Citation Nr: 21061497 Decision Date: 10/04/21 Archive Date: 10/04/21 DOCKET NO. 13-06 413A DATE: October 4, 2021 REMANDED Entitlement to service connection for skin disorder of the right lower extremity (RLE), to include as secondary to service-connected disabilities, is remanded. Entitlement to service connection for skin disorder of the left lower extremity (LLE), to include as secondary to service-connected disabilities, is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (hereinafter, TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty from December 1968 to February 1972. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued in May 2012 issued by a Department of Veterans Affairs (VA) Regional Office. This Board remanded the case in May 2015, June 2017, and August 2018 for additional development; it now returns for further appellate review. 1. Entitlement to service connection for skin disorder of the RLE, to include as secondary to service-connected disabilities. 2. Entitlement to service connection for skin disorder of the LLE, to include as secondary to service-connected disabilities. An August 2011 VA treatment record shows the Veteran reported having intermittent open wounds and lesions on his legs and feet related to his service-connected diabetes mellitus, type II, and his peripheral neuropathy of the bilateral lower extremities (BLE). Further, that same month, the Veteran submitted a private nexus opinion from Dr. H.K. stating the Veteran "has intermittent open wounds and ulcers around his feet and legs related to his diabetic condition and peripheral neuropathy." Notably, Dr. H.K. did not support the opinion with a rationale. The Veteran has undergone VA examination for his claimed lesions in July 2011, May 2016, March 2018, and March 2021, and a VA clinician provided an addendum opinion in July 2016. However, at each examination, the Veteran has not exhibited open wounds on his legs and feet. In this regard, the July 2011 examiner noted superficial ulcerations of the RLE but found that such were not a complication of, nor worsened by, the Veteran's diabetes. While the May 2016 examiner diagnosed the Veteran with onychomycosis, a fungal infection of the toenail, dyschromia, a change in color of the skin or nails, and lichen simplex of the RLE, the examiner failed to provide an etiological opinion. In July 2016, the clinician, while noting the previous diagnoses, opined such were less likely than not related to service or aggravated by any service-connected disabilities. However, the clinician did not address whether the Veteran's claimed foot lesions were diabetic foot ulcers. Further, the examiner provided no rationale for the conclusory statements and failed to address the positive evidence of record suggesting secondary service connection for the lesions due to diabetes and neuropathy. In March 2018, the Veteran underwent additional VA examination, at which time the examiner opined that it was less likely than not that the Veteran's lesions of the BLE were a result of his military service. In support thereof, the examiner noted service treatment records (STRs) were silent as to any diagnosis of lower extremity skin lesions. The examiner further opined the Veteran's lesions were less likely than not caused or aggravated by a service-connected condition. As rationale, the examiner noted the Veteran was diagnosed with superficial venous stasis ulceration, which was a result of his nonservice-connected deep vein thrombosis (DVT) and that medical literature did not support causation or aggravation of venous stasis ulceration from DVT by peripheral neuropathy. However, the examiner did not address the positive nexus opinion from Dr. H.K. as directed in the June 2017 Remand instructions. In March 2021, the VA examiner noted the diagnoses of dyschromia and onychomycosis and opined that it was less likely than not that the Veteran's dyschromia was a result of his military service. As rationale, the examiner found that such disorder was not diagnosed until 2015 and further noted there were no records of complaints of skin conditions in the service treatment records. Although specifically requested in the August 2018 Remand, the examiner failed to provide an opinion as to whether the Veteran's skin lesions of the BLE were caused or aggravated by a service-connected disability. Thus, a remand is necessary to address such matters. 3. Entitlement to a TDIU. The Veteran contends that he is unable to secure and follow a substantially gainful occupation as a result of his service-connected disabilities. As the outcome of the remanded claims may affect the Veteran's TDIU claim, the latter claim is inextricably intertwined with the former claims. See Tyrues v. Shinseki, 23 Vet. App. 166, 177 (2009) (en banc) (explaining that claims are inextricably intertwined where the adjudication of one claim could have a significant impact on the adjudication of another claim); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Therefore, adjudication of the TDIU claim must be deferred until the Veteran's service connection claims have been resolved. Additionally, while on remand, the Veteran should be requested to complete and submit an updated Application for Increased Compensation for Unemployability (VA Form 21-8940) as the record indicates the Veteran has worked as a farmer, to include owning and caring for farm animals, throughout the period on appeal. See October 2016, June 2018, August 2018, March 2020 VA treatment records. The matters are REMANDED for the following actions: 1. Request that the Veteran submit an updated VA Form 21-8940 in support of his claim for a TDIU. 2. Forward the record, to include a copy of this Remand, to an appropriate VA clinician other than the March 2018 and March 2021 examiners to obtain an addendum opinion addressing the etiology of the Veteran's claimed skin disorders of the BLE. For each opinion requested below, the clinician should address the following skin disorders diagnosed during the pendency of the appeal: open wounds, lesions, and ulcers; superficial ulcerations of the RLE; onychomycosis; dyschromia; lichen simplex of the RLE; and superficial venous stasis ulceration. (A) The clinician is requested to offer an opinion as to whether it at least as likely as not (i.e., a 50 percent or greater probability) that any skin disorder of the lower extremities diagnosed during the pendency of the appeal is related to service. (B) The clinician also should offer an opinion as to whether it is at least as like as not that any skin disorder of the lower extremities diagnosed during the pendency of the appeal is caused or aggravated by a service-connected disability. The Veteran is in receipt of service connection for the following disabilities: adjustment disorder with mixed anxiety and depressed mood; coronary artery disease; Parkinson's disease; diabetes mellitus, type II with erectile dysfunction; peripheral neuropathy of the bilateral upper and lower extremities; tinnitus; inguinal hernia; and left ear hearing loss. For any aggravation found, the examiner should state, to the best of their ability, the baseline of symptomatology and the amount, quantified if possible, of aggravation beyond the baseline symptomatology by the aggravation. The examiner must consider and discuss the Veteran's reports that such lesions are intermittent, and the letter from Dr. H.K. stating that such are "related to his diabetic condition and peripheral neuropathy." The examiner is advised that the sole basis of a negative nexus opinion may not be the fact that the Veteran's service treatment records are negative for complaints, treatment, or a diagnosis of a skin disorder. A rationale should be provided for each opinion offered. M. M. Celli Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. M. Kelly, 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.