Citation Nr: 1815887 Decision Date: 03/15/18 Archive Date: 03/23/18 DOCKET NO. 16-37 097 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUES 1. Entitlement to an increased evaluation for status-post healed left inguinal herniorrhaphy, with scar, which is currently evaluated as noncompensable. 2. Entitlement to service connection for a lung disability manifested by exposure to asbestos, including asbestosis and multiple bilateral pulmonary plaques. 3. Entitlement to service connection for a digestive condition, to include hiatal hernia, gastroparesis, and gastroesophageal reflux disease (GERD). 4. Entitlement to service connection for ischemia heart disease due to exposure to herbicides. 5. Entitlement to service connection for skin cancer due to UV light exposure. 6. Entitlement to service connection for bursitis disorders (unspecified sites). 7. Entitlement to service connection for insomnia (claimed as sleep disturbance). 8. Entitlement to service connection for high cholesterol and hypertriglyceridemia. 9. Entitlement to service connection for hypertension. 10. Entitlement to service connection for simple renal cyst (also claimed as cystic kidney disease). 11. Entitlement to service connection for abdominal aortic ectasia. 12. Entitlement to service connection for chronic dermatitis due to solar radiation (also claimed as actinic/seborrheic keratosis, keratoacanthoma). 13. Entitlement to service connection for dermatophytosis of the foot, hand, and nails. 14. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and anxiety. 15. Entitlement to service connection for a low back condition, to include arthritis. 16. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Jonathan Z. Morris, Associate Counsel INTRODUCTION The Veteran had active military service from November 1960 to October 1962 and from June 1963 to March 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from August 2014 and June 2015 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi. A claim of entitlement to service connection for a psychiatric disorder, such as PTSD, encompasses claims for all acquired psychiatric disorders that are reasonably raised by the record. Clemons v. Shinseki, 23 Vet. App. 1 (2009). As the record shows multiple psychiatric diagnoses, including PTSD and anxiety, the Board has recharacterized the claim as reflected above. 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) (West 2014). The Board is only rendering a decision with respect to the claims of entitlement to service connection for (1) high cholesterol; (2) bursitis disorders (unspecified sites); (3) a lung disability manifested by exposure to asbestos; (4) skin cancer; and, (5) a skin condition, to include actinic/seborrheic keratosis, and elastosis. All remaining matters require further development before a determination is made, so the Board is remanding these issues to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. Hypercholesterolemia and hypertriglyceridemia are laboratory findings and are not, in and of themselves, considered to be disabilities for VA purposes. 2. The preponderance of the evidence shows that the Veteran does not have a current diagnosis of bursitis disorders (unspecified sites). 3. The most probative evidence of record reflects that the Veteran has a current diagnosis of a lung disability manifested by exposure to asbestos, including asbestosis and multiple bilateral pulmonary plaques, which is etiologically related to his active military service. 4. The most probative evidence of record reflects that the Veteran has a current diagnosis of skin cancer, which is etiologically related to his active military service. 5. The most probative evidence of record reflects that the Veteran has a current diagnosis of a skin condition, to include actinic keratosis, seborrheic keratosis, and elastosis, which is etiologically related to his active military service. CONCLUSIONS OF LAW 1. The criteria for service connection for high cholesterol have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303 (2017). 2. The criteria for service connection for bursitis disorders (unspecified sites) have not been met. 38 U.S.C. §§ 1110, 1131, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.303 (2017). 3. The criteria for service connection for a lung disability manifested by exposure to asbestos, including asbestosis and multiple bilateral pulmonary plaques, have been met. 38 U.S.C. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303 (2017). 4. The criteria for service connection for skin cancer have been met. 38 U.S.C. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303 (2017). 5. The criteria for service connection for a skin condition, to include actinic keratosis, seborrheic keratosis, and elastosis, have been met. 38 U.S.C. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist VA has duties to notify and assist a claimant in substantiating a claim for VA benefits. 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2017). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Ideally, this notice should be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In a February 2014 letter, the Veteran was informed of what evidence was required to substantiate his claims, and of his and VA's respective responsibilities in obtaining this necessary supporting evidence. Additionally, this letter notified the Veteran of the criteria for assigning a disability rating and an effective date once service connection is granted. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). He was also afforded ample notice of the applicable law and requirements for substantiating his claims in the December 2015 Statement of the Case (SOC), as well in additional Supplemental SOCs (SSOCs). He has had ample opportunity to respond or supplement the record, and has not alleged that any notice was less than adequate. Thus, the Board finds that VA's duty to notify is satisfied. Regarding the duty to assist, the claims file contains the Veteran's service treatment records (STRs), relevant post-service medical records, buddy statements, and his own written statements. Neither the Veteran nor his representative has identified, nor does the record otherwise indicate, any other evidence relevant to this claim that is obtainable and has not been obtained. Furthermore, the Veteran was afforded a VA compensation examination and an opinion was provided concerning the service connection claims. Upon review of the medical evidence, the Board concludes that the examination report, opinion, and other medical records in the file, especially when considered collectively, are adequate for the purpose of rendering a decision in this case. 38 C.F.R. § 4.2; Barr v. Nicholson, 21 Vet. App. 303 (2007). Accordingly, the Board concludes that all reasonable efforts were made by VA to obtain evidence necessary to substantiate the Veteran's claim. Therefore, no further assistance to the Veteran with the development of evidence is required. II. Service Connection-Legal Criteria Service connection is granted for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Generally, to successfully establish service connection, there must be competent and credible evidence showing (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus or link between the current disability and the disease or injury incurred in or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Certain "chronic diseases" may be presumed to have been incurred in service if they manifest to a degree of 10 percent or more within one year of a Veteran's separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). This presumption is rebuttable by probative evidence to the contrary. Id. When a chronic disease is shown in service, sufficient to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). To be "shown in service," the disease identity must be established and the diagnosis must not be subject to legitimate question. Walker v. Shinseki, 708 F.3d 1331, 1335 (Fed. Cir. 2013); see also 38 C.F.R. § 3.303(b). There is no "nexus" requirement for compensation for a chronic disease which was shown in service, so long as there is an absence of intercurrent causes to explain post-service manifestations of the chronic disease. Walker, 708 F.3d at 1336. In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded to the claimant. The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show. The Veteran should not assume that the Board has overlooked pieces of evidence that are not specifically discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000). The law requires only that the Board provide reasons for rejecting evidence favorable to the Veteran. A. Service Connection for High Cholesterol Based on a thorough review of the record, the Board finds that the Veteran's claim of entitlement to service connection for hypercholesterolemia/hypertriglyceridemia must be denied. Although the medical evidence of record establishes he has current laboratory findings, these conditions are not considered a disability for VA purposes. Hypercholesterolemia is the medical term for high cholesterol. See Dorland's Illustrated Medical Dictionary 887 (32nd ed. 2012) (defining hypercholesterolemia as "excessive cholesterol in the blood."). Hyperlipidemia is "a general term for elevated concentrations of any or all of the lipids in the plasma, including hypertriglyceridemia, hypercholesterolemia, and so on." Id. at 891. Pursuant to current regulations, elevated cholesterol is a laboratory finding and not a disability for which VA compensation benefits are payable. See 61 Fed. Reg. 20440, 20445 (May 7, 1996) (diagnoses of hyperlipidemia, elevated triglycerides, and elevated cholesterol are actually laboratory results and are not, in and of themselves, disabilities. They are, therefore, not appropriate entities for the rating schedule.). The term "disability," as used for VA purposes, refers to impairment of earning capacity. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). There is no evidence of record suggesting the Veteran's elevated cholesterol causes any impairment of earning capacity. The Court has held that "Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Service connection can only be granted for a disability resulting from disease or injury. See 38 U.S.C. §§ 1110, 1113. High cholesterol is a laboratory finding that manifests itself only in laboratory test results and is not a disability for which service connection can be granted. As the preponderance of the evidence is against the Veteran's claim, the benefit-of-the-doubt rule does not apply. Consequently, service connection for hypercholesterolemia/hypertriglyceridemia is denied. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). B. Service Connection for Bursitis Disorders (unspecified sites) Generally, in order to establish direct service connection, three elements must be established: (1) a current disability; (2) an in-service event; and, (3) a nexus, or link, between the current disability and the in-service event. 38 C.F.R. § 3.303. In this case, the Veteran seeks entitlement to service connection for bursitis disorders (unspecified sites). However, while he specified "major joints" as the sites of his bursitis disorders in his June 2015 Notice of Disagreement, a current diagnosis has not been established for this claimed condition. The existence of a current disability is the cornerstone of a claim for VA disability compensation. See Degmetich v. Brown, 104 F.3d 1328, 1332 (1997) (holding that §§ 1110 and 1131's requirement of the existence of a present disability for VA compensation purposes cannot be considered arbitrary); see also McClain v. Nicholson, 21 Vet. App. 319, 323 (2007) (holding that the requirement of a current disability is met when a claimant has a disability at the time a claim for VA compensation is filed or during the pendency of that claim). Consequently, the evidence of record must show that the Veteran currently has the disability for which benefits are being claimed. Turning to review of the medical evidence of record shows that the Veteran's STRs do not contain any complaints of, treatment for, or a diagnosis of bursitis in service. More importantly, however, relevant post-service medical records do not document a diagnosis for this condition. In the absence of proof of a present disability (and, if so, of a nexus between that disability and service), there can be no valid claim for service connection. See Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (stating that service connection presupposes a current diagnosis of the condition claimed, to at least confirm the Veteran has it; without this minimum level of proof, there can be no valid claim). Therefore, as the evidence of record shows that the Veteran does not have a current disability, the Board concludes that service connection is not warranted, and no further discussion of the remaining elements is necessary. See Watson v. Brown, 4 Vet. App. 309, 314 (1993) ("A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or a disease incurred in service."); see also Coburn v. Nicholson, 19 Vet. App. 427, 431 (2006) (finding that the absence of any one element will result in denial of service connection). Accordingly, to the extent that the medical evidence addresses whether the Veteran has bursitis in multiple joints, the preponderance of the evidence indicates that he does not. The Veteran is competent to report his current symptoms, but his reports must be weighed against the medical evidence of record. See Grover v. West, 12 Vet. App. 109, 112 (1999); Jandreau, supra. To the extent that the Veteran has indicated that he currently has this claimed condition, the medical evidence showing an absence of such a disability is of greater probative weight than the Veteran's reports made during the course of his claims for VA benefits. Furthermore, as the question of causation extends beyond an immediately observable cause-and-effect relationship, he is not competent to render a diagnosis or address etiology in the present case. Although lay persons are competent to provide opinions on some medical issues, see, e.g. Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), the specific issue of whether the Veteran currently has bursitis in "every major joint" falls outside the realm of common knowledge of a lay person. See Espiritu v. Derwinski, 2 Vet. App. 492, 494-95 (1992) (stating that a layperson can provide an account of symptoms but not a diagnosis that requires medical knowledge). Thus, his statements as to a current diagnosis of any of these conditions are not probative. As the preponderance of the evidence is against a finding that the Veteran has bursitis disorders in multiple joints, the benefit of the doubt rule does not apply. See 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). C. Service Connection for Disabilities due to Sun Exposure The Veteran seeks entitlement to service connection for skin cancer of the left arm area, as well as for a chronic skin condition, to include actinic keratosis, seborrheic keratosis, and elastosis, which he contends are due to extensive sun exposure during service. In April 2017, Dr. R.L., a dermatologist, submitted a statement addressing these various skin related conditions. First, this statement confirmed the current diagnoses of these conditions. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (stating that service connection presupposes a current diagnosis of the condition claimed, to at least confirm the Veteran has it; without this minimum level of proof, there can be no valid claim). Next, Dr. R.L. indicated that "it is obvious that sun exposure has been the primary cause of [the Veteran's] elastosis, pre-skin cancers, and skin cancers." Dr. R.L. noted that there is no history of sun damage or actinic keratosis in the Veteran's family, and further stated that there is multiple actinic keratosis on his exposed areas which are not consistent with his complexion or family history. As a result, to a reasonable degree of medical certainty, Dr. R.L. concluded that, based on examination and history, excessive sun exposure acted as a major contributive factor concerning the Veteran's "skin damage of elastosis, actinic keratosis, and skin cancer." See also VA Med. R. dated July 8, 2014 (indicating that actinic and seborrheic keratosis is due to much sunlight exposure). In light of the foregoing, the Board finds that the most probative evidence of record supports a finding that the Veteran's skin cancer, as well as his skin condition, to include actinic keratosis, seborrheic keratosis, and elastosis, is etiologically related to his excessive sun exposure in the Navy. Here, Dr. R.L.'s April 2017 opinion is the only probative opinion of record, and it provides an adequate rationale to support the conclusion that the Veteran's claimed disabilities are etiologically related to service. There can be no doubt that further inquiry can be undertaken with a view towards development of the claim. However, in this regard, the Board recognizes that the Court has cautioned VA against seeking an additional medical opinion where favorable evidence in the record is unrefuted, and indicated that it would not be permissible to undertake further development if the purpose was to obtain evidence against an appellant's claim. See Mariano v. Principi, 17 Vet. App. 305, 312 (2003). Therefore, in light of the evidence of record and the applicable law, the Board concludes that service connection for skin cancer, as well as for a chronic skin condition, to include actinic keratosis, seborrheic keratosis, and elastosis, is warranted. 38 C.F.R. § 3.304. D. Service Connection for Lung Disability due to Asbestos Exposure The Veteran's post-service treatment records establish that he has a current diagnosis of lung disability manifested by exposure to asbestos, including asbestosis and multiple bilateral pulmonary plaques. See VA Med. R. dated June 18, 2002 (showing diagnosis of asbestosis); August 2014 VA Exam. Rep. (noting diagnosis of asbestosis and showing "stable asbestos related pleural disease" on CT scan); see also June 2017 VA Exam. Rep. (noting diagnosis of multiple bilateral pulmonary plaques). Consequently, there is competent medical evidence of his claimed disability. See Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (stating that service connection presupposes a current diagnosis of the condition claimed, to at least confirm the Veteran has it; without this minimum level of proof, there can be no valid claim). As already alluded to, however, there still must also be competent and credible (i.e., probative) evidence of a relationship ("nexus") between the Veteran's claimed disability and his military service. See Watson v. Brown, 4 Vet. App. 309, 314 (1993) ("A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or a disease incurred in service."). With regard to asbestos-related disorders, the VA Adjudication Procedure Manual, M21-1 (M21-1), provides guidance on how to adjudicate claims based on exposure to some environmental hazards, as well as specific guidance in adjudicating asbestos-related claims. M21-1, Part IV.ii.1.I.3 (November 19, 2015). However, there is no VA regulation that allows service connection on a presumptive basis for disorders resulting from exposure to environmental chemicals. 38 C.F.R. §§ 3.307, 3.309. Rather, service connection based on chemical exposure may be established only if a current disability is shown by the competent medical evidence to be related to chemical exposure during service. Moreover, the M21-1 provides the following non-exclusive list of occupations that have higher incidents of asbestos exposure: mining, milling, work in shipyards, insulation work, demolition of old buildings, carpentry and construction, manufacture and servicing of friction products such as clutch facings and brake linings, and manufacture and installation of roofing and flooring materials, asbestos cement sheet and pipe products, and military equipment. See M21-1, part IV, Subpart ii, Chapter 2, Section C, 9(f). Based on the Veteran's military occupation in the Navy consisting of performing maintenance in the boiler and engine rooms aboard the USS Frank Knox, USS Charles Ware, and USS Hyman, VA has determined there was a high risk for asbestos exposure during service. However, because there is no presumption that asbestos exposure automatically establishes service connection, the Veteran was afforded a VA compensation examination to address the purported relationship, if any, between his asbestos exposure during service and his current disability. In August 2014, a VA examiner determined that the Veteran's claimed lung disability was less likely as not related to service. Specifically, the examiner indicated that while the Veteran had an 8-year history of asbestos exposure during service, he also had a 40-plus year history of exposure to asbestos after leaving the Navy, including working as an electrician and in HVAC until 2005. In a May 2017 statement, the Veteran substantively described his asbestos exposure while performing maintenance on asbestos wrapped steam turbine equipment (consisting of generators, reciprocating pumps, valves, and piping) in the Navy. He also stated that he did not feel as if he was exposed to asbestos after leaving the Navy. He indicated that, while he had been self-employed as an electrician and as an air conditioning contractor, he mostly did administrative duties. Specifically, he indicated that he "had service techs that actually installed home air-conditioners." In May 2017, Dr. R.M., a pulmonologist, submitted a medical statement addressing an evaluation of an abnormal chest CT scan dated April 25, 2017. Dr. R.M. stated that the Veteran has pleural plaques on chest CT scan, which "are clearly sequelae of prior asbestos exposure and there is no question that these are present as a result of his military service." Dr. R.M. further indicated that the CT scan report shows the Veteran does not have asbestosis. In June 2017, the Veteran was afforded another VA compensation examination, where the examiner established a current diagnosis of multiple bilateral pulmonary plaques. Ultimately, the examiner concluded that the Veteran's current condition was at least as likely as not related to his service. Specifically, the examiner noted that the Veteran was exposed to asbestos working on navy ships for 8 years and further noted that he has now developed asbestos pleural plaques due to asbestos exposure. The examiner then stated that although the Veteran worked in the HVAC and electrical field after service, he did not have any asbestos exposure from these fields of work due to these roles being administrative only. See also July 2017 VA Exam. Rep. (showing a separate VA examiner also finding a positive nexus). In light of the foregoing reasons and basis, and given the favorable nexus evidence of record, the Board finds that the evidence supporting the claim supports the establishment of service connection for a lung disability manifested by exposure to asbestos, including asbestosis and multiple bilateral pulmonary plaques, on a direct basis. Despite the August 2014 VA examiner's determination that the Veteran's asbestos exposure was less likely than not related to his current condition, further competent medical evidence (both private and VA) has concluded that his current lung disability is, in fact, etiologically related to service. In this case, the Board is assigning more probative weight to these other, positive, medical nexus opinions of record because they take into account the Veteran's lack of asbestos exposure after service. 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). Undoubtedly, further medical inquiry can be undertaken with a view towards further developing this claim. However, in this regard, the Court has cautioned VA against seeking an additional medical opinion where favorable evidence in the record is unrefuted (or, as here, at worst evenly balanced for and against the claim) and indicated that it would not be permissible to undertake further development in this circumstance if the sole purpose was to obtain evidence against an appellant's claim. See Mariano v. Principi, 17 Vet. App. 305, 312 (2003). But see also Douglas v. Shinseki, 23 Vet. App. 19 (2009) (distinguishing Mariano and contrarily holding that VA may undertake the development of additional evidence if it is necessary to render an informed decision on the claim). Thus, service connection is warranted for a lung disability manifested by exposure to asbestos, including asbestosis and multiple bilateral pulmonary plaques. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to service connection for hypercholesterolemia/hypertriglyceridemia (high cholesterol) is denied. Entitlement to service connection for bursitis disorders (unspecified sites) is denied. Entitlement to service connection for a lung disability manifested by exposure to asbestos, including asbestosis and multiple bilateral pulmonary plaques, is granted. Entitlement to service connection for skin cancer is granted. Entitlement to service connection for a skin condition, to include actinic keratosis, seborrheic keratosis, and elastosis, is granted. REMAND Status-post healed left inguinal herniorrhaphy, with scar The Veteran's last VA compensation examination of his left inguinal herniorrhaphy was in March 2014. While the Board is not required to direct a new examination simply due to the passage of time, a new examination is appropriate when the claimant asserts that the disability in question has undergone an increase in severity since the time of the last examination. See Palczewski v. Nicholson, 21 Vet. App 174, 181 (2007); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); see also Bolton v. Brown, 8 Vet. App. 185, 191 (1995) (VA must provide a new examination where a veteran claims the disability is worse than when originally rated and the available evidence is too old to adequately evaluate the current severity); Caffrey v. Brown, 6 Vet. App. 377, 381 (1995). Given the Veteran's assertion that his service-connected disability has worsened, and in light of the amount of time since the last VA examination and the possible increase in severity, the Board finds a remand is necessary in order to afford him another examination which adequately addresses the current severity of that disability. Digestive Condition The Veteran was afforded a VA compensation examination in March 2014, where he was informed that his current digestive complaints are consistent with GERD and hiatal hernia. Following physical evaluation and review of the claims file, the examiner concluded that the Veteran's current condition is not etiologically related to an episode of enteritis noted in his STRs. Here, however, the examiner failed to provide an adequate rationale in support of this determination. A medical opinion must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Specifically, the examiner fail to address the Veteran's contentions that his digestive condition had its onset during service after an episode of food poisoning [see, e.g. Veteran's July 2017 Stmt.]. See Sklar v. Brown, 5 Vet. App. 140 (1993) (indicating the probative weight of a medical opinion may be reduced if the examiner fails to explain the basis for an opinion). Additionally, the examiner also failed to address the private medical statements of record. See, e.g., Schroeder v. Brown, 6 Vet. App. 220, 225 (1994) (stating that a thorough and contemporaneous medical examination must consider the records of prior medical examinations and treatment to assure a fully-informed examination). Where VA provides the Veteran with an examination in a service connection claim, such examination must be adequate. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Therefore, another VA examination is needed to assist in determining the nature and etiology of the Veteran's digestive condition, but particularly insofar as whether it is etiologically related to his military service. See Bowling v. Principi, 15 Vet. App. 1, 12(2001) (emphasizing the Board's duty to return an inadequate examination report "if further evidence or clarification of the evidence . . . is essential for a proper appellate decision"). Ischemia Heart Disease The Veteran seeks entitlement to service connection for ischemia heart disease due to exposure to herbicides-like the dioxin in Agent Orange-during his active military service. In order to establish service in the Republic of Vietnam for the purpose of the presumption of herbicide exposure under 38 C.F.R. § 3.307(a)(6), a service member generally must have set foot on the landmass of Vietnam, or served on a smaller "brown water" vessel navigating its inland waterways. Haas v. Peake, 525 F.3d 1168, 1187-1190 (Fed. Cir. 2008) (upholding VA's interpretation of the applicable regulations as requiring that a veteran must actually have been present on the landmass ("foot-on-land") or inland waters of Vietnam at some point in the course of his or her military duty in order to be entitled to the presumption of herbicide exposure); VAOPGCPREC 27-97 (July 1997) (holding that service on a deep-water naval vessel in waters off the shore of the Republic of Vietnam does not, in and of itself, qualify as "service" in Vietnam); VAOPGCPREC 7-93 (August 1993) (noting a distinction between larger ocean-going vessels, referred to as "blue water" vessels, and smaller "brown water" vessels that patrolled near shore or along rivers). Service in offshore waters, in high-altitude airspace above Vietnam, and service in other locations does not constitute service in Vietnam, unless the conditions of such service involved duty or visitation on the landmass or inland waterways of Vietnam. See id.; 38 C.F.R. §§ 3.307(a)(6)(iii), 3.313(a). In this case, the Veteran has not claimed, nor does the evidence reflect, that he was actually present on the landmass of Vietnam. Next, review of the Veteran's military personnel records indicate that he served aboard the USS Frank Knox from February 9, 1961 to October 5, 1962. According to The Naval History and Heritage Command and the Vietnam Era Navy Ship Agent Orange Exposure Development Site history, the USS Frank Knox's first Vietnam deployment started in 1965 and its only brown water service was from June 16, 1966 to June 17, 1966. See June 2015 VA Memo (finding lack of information to corroborate Agent Orange exposure). Nonetheless, the Veteran has alternatively asserted that he was directly exposed to Agent Orange during his Naval Reserve service at the Navy Construction Battalion Command (NCBC) Gulfport from June 15, 1971 to June 20, 1973. See Veteran's October 2017 Stmt. at 1 (detailing his contact with Agent Orange during the course of executing his military duties). Review of the claims file shows that VA received a statement in November 2017 from Mr. W.C., Environmental Restoration Manager at NCBC Gulfport, which indicated that NCBC Gulfport "was selected to be the main storage site in CONUS for Agent Orange." Mr. W.C. further stated that "the herbicide moved in and out of NCBC until April 1970[,] when the government declared an end to it[s] use in [Vietnam]." Pertinently, however, Mr. W.C. indicated that Agent Orange remained at NCBC Gulfport until at least 1977. VA has developed specific procedures to determine whether a veteran was exposed to herbicides when they allege exposure to herbicides in locations other than the Republic of Vietnam, along the Korean demilitarized zone (DMZ), or Thailand. See M21-1MR, Part IV, Subpart ii, Chap. 1, Sec. H, Para. 7(a) (Nov. 21, 2016). The Veterans Benefits Administration's (VBA's) Adjudication Procedure Manual (M21-1MR) directs that the Veteran should be asked for the approximate dates, location(s), and nature of the alleged herbicide exposure and their detailed description of exposure should be furnished to Compensation Service with a request to review the Department of Defense's (DoD's) inventory of herbicide operations to determine whether herbicides were used as claimed. If Compensation Service's review confirms that herbicides were used as alleged, then a determination must be made as to whether service connection is in order. If such review, however, does not confirm that herbicides were used as alleged, then a request should be sent to the Joint Services Records Research Center for verification of herbicides exposure. Despite the Veteran's detailed reports, the record does not reflect whether the AOJ attempted to verify the Veteran's claimed exposure to herbicides at NCBC Gulfport following the procedures outlined above. Thus, the Veteran's claim of entitlement to service connection for ischemia heart disease must be remanded so the AOJ can attempt to verify the Veteran's alleged exposure to herbicides, following the procedures provided in VBA's Adjudication Procedure Manual. If herbicide exposure is verified, then service connection will be presumed for ischemia heart disease on a presumptive basis under the provisions of 38 C.F.R. § 3.309(e). However, in the event that herbicide exposure is not verified, then the RO will need to afford the Veteran a VA compensation examination to address whether his ischemia heart disease was otherwise etiologically related to service. Remaining Service Connection Claims Pursuant to VA's duty to assist, VA will provide a medical examination or obtain a medical opinion based upon a review of the evidence of record if VA determines it is necessary to decide a claim. 38 C.F.R. § 3.159(c)(4)(i). In this case, the Veteran has not been afforded a VA compensation examination to address the nature and etiology of his insomnia; simple renal cyst; dermatophytosis of the foot, hand, and nails; abdominal aortic ectasia; acquired psychiatric disorder, to include PTSD and anxiety; or his low back condition, to include arthritis. As the record suggests a possible relationship between the Veteran's claimed disabilities and his military service, the "low threshold" standard for determining when a VA examination is necessary has been met. Therefore, the Board finds remand for such examinations is necessary. McLendon v. Nicholson, 20 Vet App. 79, 81 (2006). TDIU The TDIU claim is derivative of, so "inextricably intertwined" with, the Veteran's claims remaining on appeal. Therefore, consideration of this derivative TDIU claim must be deferred pending resolution of these other claims. See Tyrues v. Shinseki, 23 Vet. App. 166, 177 (2009) (en banc) (explaining that claims are "inextricably intertwined" when the adjudication of one claim could have a significant impact on the adjudication of another claim); Harris v. Derwinski, 1 Vet. App. 180 (1991). Finally, as the Board is remanding the case for further development, the AOJ should also obtain the records of all relevant treatment the Veteran has received since December 2016 (the records of which have not already been obtained, so they, too, may be considered). See Bell v. Derwinski, 2 Vet. App. 611, 613 (1992). Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Contact the appropriate VA Medical Center(s) and obtain all outstanding treatment records if relevant to these claims. Also ask the Veteran to provide, or authorize VA to obtain, all relevant private medical records that have not yet been obtained. All efforts to obtain these records must be documented in the claim file and the Veteran properly notified if unable to obtain identified records. 38 C.F.R. § 3.159(c) and (e). 2. After receiving all additional treatment records, schedule the Veteran for a VA examination to reassess the current severity of his residuals of his left inguinal herniorrhaphy, with scar. His claim file, including a copy of this remand, must be made available to the examiner in conjunction with the examination. All pertinent symptoms and findings must be reported in detail. The examiner should indicate all symptomatology associated with the Veteran's residuals of his left inguinal herniorrhaphy, with scar. The examiner should also address any functional impairment caused by this disability. All findings must be reported in detail and all opinions must be accompanied by a clear rationale. 3. Take the necessary actions to comply with the evidentiary development procedures required by M21-1MR, Part IV, Subpart ii, Chap. 1, Sec. H, Para. 7(a) (Nov. 21, 2016). Provide a detailed statement of the Veteran's claimed herbicide exposure to Compensation Service and request a review of the DoD inventory of herbicide operations to determine whether herbicides were used, tested, or stored as alleged at NCBC Gulfport. The dates of any indicated storage should be determined. If the exposure is not verified, then a request must then be sent to the JSRRC for verification of the Veteran's possible exposure to herbicides at NCBC Gulfport during the Veteran's military service. After the results of the above research have been obtained, determine whether the Veteran was, or was not, exposed to herbicides (Agent Orange) at the locations he claims. 4. After completing the requested development above, if it is determined that the Veteran was not exposed to herbicides as alleged, then schedule the Veteran for an appropriate VA medical examination to address the nature and etiology of his ischemia heart disease. His claim file, including a copy of this remand, must be made available to the examiner in conjunction with the examination. All pertinent symptoms and findings must be reported in detail. Following review of the evidence of record, the clinical examination results, and the Veteran's statements, the examiner must address whether it is at least as likely as not (50 percent or greater probability) that the Veteran's ischemia heart disease is etiologically related to his active military service. When responding, the examiner should take into account the lay statements of record regarding the nature and onset of symptoms. The examiner is advised that the Veteran is competent to report symptoms and treatment and that his reports must be considered in formulating the requested opinion. If the Veteran's reports are discounted, the examiner should provide a reason for doing so. Also, the mere absence of evidence of contemporaneous treatment in the service treatment records cannot, standing alone, serve as the sole basis for an unfavorable opinion. However, it is permissible to consider this as one factor in the determination regarding the origins of these claimed disabilities, provided there is also sufficient explanation as to why it is reasonable to have expectation of treatment in the circumstances presented. All answers to the questions listed above must be supported by a clear rationale. The examiner is asked to explain in detail the underlying reasoning for his or her opinion, to include citing to relevant evidence, supporting factual data, prior medical opinions, and medical literature, as appropriate. If any requested opinion cannot be provided without resorting to mere speculation, the examiner must explain why a more definitive response is not possible or feasible. In other words, merely saying he or she cannot respond will not suffice. 5. After receiving all additional treatment records, schedule the Veteran for an appropriate VA examination to determine the nature and etiology of his claimed digestive condition, including GERD. His claim file, including a copy of this remand, must be made available to the examiner in conjunction with the examination. All pertinent symptoms and findings must be reported in detail. Following review of the evidence of record, the clinical examination results, and the Veteran's statements, the examiner must address the following: (a) Identify and clearly describe all diagnoses related to the Veteran's claimed digestive condition. If none have been identified, the examiner should explain this finding. (b) For each condition identified above, the examiner should provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that any of these identified disabilities are etiologically related to the Veteran's active military service. When responding, the examiner should take into account the lay statements of record regarding the nature and onset of symptoms. The examiner is advised that the Veteran is competent to report symptoms and treatment and that his reports must be considered in formulating the requested opinion. If the Veteran's reports are discounted, the examiner should provide a reason for doing so. Also, the mere absence of evidence of contemporaneous treatment in the service treatment records cannot, standing alone, serve as the sole basis for an unfavorable opinion. However, it is permissible to consider this as one factor in the determination regarding the origins of these claimed disabilities, provided there is also sufficient explanation as to why it is reasonable to have expectation of treatment in the circumstances presented. All answers to the questions listed above must be supported by a clear rationale. The examiner is asked to explain in detail the underlying reasoning for his or her opinion, to include citing to relevant evidence, supporting factual data, prior medical opinions, and medical literature, as appropriate. If any requested opinion cannot be provided without resorting to mere speculation, the examiner must explain why a more definitive response is not possible or feasible. In other words, merely saying he or she cannot respond will not suffice. 6. After receiving all additional treatment records, schedule the Veteran for a VA compensation examination addressing the nature and etiology of his claimed low back disability, to include arthritis. His claim file, including a copy of this remand, must be made available to the examiner in conjunction with the examination. All pertinent symptoms and findings must be reported in detail. Following review of the evidence of record, the clinical examination results, and the Veteran's statements, the examiner must address the following: (a) Identify and clearly describe all diagnoses related to the Veteran's claimed low back condition. If none have been identified, the examiner should explain this finding. (b) For each condition identified above, the examiner should provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that any of these identified disabilities are etiologically related to the Veteran's active military service. When responding, the examiner should take into account the lay statements of record regarding the nature and onset of symptoms. The examiner is advised that the Veteran is competent to report symptoms and treatment and that his reports must be considered in formulating the requested opinion. If the Veteran's reports are discounted, the examiner should provide a reason for doing so. Also, the mere absence of evidence of contemporaneous treatment in the service treatment records cannot, standing alone, serve as the sole basis for an unfavorable opinion. However, it is permissible to consider this as one factor in the determination regarding the origins of these claimed disabilities, provided there is also sufficient explanation as to why it is reasonable to have expectation of treatment in the circumstances presented. All answers to the questions listed above must be supported by a clear rationale. The examiner is asked to explain in detail the underlying reasoning for his or her opinion, to include citing to relevant evidence, supporting factual data, prior medical opinions, and medical literature, as appropriate. If any requested opinion cannot be provided without resorting to mere speculation, the examiner must explain why a more definitive response is not possible or feasible. In other words, merely saying he or she cannot respond will not suffice. 7. After receiving all additional treatment records, schedule the Veteran for a VA compensation examination addressing the nature and etiology of his claimed acquired psychiatric disorder, to include PTSD and anxiety. His claim file, including a copy of this remand, must be made available to the examiner in conjunction with the examination. All pertinent symptoms and findings must be reported in detail. Following review of the evidence of record, the clinical examination results, and the Veteran's statements, the examiner must address the following: (a) Identify and clearly describe all diagnoses related to the Veteran's claimed acquired psychiatric disorder, to include PTSD and anxiety. If none have been identified, the examiner should explain this finding. (b) For each condition identified above, the examiner should provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that any of these identified disabilities are etiologically related to the Veteran's active military service. (c) Also, the examiner should indicate whether the Veteran's insomnia (claimed as sleep disturbance) is a symptom of his acquired psychiatric condition or whether it is a separate, primary diagnosis. (d) If the examiner determines that the Veteran's insomnia is a separate condition, and not a symptom of his psychiatric condition, then indicate whether it is at least as likely as not etiologically related to his military service. When responding, the examiner should take into account the lay statements of record regarding the nature and onset of symptoms. The examiner is advised that the Veteran is competent to report symptoms and treatment and that his reports must be considered in formulating the requested opinion. If the Veteran's reports are discounted, the examiner should provide a reason for doing so. Also, the mere absence of evidence of contemporaneous treatment in the service treatment records cannot, standing alone, serve as the sole basis for an unfavorable opinion. However, it is permissible to consider this as one factor in the determination regarding the origins of these claimed disabilities, provided there is also sufficient explanation as to why it is reasonable to have expectation of treatment in the circumstances presented. All answers to the questions listed above must be supported by a clear rationale. The examiner is asked to explain in detail the underlying reasoning for his or her opinion, to include citing to relevant evidence, supporting factual data, prior medical opinions, and medical literature, as appropriate. If any requested opinion cannot be provided without resorting to mere speculation, the examiner must explain why a more definitive response is not possible or feasible. In other words, merely saying he or she cannot respond will not suffice. 8. After receiving all additional treatment records, schedule the Veteran for a VA compensation examination assessing the nature and etiology of his hypertension. His claim file, including a copy of this remand, must be made available to the examiner in conjunction with the examination. All pertinent symptoms and findings must be reported in detail. Following review of the evidence of record, the clinical examination results, and the Veteran's statements, the examiner must address the following: (a) Is it at least as likely as not (50 percent or higher degree of probability) that the Veteran's hypertension, had its onset during service or is otherwise etiologically related to service? When responding, the examiner is advised that the Veteran is competent to report injuries and symptoms and that his reports must be considered in formulating the requested opinion. If the Veteran's reports are discounted, the examiner must discuss the reasons for doing that. The mere absence of evidence of contemporaneous treatment in the service treatment records cannot, standing alone, serve as the sole basis for an unfavorable opinion. However, it is permissible to consider this as one factor in the determination regarding the origins of these claimed disabilities, provided there is also sufficient explanation as to why it is reasonable to have expectation of treatment in the circumstances presented. (b) Is it at least as likely as not that the Veteran's hypertension had its onset during the year immediately following his separation from active duty? (c) Is it at least as likely as not that the Veteran's hypertension is proximately due to or aggravated by his ischemia heart disease and/or his digestive condition? The examiner should note that the term "aggravated by" refers to "any increase in severity" of a nonservice-connected disability that is proximately due to or the result of a service-connected disability, and not due to the natural progress of the nonservice-connected disability. If the examiner finds that the Veteran's ischemic heart disease or his digestive condition, either combined or independently, have aggravated his hypertension, then the examiner should specify, so far as possible, the degree of disability resulting from such aggravation. All answers to the questions asked must be supported by a clear rationale. That is, the examiner is asked to explain in detail the underlying reasoning for his or her opinion, preferably citing to relevant evidence, supporting factual data, prior medical opinions, and medical literature, as appropriate. If any requested opinion cannot be provided without resorting to mere speculation, the examiner must explain why a more definitive response is not possible or feasible. In other words, merely saying he or she cannot respond will not suffice. 9. After receiving all additional treatment records, schedule the Veteran for a VA compensation examination to address the nature and etiology of his simple renal cyst. His claim file, including a copy of this remand, must be made available to the examiner in conjunction with the examination. All pertinent symptoms and findings must be reported in detail. Following review of the evidence of record, the clinical examination results, and the Veteran's statements, the examiner must address whether it is at least as likely as not (50 percent or greater probability) that the Veteran's simple renal cyst is etiologically related to his active military service. When responding, the examiner should take into account the lay statements of record regarding the nature and onset of symptoms. The examiner is advised that the Veteran is competent to report symptoms and treatment and that his reports must be considered in formulating the requested opinion. If the Veteran's reports are discounted, the examiner should provide a reason for doing so. Also, the mere absence of evidence of contemporaneous treatment in the service treatment records cannot, standing alone, serve as the sole basis for an unfavorable opinion. However, it is permissible to consider this as one factor in the determination regarding the origins of these claimed disabilities, provided there is also sufficient explanation as to why it is reasonable to have expectation of treatment in the circumstances presented. All answers to the questions listed above must be supported by a clear rationale. The examiner is asked to explain in detail the underlying reasoning for his or her opinion, to include citing to relevant evidence, supporting factual data, prior medical opinions, and medical literature, as appropriate. If any requested opinion cannot be provided without resorting to mere speculation, the examiner must explain why a more definitive response is not possible or feasible. In other words, merely saying he or she cannot respond will not suffice. 10. After receiving all additional treatment records, schedule the Veteran for a VA compensation examination to address the nature and etiology of his abdominal aortic ectasia. His claim file, including a copy of this remand, must be made available to the examiner in conjunction with the examination. All pertinent symptoms and findings must be reported in detail. Following review of the evidence of record, the clinical examination results, and the Veteran's statements, the examiner must address whether it is at least as likely as not (50 percent or greater probability) that the Veteran's abdominal aortic ectasia is etiologically related to his active military service. When responding, the examiner should take into account the lay statements of record regarding the nature and onset of symptoms. The examiner is advised that the Veteran is competent to report symptoms and treatment and that his reports must be considered in formulating the requested opinion. If the Veteran's reports are discounted, the examiner should provide a reason for doing so. Also, the mere absence of evidence of contemporaneous treatment in the service treatment records cannot, standing alone, serve as the sole basis for an unfavorable opinion. However, it is permissible to consider this as one factor in the determination regarding the origins of these claimed disabilities, provided there is also sufficient explanation as to why it is reasonable to have expectation of treatment in the circumstances presented. All answers to the questions listed above must be supported by a clear rationale. The examiner is asked to explain in detail the underlying reasoning for his or her opinion, to include citing to relevant evidence, supporting factual data, prior medical opinions, and medical literature, as appropriate. If any requested opinion cannot be provided without resorting to mere speculation, the examiner must explain why a more definitive response is not possible or feasible. In other words, merely saying he or she cannot respond will not suffice. 11. After receiving all additional treatment records, schedule the Veteran for a VA compensation examination to address the nature and etiology of his dermatophytosis of the foot, hand, and nails. His claim file, including a copy of this remand, must be made available to the examiner in conjunction with the examination. All pertinent symptoms and findings must be reported in detail. Following review of the evidence of record, the clinical examination results, and the Veteran's statements, the examiner must address the following: (a) Is it at least as likely as not (50 percent or greater probability) that the Veteran's dermatophytosis of the foot, hand, and nails is etiologically related to service? (b) Is it at least as likely as not that the Veteran's dermatophytosis of the foot, hand, and nails is proximately due to or aggravated by his service-connected skin cancer and/or skin condition, to include actinic keratosis, seborrheic keratosis, and elastosis? The examiner should note that the term "aggravated by" refers to "any increase in severity" of a nonservice-connected disability that is proximately due to or the result of a service-connected disability, and not due to the natural progress of the nonservice-connected disability. If the examiner finds that the Veteran's skin cancer and/or his skin condition, to include actinic keratosis, seborrheic keratosis, and elastosis, either combined or independently, have aggravated his dermatophytosis of the foot, hand, and nails, then the examiner should specify, so far as possible, the degree of disability resulting from such aggravation. When responding, the examiner should take into account the lay statements of record regarding the nature and onset of symptoms. The examiner is advised that the Veteran is competent to report symptoms and treatment and that his reports must be considered in formulating the requested opinion. If the Veteran's reports are discounted, the examiner should provide a reason for doing so. Also, the mere absence of evidence of contemporaneous treatment in the service treatment records cannot, standing alone, serve as the sole basis for an unfavorable opinion. However, it is permissible to consider this as one factor in the determination regarding the origins of these claimed disabilities, provided there is also sufficient explanation as to why it is reasonable to have expectation of treatment in the circumstances presented. All answers to the questions listed above must be supported by a clear rationale. The examiner is asked to explain in detail the underlying reasoning for his or her opinion, to include citing to relevant evidence, supporting factual data, prior medical opinions, and medical literature, as appropriate. If any requested opinion cannot be provided without resorting to mere speculation, the examiner must explain why a more definitive response is not possible or feasible. In other words, merely saying he or she cannot respond will not suffice. 12. Ensure that the requested examination reports are responsive to the applicable rating criteria in the case of the claim for increase, as well as the determinative issue of causation in the service connection claims remaining on appeal. If the reports are not responsive to these claims, obtain all necessary additional information. Stegall v. West, 11 Vet. App. 268, 271 (1998); 38 C.F.R. § 4.2. 13. After completing this and any other development deemed necessary, readjudicate these claims, including for a TDIU, in light of this and all other additional evidence. If these claims continue to be denied, or are not granted to the Veteran's satisfaction, send him and his representative a Supplemental Statement of the Case (SSOC) and give them time to respond to it before returning the file to the Board for further appellate consideration of these claims. The appellant has the right to submit additional evidence and argument on the 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 that are 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 (West 2014). ______________________________________________ M. H. Hawley Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs