Citation Nr: 21061345 Decision Date: 10/01/21 Archive Date: 10/01/21 DOCKET NO. 16-34 510 DATE: October 1, 2021 ISSUE Entitlement to service connection for skin condition, claimed as chronic skin furuncles and/or scars on entire body. REMANDED Entitlement to service connection for skin condition, claimed as chronic skin furuncles and/or scars on entire body is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Air Force from April 1956 to April 1960. This matter is before the Board of Veterans' Appeals (Board) on appeal from an August 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In June 2018, the Veteran testified before a Veterans Law Judge. A copy of the transcript has been associated with the claims file. This hearing was before a now-retired judge. In March 2021 correspondence, the Veteran was given the opportunity to request another hearing and was notified that if he did not provide a response in 30 days, it would be assumed that he did not want another hearing. The Veteran did not respond to the letter. The Board remanded this issue in February 2019 and May 2021 for further development. As this matter is now again before the Board, the Board finds that there still has not been substantial compliance with the Board's previous remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998); D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). Therefore, unfortunately, this matter must be remanded once again for further evidentiary development. This matter is advanced on the docket pursuant to 38 C.F.R. § 20.902 (c). Entitlement to service connection for skin condition, claimed as chronic skin furuncles and/or scars on entire body is remanded. The Veteran contends that his current skin condition was aggravated beyond its natural progression due to long-term exposure to jet fuel while in service. The Veteran's February 1956 enlistment examination did not note that he had a skin condition existing prior to service. The Veteran's STRs reflect that in May 1956 he sought treatment for a boil on the back of his neck. During his March 1960 separation examination, the Veteran reported that he had a history of furuncles of the upper extremities and posterior neck during his childhood. During the June 2018 Board hearing the Veteran credibly testified that in fulfilling his duties as an Airline Mechanic he came into contact with jet fuel. The Veteran also testified that it was his belief that his current skin condition was separate from his furuncles/boils and that his current skin condition did not exist prior to service. He testified that he believed that his current skin condition was the result of his skin coming into contact with jet fuel while in service. In July 2018 a Skin Diseases Disability Benefits Questionnaire was completed. The examiner noted diagnoses of folliculitis, multiple acrochordon and actinic keratosis. No opinion was offered at that time as to the etiology of any skin disorder. The Veteran was afforded a VA examination in March 2020 at which time the examiner noted only a current diagnosis of actinic keratosis. The examiner noted that the Veteran's skin furuncles had been resolved since service. The examiner opined that the Veteran's skin disorder which clearly and unmistakably existed prior to service, was clearly and unmistakably not aggravated beyond its natural progression by the in-service event. The examiner stated that there were no reports of active furuncles during the Veteran's military service. The Board in its May 2021 remand however found that the examiner failed to consider that the Veteran's STRs from May 1956 reflect that the Veteran sought treatment for a boil on his back while in service. Therefore, this matter was remanded in May 2021 for an addendum opinion to be obtained. The Veteran was afforded the Board- directed VA examination in June 2021 and an addendum medical opinion was completed. The examiner noted only a current diagnosis of actinic keratosis. In providing an opinion on direct service connection the examiner opined that the Veteran's actinic keratosis was less likely than not directly related to his military service because there were no records available to support that the claimed condition was incurred in service without resorting to speculation. In providing an opinion on aggravation of a pre-existing condition, the examiner opined that the Veteran's 'claimed skin disorder' clearly and unmistakably pre-existed service and clearly and unmistakably was not aggravated by service. As a rationale, the examiner stated that there was insufficient medical evidence showing that there was a progression of the skin condition to a permanent position or was aggravated beyond its natural progression. The examiner stated that the record was silent during service relative to the skin condition. The Board however finds that the opinion of the June 2021 examiner is inadequate for adjudication purposes. The examiner's opinion is confusing as the Veteran has received multiple diagnoses for skin disorders over the period on appeal. Therefore, it is unclear which diagnosis of a 'claimed skin disorder' the examiner is referring to when providing an opinion on the aggravation of a pre-existing condition. Further, in providing a rationale for a negative nexus opinion the examiner cited to the lack of medical documentation in service as the basis for this opinion. However, the lack of medical documentation alone cannot be the basis of the opinion. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). Unfortunately, as such, the Board finds that there is insufficient competent medical evidence on file for the Board to make a decision on this claim. Once VA undertakes the effort to provide an examination when developing a claim, the exam must be an adequate one. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Accordingly, the Board finds a remand is necessary so that an adequate opinion on service connection for the Veteran's skin condition can be obtained. The matters are REMANDED for the following action: 1. Obtain any outstanding and relevant private and/or VA treatment records. Should such exist, associate such with the claims file. 2. Forward the claims file to the examiner who conducted the June 2021 VA examination, or if the examiner is unavailable, another suitably qualified examiner, for completion of an addendum opinion to determine the nature and etiology of any skin condition demonstrated at any time during the appeal period. If the examiner determines that another in-person examination of the Veteran is required to provide the below-requested information, then such an examination should be scheduled. The claims file, and a copy of this remand, must be made available to the examiner for review, and the examination report must reflect that such a review was performed. The examiner is asked to address the following: a) Identify the diagnosis of any skin condition(s) present since the Veteran filed his claim for service connection in May 2015, or within close proximity thereto. The examiner should address and reconcile any current findings with any other previous diagnosis of a skin condition(s) during the period on appeal. b) Does the evidence of record clearly and unmistakably (i.e., it is undebatable) show that the Veteran has any skin condition(s) diagnosed during the appeal period which pre-existed service, and if so, whether it is a pre-existing condition that is not congenital, or a congenital condition? c) If a pre-existing condition by clear and unmistakable evidence existed, is it at least as likely as not (50 percent or greater likelihood) that the pre-existing skin condition underwent any worsening (i.e., increase in severity) during service? d) If so, is there clear and unmistakable evidence (undebatable) that such worsening of the pre-existing condition(s) during service was due to the natural progress of the disease? e) If the Veteran's pre-existing condition is a congenital defect, is there evidence of additional disability due to aggravation during service of the congenital defect by any superimposed disease or injury? f) If there is not clear and unmistakable evidence that any currently diagnosed skin condition(s) preexisted service and is not congenital, then the Veteran must be considered to have been sound at entry without a diagnosis of a skin condition. Based upon that premise, is it at least as likely as not (a probability of 50 percent or greater) that the Veteran has any diagnosed skin condition that had its onset during active service or is related to any in-service injury, event, or disease, including skin contact with jet fuel as an aircraft mechanic. When considering this question, the examiner is to consider all lay statements of record carefully, VA treatment records and private treatment records and evaluations. The examiner's attention is directed to the Veteran's May 1956 STR note indicating that he sought treatment for a boil on his back while in service. The examiner should view the Veteran as a reliable historian as to his service and his report of his activities in service. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The examiner is reminded that the absence of documented treatment in service or thereafter is not fatal to a service connection claim, and the absence of evidence in the service treatment records is an insufficient basis, by itself, for a negative opinion. Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). A significant lapse in time between service and post-service medical treatment may be considered a factor in the analysis. Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). A detailed rationale must be provided for any opinion offered. 3. After completing the requested actions, readjudicate the claim in light of all pertinent evidence and legal authority. If the benefit sought remains denied, furnish to the Veteran and his representative with a Supplemental Statement of the Case and afford them the appropriate time period for response before the claims file is returned to the Board for further appellate consideration. 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. It further is reiterated that this matter has been advanced on the Board's docket. 38 U.S.C. § 7107(a)(2); 38 C.F.R. § 20.900(c). Michael A. Pappas Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Nettey, Associate Counsel 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.