Citation Nr: 19123745 Decision Date: 03/29/19 Archive Date: 03/29/19 DOCKET NO. 14-24 063 DATE: March 29, 2019 REMANDED Entitlement to service connection for a skin condition, to include as due to an undiagnosed illness or as secondary to service-connected chronic fatigue syndrome with joint pain, is remanded. REASONS FOR REMAND The Veteran had active duty service in the U.S. Army from January 1985 to December 1987 and from November 1988 to March 1993. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a March 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. In April 2016, the Board remanded the issues of entitlement to service connection for a disability manifested by fatigue, to include under the diagnosis of chronic fatigue syndrome, to include as due to an undiagnosed illness; entitlement to service connection for a skin condition, to include as due to an undiagnosed disease; and entitlement to service connection for joint pain, to include as due to an undiagnosed illness. As the Veteran received a diagnosis of chronic fatigue syndrome after the April 2016 Board decision, the Board has reclassified the issue of entitlement to service connection for a skin condition, to include as due to an undiagnosed illness or as secondary to service-connected chronic fatigue syndrome with joint pain. In a November 2016 rating decision, the Appeals Management Center (AMC) granted the Veteran’s claim for entitlement to service connection for chronic fatigue syndrome with joint pain and granted an evaluation of 60 percent, effective July 12, 2011. As this grant represents a full grant of the benefits sought, the issues of entitlement to service connection for a disability manifested by fatigue, to include under the diagnosis of chronic fatigue syndrome, to include as due to an undiagnosed illness, and entitlement to service connection for joint pain, to include an undiagnosed illness, are no longer on appeal. See Grantham v. Brown, 114 F.3d. 1156 (Fed. Cir. 1997). The Board is obligated by law to ensure that the AOJ complies with its directives; where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance. See Stegall v. West, 11 Vet. App. 268 (1998). A review of the record reflects that the AOJ has complied with some of the Board's remand directives. Unfortunately, as discussed in detail below, the VA examination for the Veteran’s claimed skin condition provided to the Veteran has been found inadequate in part. 1. Entitlement to service connection for a skin condition, to include as due to an undiagnosed illness or as secondary to service-connected chronic fatigue syndrome with joint pain As stated above, in an April 2016 Board decision, the issue of entitlement to service connection for a skin condition, to include as due to an undiagnosed disease, was remanded to obtain an additional VA examination with opinion as to whether the Veteran’s skin condition was due to his military service. In June 2016, consistent with the remand orders, the Veteran was afforded a VA examination for the skin. A diagnosis of maculopapular eruption was noted. The June 2016 VA examiner then opined that the condition claimed was less likely than not (less than 50% probability) incurred in or caused by the claimed in-service injury, event or illness. The examiner reasoned that, after carefully reviewing the Veteran’s file and the medical literature, it was her opinion that the Veteran did not have evidence of a leishmania infection as claimed from sand fly bites. His lab testing was negative for the antibody. The examiner noted that the Veteran has had consultations regarding the boils, and, according to a March 2015 notation, it is more likely that his low IgA & IgM have led to the skin infections. The various skin infections clear with repeated use of oral antibiotics. While the Board regrets the additional delay, another opinion must be obtained regarding the nature and etiology of the Veteran’s skin condition. While a VA examination and opinion was obtained per the remand instructions in the April 2016 Board decision, the June 2016 etiology opinion did not address the issue of secondary service connection. Therefore, an opinion must be obtained to determine whether the Veteran’s claimed skin condition is proximately due to a service-connected disability or aggravated beyond its natural progression by service-connected disability. The matter is REMANDED for the following action: 1. Give the Veteran an opportunity to identify any outstanding pertinent treatment records, VA or private, that have not already been associated with the claims file. The AOJ should then attempt to obtain those records if the appellant provides the appropriate authorization. 2. Then, obtain an addendum opinion from an appropriate clinician regarding whether it is at least as likely as not (fifty percent or greater probability) that the Veteran’s claimed skin condition is proximately due to or aggravated beyond its natural progression by the Veteran’s service-connected chronic fatigue syndrome with joint pain. 3. After completing the above action, and any other development as may be indicated by any response received as a consequence of the actions taken in the paragraphs above, the claim must be readjudicated. If the claim remains denied, a supplemental statement of the case must be provided to the Veteran. After the Veteran has had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. GAYLE STROMMEN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Christine E. Grossman, Associate Counsel