Citation Nr: 1808005 Decision Date: 02/08/18 Archive Date: 02/20/18 DOCKET NO. 14-18 536 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Whether new and material evidence has been received to reopen a claim of service connection for hypertension. 2. Whether new and material evidence has been received to reopen a claim of service connection for erectile dysfunction. 3. Whether new and material evidence has been received to reopen a claim of service connection for a vision disability. 4. Entitlement to service connection for fibromyalgia. 5. Entitlement to service connection for a respiratory disability (claimed as asthma or reactive airway disease). 6. Entitlement to service connection for a neurocognitive disability. 7. Entitlement to service connection for hypertension. 8. Entitlement to service connection for erectile dysfunction. 9. Entitlement to service connection for a vision or eye disability. 10. Entitlement to compensation under 38 U.S.C. § 1151 for methicillin-resistant staphylococcus aureus (MRSA) (claimed as boils or furuncles). 11. Entitlement to a rating in excess of 20 percent for service-connected cervical strain with headaches (neck disability). 12. Entitlement to a rating in excess of 10 percent for pseudofolliculitis barbae (PFB). [The matter of whether an award of attorney's fees (from past-due benefits based on a July 2013 rating decision to the Veteran's former attorney) is proper is addressed in a separate decision] REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD M. Yuan, Associate Counsel INTRODUCTION The appellant is a Veteran who served on active duty from March 1989 to March 1993 with subsequent Reserve service. His service personnel records confirm that he served with Fleet Hospital Five in Saudi Arabia from February 1990 to January 1991. These matters are before the Board of Veterans' Appeals (Board) on appeal from June 2010 and September 2011 decisions of a Department of Veteran Affairs (VA) Regional Office (RO). The Board notes that the matters of entitlement to service connection for posttraumatic stress disorder (PTSD), anxiety, and depression, entitlement to a total disability rating based on individual unemployability (TDIU), and entitlement to nonservice-connected pension (NSCP) were also previously on appeal. However, an October 2012 rating decision granted service connection for the Veteran's acquired psychiatric disability (specifically encompassing PTSD and depressive features) and a July 2013 rating decision granted TDIU (rendering moot the matter of nonservice-connected pension, as the Veteran's service-connected disabilities are considered totally disabling). The Veteran has not disagreed with any of those decisions. Thus, they are no longer before the Board. With respect to the reopened claim of service connection for a vision disability, the Board's review of the record has revealed both eye and vision diagnoses; thus, it has recharacterized the downstream claim as indicated above to afford the Veteran the broadest scope of review. See Clemons v. Shinseki, 23 Vet. App. 1, 5-6 (2009). The issues of service connection for hypertension, vision or eye disability, fibromyalgia, and asthma or respiratory disease, entitlement to 38 U.S.C. § 1151 compensation for MRSA, increased ratings for neck disability and PFB, and the propriety of payment of attorney fees are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. An unappealed December 2004 rating decision denied the Veteran service connection for hypertension based essentially on a finding that such disability was not related to service. 2. Evidence received since that denial includes new allegations that hypertension is related to the Veteran's time in the Persian Gulf and an August 2013 VA examination report indicating that hypertension may either have been incurred during active duty in the Veteran's Reserve service or, alternatively, be secondary to a service-connected disability; relates to unestablished facts necessary to substantiate the underlying claim of service connection; and raises a reasonable possibility of substantiating that claim. 3. An unappealed December 2004 rating decision denied the Veteran service connection for erectile dysfunction based essentially on a finding that such disability was not shown to be related to the Veteran's service or service-connected disabilities. 4. Evidence received since that denial includes new allegations that erectile dysfunction is related to the Veteran's time in the Persian Gulf, new VA treatment records suggesting erectile dysfunction is due to an episode of priapism secondary to Trazodone use and that Trazodone was prescribed for sleep difficulties associated with service-connected PTSD, and an August 2013 VA opinion indicating that medications such as Sertraline (which is prescribed for the Veteran's PTSD) may cause erectile dysfunction; relates to unestablished facts necessary to substantiate the underlying claim of service connection; and raises a reasonable possibility of substantiating that claim. 5. An unappealed November 1993 rating decision denied the Veteran service connection for a vision disability based essentially on a finding that no compensable vision or eye disability was found, because his documented myopic astigmatism constituted refractive error, which is a noncompensable developmental defect; a subsequent July 1998 rating decision declined to reopen the matter because new and material evidence had not been received; following submission of new evidence and allegations pertaining to the nature and cause of the Veteran's alleged disability, an unappealed December 1998 rating decision continued to deny service connection for myopic astigmatism because it remained a noncompensable developmental defect. 6. Evidence received since the prior final denial (in December 1998) includes new allegations that the Veteran's vision disability is related to the Veteran's time in the Persian Gulf and that he has developed new disabilities, including "holes" in his eyes and updated VA treatment records showing diagnoses of lattice degeneration with atrophic holes and dry eye syndrome; relates to unestablished facts necessary to substantiate the underlying claim of service connection; and raises a reasonable possibility of substantiating that claim. 7. VA treatment records reasonably show that the Veteran's erectile dysfunction is related to an episode of priapism treated in December 2010 that, in turn, was deemed secondary to his use of Trazodone; that Trazodone was prescribed to help the Veteran sleep; and that the Veteran's service-connected PTSD symptoms include chronic sleep impairment; moreover, the August 2013 VA opinion indicates that medications such as Sertraline (a psychiatric medication prescribed to treat PTSD symptoms) may cause the Veteran's erectile dysfunction. 8. VA treatment records clearly show that neuropsychological evaluations found cognitive disruption secondary to service-connected PTSD and that he was formally diagnosed with cognitive disorder not otherwise specified (NOS) secondary to service-connected PTSD. CONCLUSIONS OF LAW 1. New and material evidence has been received; service connection for hypertension may be reopened. 38 U.S.C. §§ 5108, 7105 (2014); 38 C.F.R. § 3.156 (2017). 2. New and material evidence has been received; service connection for erectile dysfunction may be reopened. 38 U.S.C. §§ 5108, 7105 (2014); 38 C.F.R. § 3.156 (2017). 3. New and material evidence has been received; service connection for a vision or eye disability may be reopened. 38 U.S.C. §§ 5108, 7105 (2014); 38 C.F.R. § 3.156 (2017). 4. Service connection for erectile dysfunction is warranted. 38 U.S.C. §§ 1110, 1131, 5107 (2014); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2017). 5. Service connection for a neurocognitive disability is warranted. 38 U.S.C. §§ 1110, 1131, 5107 (2014); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2017). ORDER The appeal to reopen service connection for hypertension is granted. The appeal to reopen service connection for erectile dysfunction is granted. The appeal to reopen service connection for an eye disability is granted. Service connection for erectile dysfunction is granted. Service connection for neurocognitive disability is granted. REMAND Regrettably, additional development is still needed before the Board may adjudicate the remaining matters on appeal. First, the Board notes that the Veteran has broadly alleged that his disabilities are either related to his active duty service or, alternatively, to exposure during his time in the Persian Gulf (to toxins such as aflatoxins and trichothecene) or qualifying service (for VA purposes) during his time in the Reserves. However, it is unclear at this juncture whether the Veteran did have such qualifying service and, if so, when such service occurred. Thus, development to answer those questions is needed. In addition, there are no medical opinions in the record which consider the Veteran's allegations regarding environmental or toxic exposures in the Persian Gulf-thus, new examinations and opinions are required to address this developmental oversight. Turning to the substantive evidence, the Board notes that while the Veteran was examined in August 2013 for hypertension, the nexus opinion rendered at that time is not adequate to decide the claims because the opinion indicates that hypertension is related to the Veteran's service, but then states in the rationale that it is, in fact, unrelated to his active service. Moreover, while the examiner felt that hypertension was at least as likely as not incurred during active Reserve service in 1998, he acknowledged that he had no idea whether such qualifying service even exists. Similarly, the examiner also indicated that hypertension is secondary to a service-connected disability, but included no further explanation. Moreover, there is no opinion of record addressing the Veteran's contentions regarding his exposures and service in the Persian Gulf. Thus, a new opinion is needed to clarify the likely cause of the Veteran's hypertension. A review of the record shows that the Veteran has yet to be examined in conjunction with his claimed vision or eye disability. While the Board acknowledges that this is likely because the AOJ has determined on multiple occasions that the Veteran's documented myopic astigmatism is a noncompensable refractive error under 38 C.F.R. § 3.303, a review of the record shows additional disabilities, including dry eye syndrome and lattice degenerative with atrophic holes, that have not been considered in earnest. This is particularly troubling given his STRs do note eye complaints in March 1989 (of sore, scratchy, itchy, and watery eyes). Moreover, as noted above, any opinion obtained must also discuss the Veteran's alleged exposures in the Persian Gulf and consider any pertinent evidence from verified periods of qualifying Reserve service. Thus, a VA examination is needed. The Veteran also alleges he has fibromyalgia that should be presumptively service-connected based on his service in the Persian Gulf (citing 38 U.S.C. § 1117). While he is correct in asserting that fibromyalgia would be presumptively service-connected under that section, there is, unfortunately, no conclusive diagnosis of fibromyalgia documented for the record. A review of his treatment records reveals several notations of myalgias, myositis, and myofascial pain, as well as allegations of several assorted symptoms (including fatigue, muscle and joint pain, and dry mouth). However, no examination has been conducted to determine whether such findings confirm that he indeed has fibromyalgia, an undiagnosed illness, or another chronic multisymptom illness of unknown cause. Alternatively, if he is found to have a diagnosable disability that is not a chronic multisymptom illness of unknown cause, the Board would require a nexus opinion addressing the cause of that disability and the Veteran's various contentions. Thus, a VA examination is needed. The Veteran has not yet been afforded an examination for his asthma or respiratory disease, despite the fact that his VA treatment records confirm diagnoses of asthma and reactive airway disease and the Veteran has provided several allegations linking such disability to his military service, particularly in the Persian Gulf. Moreover, a review of the records shows the Veteran was also diagnosed with bronchospasms in 2000. Thus, there is a lingering medical question as to whether a relationship exists between the Veteran's asthma or reactive airway disease and his military service, to include active Reserve duty. Thus, a VA examination is needed. The only VA opinion addressing the Veteran's MRSA was provided in August 2011. At that time, the examiner opined that the Veteran was appropriately treated for boils when first seen and recurrent boils were not obvious on his next visit to VA providers. However, there are several problems with this opinion. First, the Board notes that it does not adequately answer the threshold question in such cases, which is whether the Veteran's additional disability (in this case MRSA, which was confirmed by a nasal swab test) is the result of training, hospital care, medical or surgical treatment, or an examination by VA. To that end, the Board notes that the Veteran and his wife have alleged that his boils (that are apparently a conceded symptom of his MRSA) first appeared following VA's administration of steroid treatments for reactive airway disease and asthma. The August 2011 opinion does not address this alleged cause at all. Moreover, the Veteran and his wife further alleged that his doctor was unable to diagnose the lesions at the time and characterized them as sebaceous cysts. However, he and his wife quickly learned they were contagious, as his wife began developing them in the same areas. According to them, multiple attempts to have this problem treated, beginning in February 2009 (when they first arose), were met with subpar concern from their local VA clinic in Oxford, Alabama. They alleged that the Oxford clinic initially offered no treatment and told them to go to the Birmingham VA medical center instead, citing their inability to test for staph infections at the clinic. In November 2009, the Veteran's wife said she saw her own physician and was diagnosed with a contagious staph infection based on symptoms that were identical to her husband's. When they returned to the Oxford clinic, they were again rerouted to the Birmingham facility, where a nasal swab test eventually confirmed a diagnosis of MRSA. The Veteran and his wife allege that this problem could have been prevented had the Veteran's condition been treated when he initially presented with complaints in February 2009. At no point does the August 2011 opinion address any of these contentions in opining as to the standard of care offered at VA, or provide any context as to what the normal, expected, or reasonable standard of care in such situations would be. Thus, the Board finds that a new opinion is needed. Regarding his increased rating claims, the Board notes that the Veteran was last examined for his neck and PFB disabilities in August 2013, over four years ago. However, he has continued to receive treatment for such disabilities. Moreover, his neck disability involves arthritis, which is, by its nature, degenerative. Thus, a contemporaneous examination is needed. Finally, the Board notes that multiple submissions from the Veteran indicate that he has been deemed disabled by the Social Security Administration (SSA), though the basis of such determination is unclear. As a result, the Board finds that any and all records associated with that SSA decision should be obtained, as they may include pertinent information regarding the disabilities on appeal and are constructively of record. Accordingly, the case is REMANDED for the following action: 1. Conduct exhaustive development to obtain complete copies of the Veteran's service personnel files, to include all records pertaining to his Reserve service. The AOJ must document its efforts to obtain such records. If any records sought are unavailable, the AOJ should issue a formal finding documenting such fact and the reason for such unavailability. 2. ONLY AFTER the above development is completed, the AOJ should issue a formal finding identifying the dates of ALL PERIODS OF ACDUTRA, INACDUTRA, OR OTHER SERVICE QUALIFYING FOR VA BENEFITS during the Veteran's Reserve service. 3. Obtain all updated records of VA or adequately identified private evaluations or treatment the Veteran has received for the disabilities remaining on appeal. 4. Obtain all records associated with the Veteran's claim or claims before the SSA, to include any final determinations, evaluations, or medical records considered during the adjudication of such claims. 5. Then, the AOJ should forward the Veteran's entire record to a cardiologist or other appropriate physician for a supplemental medical opinion regarding the etiology of his hypertension. The AOJ MUST PROVIDE the examiner a list of ALL VERIFIED PERIODS OF SERVICE QUALIFYING FOR VA BENEFITS. Based on a review of the entire record, the consulting physician should opine as to the following: a. Is it AT LEAST AS LIKELY AS NOT (A 50 PERCENT PROBABILITY OR GREATER) that the Veteran's hypertension is related to his military service, to include elevated blood pressures noted during any periods of service THAT QUALIFY for VA benefits, as identified by the AOJ? In so finding, the examiner must not only consider whether there is evidence of hypertension, but also whether earlier notations of elevated blood pressure may reflect early manifestations of hypertension, even if they do not yet rise to the level of persistence required for a mature diagnosis of such disability. b. Is it AT LEAST AS LIKELY AS NOT (A 50 PERCENT PROBABILITY OR GREATER) that the Veteran's hypertension is related to his alleged exposure to toxins (such as aflatoxins and trichothecene) or other environmental factors during his time in the Persian Gulf? c. Is it AT LEAST AS LIKELY AS NOT (A 50 PERCENT PROBABILITY OR GREATER) that the Veteran's hypertension is CAUSED OR AGGRAVATED (WORSENED BEYOND ITS NATURAL PROGRESSION) BY any of his service-connected disabilities (PTSD with depressive features, cervical strain with headaches, temporomandibular joint syndrome, pseudofolliculitis barbae, lumbar strain, hemorrhoids, and anal fissure)? A detailed explanation (rationale) is requested for all opinions provided. (By law, the Board is not permitted to rely on any conclusion that is not supported by a thorough explanation. Providing an opinion or conclusion without a thorough explanation will delay processing of the claim and may also result in a clarification being requested). 6. Then, arrange for the Veteran to be examined by an ophthalmologist to determine the nature and likely cause of his alleged vision or eye disability. The AOJ MUST PROVIDE the examiner a list of ALL QUALIFYING PERIODS OF RESERVE SERVICE. Based on an examination, review of the record, and any tests or studies deemed necessary, the examiner should provide opinions responding to the following: a. Please identify, by diagnosis, each eye or vision disability entity found. The examiner must reconcile all diagnoses with conflicting evidence in the record, to specifically include notations of myopic astigmatism, lattice degeneration with atrophic holes, and dry eye syndrome in his VA treatment records. In so finding, the examiner should also indicate whether the Veteran has signs and symptoms of a vision or eye disability that, by history, physical examination, and laboratory tests, cannot be attributed to a known diagnosis. b. For each diagnosable vision or eye disability identified, please indicate whether such is a compensable disability or a noncompensable developmental or congenital defect. c. Please also indicate whether any diagnosed disability constitutes a medically unexplained chronic multisymptom illness. The examiner should note that a medically unexplained chronic multisymptom illness is a diagnosed illness without conclusive pathophysiology or cause, characterized by overlapping symptoms and signs, with features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multisymptom illnesses of partially understood etiology and pathophysiology, such as diabetes and multiple sclerosis, will not be considered medically unexplained. d. For each diagnosable vision or eye disability identified, please also opine as to whether it is AT LEAST AS LIKELY AS NOT (A 50 PERCENT PROBABILITY OR GREATER) that such disability is related to the Veteran's military service, to include the notations of scratchy, itchy, and watery eyes therein, the Veteran's own allegations of environmental and toxic exposures (such as aflatoxins and trichothecene) in the Persian Gulf, and any confirmed periods of qualifying Reserve service. A detailed explanation (rationale) is requested for all opinions provided. (By law, the Board is not permitted to rely on any conclusion that is not supported by a thorough explanation. Providing an opinion or conclusion without a thorough explanation will delay processing of the claim and may also result in a clarification being requested). 7. Then, arrange for the Veteran to be examined by an appropriate physician to determine the nature and likely cause of his alleged fibromyalgia. The AOJ MUST PROVIDE the examiner a list of ALL QUALIFYING PERIODS OF RESERVE SERVICE. Based on an examination, review of the record, and any tests or studies deemed necessary, the examiner should provide opinions responding to the following: a. Does the Veteran have fibromyalgia? In so finding, the examiner should consider the notations of myalgias, myositis, fatigue, joint pains, dry mouth, and other assorted symptoms in the record. b. If not, does the Veteran have a disability characterized by myalgias, myositis, fatigue, joint pains, dry mouth, or any other symptoms (either together, alone, or in any combination) that, by history, physical examination, and laboratory tests, cannot be attributed to any known diagnosis? c. If the Veteran's reported symptoms can be attributed to any known diagnoses, please identify those diagnoses (as well as the corresponding reported symptoms). Then, please respond to the following: i. For each diagnosable disability entity, please indicate whether such is a medically unexplained chronic multisymptom illness. The examiner should note that a medically unexplained chronic multisymptom illness is a diagnosed illness without conclusive pathophysiology or cause, characterized by overlapping symptoms and signs, with features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multisymptom illnesses of partially understood cause and pathophysiology, such as diabetes and multiple sclerosis, will not be considered medically unexplained. ii. For each diagnosable disability entity, please also opine as to whether such diagnoses are related to the Veteran's military service, to include his allegations of environmental and toxic exposures (such as aflatoxins or trichothecene) in the Persian Gulf or any confirmed periods of QUALIFYING Reserve service. A detailed explanation (rationale) is requested for all opinions provided. (By law, the Board is not permitted to rely on any conclusion that is not supported by a thorough explanation. Providing an opinion or conclusion without a thorough explanation will delay processing of the claim and may also result in a clarification being requested). 8. Then, arrange for the Veteran to be examined by a respiratory specialist to determine the nature and likely cause of his asthma or reactive airway disease. The AOJ MUST PROVIDE the examiner a list of ALL QUALIFYING PERIODS OF RESERVE SERVICE. Based on an examination, review of the record, and any tests or studies deemed necessary, the examiner should provide opinions responding to the following: a. Does the Veteran have any signs or symptoms of a respiratory disability that cannot, by history, physical examination, or laboratory testing, be attributed to any known clinical diagnosis? b. Please identify, by diagnosis, all identifiable respiratory disability entities found. The examiner must reconcile all diagnoses made with conflicting evidence in the record, to include the notations of reactive airway disease and asthma in his treatment records. c. For each diagnosis rendered, the examiner should indicate whether such disability constitutes a medically unexplained chronic multisymptom illness. The examiner should note that a medically unexplained chronic multisymptom illness is a diagnosed illness without conclusive pathophysiology or cause, characterized by overlapping symptoms and signs, with features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multisymptom illnesses of partially understood cause and pathophysiology, such as diabetes and multiple sclerosis, will not be considered medically unexplained. d. For each respiratory disability diagnosed (other than any medically unexplained chronic multisymptom illnesses identified), the examiner should opine whether such disability is AT LEAST AS LIKELY AS NOT (A 50 PERCENT PROBABILITY OR GREATER) related to the Veteran's military service, to include his alleged environmental and toxic exposures (such as aflatoxins and trichothecene) in the Persian Gulf, or any confirmed periods of qualifying Reserve service (including notations of bronchospasm or shortness of breath in 2000 and 2001). A detailed explanation (rationale) is requested for all opinions provided. (By law, the Board is not permitted to rely on any conclusion that is not supported by a thorough explanation. Providing an opinion or conclusion without a thorough explanation will delay processing of the claim and may also result in a clarification being requested). 9. Forward the Veteran's entire record to an appropriate physician for a supplemental medical opinion regarding his claim seeking benefits under 38 U.S.C. § 1151 for MRSA. Based on a review of the entire record, the consulting physician should opine as to the following: a. Is it AT LEAST AS LIKELY AS NOT (A 50 PERCENT PROBABILITY OR GREATER) that the Veteran's MRSA was the result of training, hospital care, medical or surgical treatment, or an examination by VA, to include-but not limited to-steroid treatments for reactive airway disease and asthma? b. Is it AT LEAST AS LIKELY AS NOT (A 50 PERCENT PROBABILITY OR GREATER) that the proximate cause of the Veteran's MRSA was also due to carelessness, negligence, lack of proper skill, error in judgment, or a similar instance of fault on VA's part in furnishing medical or surgical treatment? c. Is it AT LEAST AS LIKELY AS NOT (A 50 PERCENT PROBABILITY OR GREATER) that the proximate cause of the Veteran's MRSA was an event not reasonably foreseeable? The consulting physician MUST RECONCILE all findings and opinion with conflicting evidence in the record, to include the August 2013 VA opinion. In addition, the consulting physician should also describe the ordinary or reasonable standard of care expected of providers in the diagnosis, treatment, and care of pertinent symptoms as they presented in the Veteran. Finally, the consulting physician MUST ALSO consider the Veteran and his wife's allegations regarding the level of care and attention they received at the Oxford and Birmingham, Alabama VA facilities as it relates to the aforementioned reasonable or expected standard of care. A detailed explanation (rationale) is requested for all opinions provided. (By law, the Board is not permitted to rely on any conclusion that is not supported by a thorough explanation. Providing an opinion or conclusion without a thorough explanation will delay processing of the claim and may also result in a clarification being requested). 10. Then, arrange for the Veteran to be examined by an orthopedic spine surgeon to determine the current severity of his neck disability. Based on an examination, review of the record, and any tests or studies deemed necessary, the examiner should describe all pathology, symptoms (frequency and severity), and associated impairment of function in sufficient detail to allow for application of the pertinent rating criteria. Range of motion studies must be completed, and must include active and passive motion and weight-bearing and non-weight-bearing and note where, in degrees, any noted pain begins. The examiner should also note any further functional limitations due to pain, weakness, fatigue, incoordination, or any other such factors. The examiner must also describe any neurological manifestations of neck disability, to include identifying any nerves affected and the severity of such involvement. A detailed explanation (rationale) is requested for all opinions provided. (By law, the Board is not permitted to rely on any conclusion that is not supported by a thorough explanation. Providing an opinion or conclusion without a thorough explanation will delay processing of the claim and may also result in a clarification being requested). 11. Then, arrange for the Veteran to be examined by a neurologist to determine the current severity of his headaches associated with his neck disability. Based on an examination, review of the record, and any tests or studies deemed necessary, the examiner should describe all pathology, symptoms (frequency and severity), and functional impairment associated with his headaches. A detailed explanation (rationale) is requested for all opinions provided. (By law, the Board is not permitted to rely on any conclusion that is not supported by a thorough explanation. Providing an opinion or conclusion without a thorough explanation will delay processing of the claim and may also result in a clarification being requested). 12. Then, arrange for the Veteran to be examined by a dermatologist to determine the current severity of his PFB. Based on an examination, review of the record, and any tests or studies deemed necessary, the examiner should describe all symptoms, pathology, and functional impairment associated with the Veteran's PFB in sufficient detail to allow for application of the pertinent rating criteria. The findings should specifically include-but not be limited to-noting the type and frequency of any treatments for PFB (as well as whether such treatment constitutes topical, oral, or parenteral corticosteroids or immunosuppressants) AND the percentage of total and exposed body areas affected by PFB. A detailed explanation (rationale) is requested for all opinions provided. (By law, the Board is not permitted to rely on any conclusion that is not supported by a thorough explanation. Providing an opinion or conclusion without a thorough explanation will delay processing of the claim and may also result in a clarification being requested). 13. The AOJ should then review the record, arrange for any further development indicated, and readjudicate the claims. If any remain denied, the AOJ should issue an appropriate supplemental statement of the case, afford the Veteran and his representative opportunity to respond, and return the record to the Board. The Veteran has the right to submit additional evidence and argument on the remanded matter. Kutscherousky v. West, 12 Vet. App. 369 (1999). As a remand, this matter must be handled expeditiously. 38 U.S.C.A. §§ 5109B, 7112 (2014). _________________________________________________ VICTORIA MOSHIASHWILI Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs