. The Veteran reported that his left great toe was painful and swollen, and denied any injury to the toe. In April 2010, the Veteran was afforded a VA examination in which he was diagnosed with pes cavus, left foot. The Veteran's gait was slightly antalgic because he favored the right foot. The examiner described the Veteran's right foot as slightly rotated out; the toes did not make contact with the ground through toe strike; and the Veteran's weight was placed on the ball of his foot. In May 2013, the Veteran was diagnosed with bilateral cavus foot deformity and metatarsalgia. VA examined the Veteran in April 2014. The Veteran was diagnosed with metatarsalgia of the left foot and his left foot pes cavus diagnosis was confirmed. The Veteran reported that his left foot condition was due to his service-connected right foot disability. The examiner conducted an in-person examination, did not review the Veteran's claims file, but reviewed the CRPS records. The examiner determined that it is less likely than not that the Veteran's left foot condition is proximately due to or the result of his service-connected residuals of fracture right first phalanx (right little toe). According to the examiner, current medical literature does not support a right little toe fracture residuals in one foot causing cavus deformity or metatarsalgia in the contralateral foot. The examiner explained that pes cavus is typically a hereditary disorder but can also be caused from neurological or neuromuscular disorders, which subsequently leads to metatarsalgia due to a high arch, which causes metatarsal compression, leading to pain. In an April 2014 addendum medical opinion, the examiner opined that it is less likely as not that the Veteran's left foot condition is related to his service-connected right foot condition. The examiner rendered the clinical assessment that "claw foot on one side does not produce claw foot on the other side." The examiner expounded on the fact that the foot itself has to be abnormal because of trauma to produce claw foot. In fact, according to the examiner, the Veteran sustained an injury to his left foot in July 2003 while working on a farm when the tongue of a two ton air conditioner fell on his left foot causing a fracture. The examiner emphasized the fact that there was no left foot injury or abnormality noted in the Veteran's service medical records. In May 2017, the Veteran was afforded a VA examination and his left foot diagnoses were confirmed. The Veteran reported intermittent left midfoot pain with prolonged standing and walking with onset of 10-15 years prior. The Veteran reported that he sustained a fracture of the 2nd, 3rd, and 4th metatarsals of the left foot in August 2003 after dropping an air conditioner tongue on his foot. Upon examining the Veteran and reviewing the claims file, the examiner rendered the clinical assessment that it is not likely that the Veteran's left foot condition was aggravated beyond the expected progression by the Veteran's service-connected right foot disability. According to the examiner, the right foot digit fractures healed without complications. In the absence of medical evidence of any significant residuals or sequalae of the in-service right foot phalanx fracture, there is no science-based rationale for any aggravation of the left foot metatarsalgia beyond the expected progression. The examiner opined that the far more likely cause of the Veteran's left midfoot pain is residuals of the healed 2nd, 3rd, and 4th metatarsal fractures from the 2003 injury. The examiner explained that she based her opinion on the Veteran's clinical history, clinical examination findings, and upon the fact that the Veteran's bilateral foot problems/complaints are significantly improved by the built-up orthotic shoes which have been provided for treatment of his bilateral pes cavus and metatarsalgia conditions. The examiner explained that the Veteran's minor residual tenderness and complaint at the left metatarsalgia dorsum areas correspond to the 2003 healed fracture sites. In statements and during the August 2017 hearing, the Veteran contended that his left foot condition was due to his service-connected right foot disability. The Veteran claimed that his May 2017 VA examination was inadequate because the examiner was a nurse practitioner and not a podiatrist. The Veteran subsequently requested an examination with a "specialist or podiatrist." During the hearing, the Veteran testified that his gait was altered due to his service-connected right foot disability, that he wore orthotic shoes, and falls when he does not wear them. Notably the April 2014 examiner expounded on the fact that claw foot is not caused by claw foot of the contralateral foot. Most critically, the examiner highlighted that when claw foot occurs, the foot itself has to be abnormal due to trauma. The examiner emphasized that the Veteran fractured his left foot in 2003 when a two ton air conditioner tongue fell on his foot. With regard to whether or not the Veteran's left foot condition was aggravated by his service-connected right foot condition, the May 2017 examiner attributed the Veteran's left foot condition to the 2003 left foot fracture. The examiner rendered the clinical assessment that the Veteran's left midfoot pain is residuals of the healed 2nd, 3rd, and 4th metatarsal fractures sustained in 2003. The examiner rendered the clinical assessment that in the absence of medical evidence of any significant residuals or sequalae of the in-service right foot phalanx fracture, there is no science-based rationale for any aggravation of the left foot metatarsalgia beyond the expected progression. According to the examiner, the Veteran's minor residual tenderness and complaint of pain at the left metatarsalgia dorsum area correspond to the 2003 healed fracture sites. The Board finds that an addendum medical opinion is needed to determine whether the Veteran's left foot cavus foot deformity is aggravated by his service-connected right foot disability. The May 2017 VA examiner only addressed whether the Veteran's left foot metatarsalgia was aggravated by his service-connected right foot disability. A medical opinion is needed to determine if the Veteran's left foot pes cavus is aggravated by his service-connected right foot disability. Accordingly, the case is REMANDED for the following action: 1. The AOJ should ask the Veteran to identify the provider(s) of any and all evaluations and/or treatment he has received for his skin and left foot conditions and to provide authorizations for VA to obtain records of any such private treatment. The AOJ should obtain for the record complete clinical records of all pertinent evaluations or treatment (records of which are not already of record) from the providers identified. If any records sought are unavailable, the reason for their unavailability must be noted in the record. If a private provider does not respond to the AOJ's request for identified records sought, the Veteran must be so notified, and reminded that ultimately it is his responsibility to ensure that private records are received. 2. After instruction (1) is completed, the AOJ should schedule the Veteran for a VA dermatology examination to determine the nature and cause of any skin disorder shown by the record, to include basal cell carcinoma, lichenoid keratosis, and superficial perivascular and interstitial dermatitis, mixed. The claims folder must be provided to the examiner for review. The examiner must state in the examination report that the claims folder has been reviewed. Based on a full review of the record, to include the Veteran's lay statements regarding the incurrence and symptomatology of his skin disorder, please answer the following: a) Please identify (by diagnosis) each skin disorder shown by the record, to specifically include basal cell carcinoma, lichenoid keratosis, and superficial perivascular and interstitial dermatitis, mixed. b) Please identify the likely cause for each skin disorder entity diagnosed (to specifically include basal cell carcinoma, lichenoid keratosis, and superficial perivascular and interstitial dermatitis, mixed). Specifically, is it at least as likely as not (a 50 percent or greater probability) that any such disorder began in (or is otherwise related to) the Veteran's military service? **In so responding, the examiner should consider the testimony from the Veteran that he was exposed to hair follicles as barber and exposed to fuel and motor oil as a automotive mechanic, and his statement that he was exposed to chemical pesticides as a driver during service. In this context, while the exposures described by the Veteran are not documented in the service treatment records, the examiner is asked to comment on whether the pathology of any skin disorder that he now has is consistent with the kind of exposures described and detailed in the testimony and statement from the Veteran. If a skin disorder shown is deemed to be unrelated to service, the examiner should, if possible, identify the cause considered more likely and explain why this is so. A detailed explanation (rationale) is requested for all opinions provided, citing to supporting clinical data and/or medical literature, as appropriate. (Providing an opinion or conclusion without a thorough explanation will delay processing of the claim or may also result in a clarification opinion being requested). 2. After instruction (1) is completed, obtain an addendum opinion to the May 2017 VA examination, with respect to the Veteran's left foot disability. The examiner is requested to review all pertinent records associated with the claims file. The examiner should state that the claims file was reviewed. The examiner should respond to the following: a) Please identify (by diagnosis) each left foot disorder shown by the record, to specifically include left foot cavus deformity and metatarsalgia. b) Please identify the likely cause for any left foot disorder entity diagnosed, to include left foot cavus deformity and metatarsalgia. Specifically, is at least as likely as not (a 50 percent or greater probability) that any such disorder, to include left foot cavus deformity and metatarsalgia, progressed at a greater rate than normally expected (i.e., aggravated) due to or as a result of the Veteran's service-connected residuals, fracture of first phalanx, right little toe with cavovarus foot? If a left foot disorder, to include left foot cavus foot deformity and metatarsalgia, is not deemed to be proximately due to or aggravated (worsened beyond its natural progression) by his service-connected residuals, fracture of first phalanx, right little toe with cavovarus foot right, the examiner should, if possible, identify the cause considered more likely and explain why this is so. A detailed explanation (rationale) is requested for all opinions provided, citing to supporting clinical data and/or medical literature, as appropriate. (Providing an opinion or conclusion without a thorough explanation will delay processing of the claim or may also result in a clarification opinion being requested). 3. Then, the AOJ should review the record, conduct any additional development deemed necessary, and readjudicate the claims. If the claims remain denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. The case should be returned to the Board for further appellate consideration, if otherwise in order. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ____________________________________________ DEBORAH W. SINGLETON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs