Citation Nr: 20042733 Decision Date: 06/24/20 Archive Date: 06/24/20 DOCKET NO. 97-09 877 DATE: June 24, 2020 REMANDED Entitlement to service connection for porphyria cutanea tarda (PCT), to include as due to herbicide agent exposure, is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1967 to May 1969, to include service in the Republic of Vietnam. VA has conceded the Veteran’s exposure to herbicide agents in the Republic of Vietnam. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a November 1996 rating decision of the Department of Veteran Affairs (VA) Regional Office (RO). The appeal was remanded by the Board in July 2014. In February 2016, the Board requested an advisory medical opinion from a Veteran’s Health Administration (VHA) dermatologist to assist in the equitable adjudication of this matter. 38 C.F.R. § 20.901. The dermatologist’s opinion was received in May 2016. The Veteran was furnished a copy of this evidence and afforded 60 days to submit additional evidence or argument. In July 2016, the Veteran’s representative submitted an Informal Hearing Presentation that contained new argument responsive to the dermatologist’s opinion. In a September 2016 decision, the Board, inter alia, denied entitlement to service connection for PCT, Raynaud’s syndrome, cellulitis, skin cancer, CVD, and contact dermatitis and eczema. The Veteran appealed the Board’s denial to the United States Court of Appeals for Veterans Claims (Court). By way of a June 2017 Order, the Court granted a Joint Motion for Partial Remand (JMPR) that vacated the September 2016 decision, as pertinent to the issues noted above, and remanded the matter for adjudication consistent with its terms. In July 2017, the Veteran was sent a notice letter informing him of the JMPR and his right to submit additional argument or evidence. In April 2018, the Board remanded this matter for an addendum VA medical opinion. There has been substantial compliance with the Board’s remand directives. Dyment v. West, 13 Vet. App. 141 (1999). Entitlement to service connection for PCT. The Veteran contends that he developed PCT as a result of Agent Orange exposure. See Hearing Testimony (October 1997). He detailed that he cannot tolerate sunlight. Id. Alternatively, he contends that it is due to Project Shad or sprays used at Wonder Beach in September 1968. See Form 9 (January 2004). The Veteran’s representative also asserted that the Veteran should undergo urine and blood testing. See Appellate Brief (July 2016). For reasons explained below, the Board finds that a remand is necessary to obtain relevant outstanding private treatment records. See 38 U.S.C. § 5103A(b), (c); 38 C.F.R. § 3.159(b); see also Sullivan v. McDonald, 815 F.3d 786 (Fed. Cir. 2016). By way of background, the Veteran’s exposure to herbicides has been conceded. A June 1967 pre-induction medical history report noted headaches and eye trouble, and the Veteran noted that he did not have skin diseases. A May 1969 service separation examination reflect normal clinical evaluation of the skin and no history of skin diseases. Post-service, a September 1984 Agent Orange Registry examination noted that the Veteran had a history of intermittent lesions that were suggestive of intermittent herpes simplex. In 1990, the Veteran was diagnosed with contact dermatitis. In May 1990, the Veteran reported a 20-year history of lesions on his neck and chest that occasionally blistered. In August 1996, the Veteran reported experiencing skin lesions for 27 years with burning and itching. A May 1998 treatment note from University of Michigan Hospitals notes “PCT unsure of diagnosis.” The Veteran underwent a VA examination October 2006, and, after urine test was obtained, the examiner provided an addendum that the laboratory tests did not support diagnosis of a thrombo-occlusive disorder. In January 2011, the Veteran was noted to have a past medical history of porphyria. In September 2014, a VA examiner indicated that treatment records did not confirm either a diagnosis of a or treatment for PCT, and that service treatment records and records from within a year of discharge were silent for PCT. In May 2015, the Veteran was noted to have a history of acute intermittent porphyria. In a June 2015 VA treatment record, it was noted that the Veteran had been diagnosed with porphyria in 1990s. A May 2016 VA opinion reflects that it was less likely than not that the Veteran had PCT. The opinion indicated that the record contained no blood or urinate tests for porphyria of any type. The examiner also found that the record did not contain descriptions of common skin findings of PCT. VA examinations for Housebound Status, conducted by VA Dr. D.M., were conducted in November 2014 and August 2016, which show a diagnosis of porphyria. It is noted that, these examination reports contain limited information. The JMPR suggested that the diagnosis for porphyria was based on blood and urine testing (“In 2014 and 2016, VA physician Dr. Miller diagnosed Appellant with porphyria, R. at 63 (August 1, 2016, VA Form 321-2680), 611-12 (November 5, 2014, VA Form 21-2680), after having ordered blood and urine testing or porphyrins in January 2011. R. at 1593-94 (January20, 2011, Dingell VA Medical Center Clinical Laboratory Report).”) The record also includes blood and urine tests results in January 2014 and August 2016, and there is nothing in the four corners of the 2014 and 2016 VA Housebound examination reports indicating that the diagnosis of porphyria shown was based on any specific blood and/or urine test results as oppose to medical history noted in the VA treatment records or as provided by the Veteran. Notwithstanding, the JMPR makes clear that the parties seek that any medical opinion relied upon by the Board in this matter consider those blood and urine test results. A January 2019 VA opinion provides that it is not at least as likely as not that the Veteran “has or ever had” PCT based on a thorough review of the Veteran’s claims file, including blood and urine tests, including those dated in January 2014 and August 2016. Although a January 2019 VA medical opinion was obtained as directed by the Board’s prior remand, the Board observes that the Veteran’s private treatment records appear to be outstanding, necessitating a remand. 38 C.F.R. § 3.159(c). In this regard, a January 2018 VA treatment note shows that the Veteran is treated for PCT at Dermatology A & A C. This includes a scanned note by Dr. C. dated September 24, 2018, referred to in the January 2019 VA examination, which is not presently associated with the Veteran’s file. A January 2019 VA treatment record shows a notation of “Suspected porphyria cutanea tarda: Patient is being worked up by community hematologist for this.” A January 2019 VA addendum opinion also refers to findings of and treatment by private providers, Dr. A. Cardello [Cardellio], Dr. Diab and Koppany Vysnei. A March 2019 VA treatment record indicates that the Veteran is undergoing work-up for suspected porphyria cutanea tarda with outside hematology. Another March 2019 VA treatment note refers to Community Care-non-VA consult at Van Eslander Cancer Center for hematology. A May 2019 VA treatment note reflects “Suspected porphyria cutanea tarda: Patient is followed by a hematologist in the community.” A September 2019 VA treatment note indicates that the Veteran saw Dr. D.L., a hematologist, for PCT and underwent phlebectomy, and the Veteran saw a private hematologist the following week. An October 2019 VA treatment note showed that the Veteran was receiving treatment, including phlebectomy, with an outside provider at St. John, Dr. Lubilik. That treatment note also indicated he had treatment at University of M[ichigan], where he was diagnosed with plasma cell disorder. As a result, a remand is needed to obtain these potentially relevant identified outstanding private treatment records. See Sullivan, 815 F.3d at 793 (citing 38 C.F.R. § 3.159(c)(3)). The matter is REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records for the period from October 2019 to the Present 2. Ask the Veteran to complete a VA Form 21-4142 for all non-VA medical providers seen for skin disorder symptoms since service discharge, including, but not limited to, Dr. A. Cardellio, Dr. Diab, and clinician Koppany Visnyei, and University of Michigan. Make two requests for the authorized records from all non-VA medical providers, unless it is clear after the first request that a second request would be futile. 3. If deemed necessary, return the Veteran’s claims file to the January 2019 examiner, or another similarly qualified medical expert if he is unavailable, for a supplemental medical opinion. The entire claims file and a copy of this REMAND must be made available to the examiner for review. A new examination is only required if deemed necessary by the RO or medical opinion provider. C.A. SKOW Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. M. Pesin The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.