Citation Nr: 21063985 Decision Date: 10/18/21 Archive Date: 10/18/21 DOCKET NO. 17-40 564 DATE: October 18, 2021 ORDER New and material evidence having been received, the application to reopen the previously denied claim for service connection for a right knee disability is granted. Service connection for a right knee disability, diagnosed as degenerative arthritis, as secondary to service-connected left knee disability, is granted. Service connection for posttraumatic stress disorder (PTSD) is granted. Service connection for erectile dysfunction (ED), as secondary to PTSD is granted. REMANDED Service connection for a neck disability is remanded. Service connection for a low back disability is remanded. Service connection for chronic coughing/pulmonary disorder, including as due to service in Southwest Asia, is remanded. Service connection prostate cancer is remanded. Service connection for a skin disorder, to include pseudofolliculitis barbae (PFB), is remanded. FINDINGS OF FACT 1. An unappealed August 1980 rating decision denied service connection for a right knee disorder; new and material evidence was not received within one year of that decision. 2. Additional evidence received since the final August 1980 rating decision relates to previously unestablished facts necessary to substantiate the service connection claim for a right knee disability. 3. Resolving reasonable doubt in the Veteran's favor, his diagnosed right knee degenerative arthritis is at least as likely as not etiologically related to his service-connected left knee strain. 4. Resolving reasonable doubt in the Veteran's favor, the evidence indicates that he has a current PTSD diagnosis, and that his PTSD is etiologically related to reasonably confirmed stressors that he experienced during service. 5. The Veteran's diagnosed ED is at least as likely as not etiologically related to his now service-connected PTSD. CONCLUSIONS OF LAW 1. The August 1980 rating decision that denied entitlement to service connection for a right knee disability is final. 38 U.S.C. § 4005(c) (1976); 38 C.F.R. §§ 3.104, 19.118, 19.153 (1980). 2. The criteria to reopen the previously denied claim for service connection for the claimed right knee disability have been met. 38 U.S.C. § 5108; 38 C.F.R. §§ 3.156(a). 3. The criteria for service connection for a right knee disability, diagnosed as degenerative arthritis, as secondary to service-connected left knee strain, have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.110 4. The criteria for service connection for PTSD have been met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. § 3.102, 3.303, 3.304. 5. The criteria for service connection for ED, as secondary to service-connected PTSD, have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.110 REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1976 to June 1980, November 1990 to July 1991, November 1993 to February 1994, and from January 2003 to March 2004. This current appeal before the Board of Veterans' Appeals (Board) arose from an October 2013 rating decision in which a Department of Veterans Affairs (VA) Regional Office (RO) denied each of the service connection claims on appeal. Irrespective of the RO's consideration of the service connection claim for a right knee disability on its underlying merits, the question of whether new and material evidence has been received sufficient to reopen a previously denied claim must be addressed in the first instance by the Board because the issue goes to the Board's jurisdiction to reach the underlying claim and adjudicate it on a de novo basis. Barnett v. Brown, 83 F.3d 1380, 1383 (Fed. Cir. 1996). New and Material Evidence Right Knee Disability Generally, a final decision issued by the AOJ may not thereafter be reopened and allowed, and a claim based on the same factual basis may not be considered. 38 U.S.C. §§ 7104, 7105(c), (d). The exception to this rule is found at 38 U.S.C. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim that has been disallowed, VA shall reopen the claim and review the former disposition of the claim. "New evidence" is evidence that has not previously been reviewed by VA adjudicators. "Material evidence" is existing evidence, that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). There is a low threshold for determining whether evidence raises a reasonable possibility of substantiating a claim. Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). Moreover, in determining whether this low threshold is met, consideration need not be limited to whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but also whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering the VA's duty to assist or through consideration of an alternative theory of entitlement. Id. at 118. For the purposes of establishing whether new and material evidence has been submitted, the credibility of the evidence is presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). The Board must review all the evidence submitted since the last final disallowance of the claim on any basis in order to determine whether the claim may be reopened. Hickson v. West, 12 Vet. App. 247 (1999). The Veteran's previous service connection claim for a right knee disability was denied in the August 1980 rating decision on the basis that an in-service right knee sprain was considered to be acute, with no residual disability. The Veteran was notified of the decision and his appellate rights in an August 1980 letter, but he did not initiate an appeal. See 38 C.F.R. §§ 19.20, 19.21. There is no indication that new and material evidence pertinent to the claim was received within one year following the decision, or that additional service records (warranting reconsideration of the claim) have been received at any time. 38 C.F.R. § 3.156(b), (c). Thus, the August 1980 decision became final. 38 U.S.C. § 4005(c) (1976); 38 C.F.R. §§ 3.104, 19.118, 19.153 (1980). Evidence of record at that time of the August 1980 rating decision primarily consisted of the Veteran's service treatment records (STRs), which reflected at least three instances of reports of right knee injury during service, all as a result of playing basketball. New evidence pertinent to this service connection claim includes VA clinical treatment records dated through April 2020, which reflect treatment for knee conditions; an August 2013 report of VA examination of the Veteran's right knee, which notes a diagnosis of right knee arthralgia; a December 2018 report of VA examination of the right knee, which reflects a diagnosis of right knee arthritis and contained an unfavorable etiology opinion with respect to the relationship between the disability and service-connected left knee disability; and a November 2018 private examination report of the Veteran's right knee, providing the opinion that his current right knee osteoarthritis is at least as likely as not secondary to service-connected left knee strain, by way of associated compensatory walking strategies and kinematic changes. Given the "low threshold" standard of Shade, and presuming the credibility of the evidence, the Board finds that the additional evidence received since the August 1980 rating decision is new and material within the meaning of 38 C.F.R. § 3.156(a), as it provides evidence of ongoing treatment for the claimed right knee disability, and contains a competent private opinion etiologically relating the Veteran's current right knee degenerative arthritis to service-connected left knee disability. Thus, the new evidence suggests bases for awarding service connection, including specifically, a basis pursuant to an alternative theory of entitlement not previously considered. Under these circumstances, the Board concludes that the criteria for reopening the service connection claim for right knee disability are met. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may be granted for any disease diagnosed after discharge from service when all the evidence, including that pertinent to service, establishes that the disease was incurred in or aggravated by service. 38 C.F.R. § 3.303(d). Generally, to establish service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). The determination as to whether each element of a claim is met is based on an analysis of all pertinent evidence of record and evaluation of its competency, credibility and probative value. See Buchanan v. Nicholson, 451 F.3d 1331(Fed. Cir. 2006) Baldwin v. West, 13 Vet. App. 1, 8 (1999). Service connection also may be established on a secondary basis for disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that current disability exists, and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310(a), (b); Allen v. Brown, 7 Vet. App. 439 (1995). In adjudicating a claim for VA benefits, 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(b); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990); 38 C.F.R. § 3.102. 1. Right Knee Disability Although service connection for a right knee disability was adjudicated on a direct basis in the October 2013 rating decision, the Veteran has since specifically contended that his right knee disability was incurred as secondary to his service-connected left knee disability. First addressing the matter of current disability, the December 2018 VA examination report specifically noted the diagnosis of right knee degenerative arthritis. A right knee osteoarthritis diagnosis was additionally reflected in the October 2018 private clinical opinion. On the question of medical etiology of the Veteran's diagnosed right knee disability, in the October 2018 opinion, the private clinician specifically stated that it was at least as likely as not the current right knee condition, to include osteoarthritis, was secondary to, related to, and/or aggravated by his service-connected left knee strain, with associated compensatory walking strategies and biomechanical and kinematic changes. In providing this opinion, the clinician noted the Veteran's report of having to walk unevenly after developing the left knee strain, and that he had to shift his weight from side to side as a result of knee pain. The clinician cited to multiple studies documented in medical literature that in support of the notion that alterations in joint kinematics affect other major joints, including the knees, over time, and can accelerate wear on those joints by means of compensation and altered biomechanics. The Board finds the foregoing private opinion to be of significant probative value. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). The clinician who provided the opinion demonstrated significant familiarity with the Veteran's medical history, including his history of left and right knee joint disability, and his reported symptomatology, to include left knee symptomatology which directly affected right knee functioning. The clinician fully considered the evidence together with her expertise and medical research. The opinion, therefore, constitutes competent, probative evidence tending to support an award of secondary service connection for the diagnosed right knee disability on a causation basis. 38 C.F.R. § 3.310(a); Allen, 7 Vet. App. 439. While the December 2018 VA examiner provided an unfavorable opinion with respect to the etiology of the Veteran's right knee disability, the examiner plainly stated that the preponderance of the medical literature did not support a causative relationship between knee strain and osteoarthritis. The examiner did not discuss any actual medical literature, or consider the altered joint kinematics and biomechanics as relied upon by the private clinician. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008) (a medical examination report must contain clear conclusions with supporting data and a reasoned medical explanation connecting the two). Thus, the opinion does not offer a complete rationale and is of little probative value. Thus, reading the October 2018 private clinician's opinion as a whole, and in the context of the evidence of record, the Board finds that the opinion is of sufficient probative weight to warrant a finding that the Veteran's current right knee degenerative arthritis is at least as likely as not etiologically related to his service-connected left knee disability. See Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2012) (medical reports must be read as a whole and in the context of the evidence of record). Accordingly, in view of the totality of the evidence, with resolution of reasonable doubt on this appeal in the Veteran's favor, the Board concludes that the criteria for service connection for a right knee disability, as secondary to the service-connected left knee disability, are met. 2. PTSD Service connection for PTSD requires medical evidence diagnosing the disorder in accordance with 38 C.F.R. § 4.125(a); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the in-service stressor occurred. 38 C.F.R. § 3.304(f). Pursuant to current VA regulations, a diagnosis of PTSD must be rendered in accordance with the fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5). See 38 C.F.R. § 4.125. Prior to effective date for amendments to 38 C.F.R. § 4.125, however, a PTSD diagnosis must have been rendered in accordance with the fourth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). The evidence needed to establish the occurrence of a claimed in-service stressor is typically dependent upon whether a veteran engaged in combat with the enemy, as well as whether the claimed in-service stressor is related to such combat; or, if not, whether there is objective evidence to verify the occurrence of the claimed stressor. See 38 C.F.R. § 3.304(f); Cohen v. Brown, 10 Vet. App. 128, 147 (1997); Moreau v. Brown, 9 Vet. App. 389, 395 (1996); see also 38 U.S.C. § 1154(b). If a stressor claimed by a veteran is related to his or her fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of PTSD and that the veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f)(3). "Fear of hostile military or terrorist activity" means that a veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. Id. The evidence of record includes private and VA examination reports, and VA clinical consultation reports. This evidence provides contrasting conclusions with respect to whether the Veteran has a current PTSD diagnosis. Although dated prior to the appeal period, a December 2008 initial VA psychiatry assessment concluded that the Veteran met the diagnostic criteria for PTSD based on his experiences during service. While the psychiatrist did not specifically enumerate how the Veteran met the pertinent DSM-IV criteria for the PTSD diagnosis, he provided an adequate description which corresponds with the listed diagnostic criteria. See DSM-IV, Appendix E. Specifically considering the diagnostic criteria for PTSD, in the report, the psychiatrist described the Veteran's traumatic events during service, including working as a special handler when he served on active duty with the Air Force in Iraq and Afghanistan, where his work consisted of storing and loading men and women who had been killed in combat, their body parts, and service men and women who had been wounded in combat, and serving on guard duty where he experienced rocket and mortar attacks. The psychiatrist noted that the Veteran reexperienced his traumatic events during "down times" when he would have intense, vivid recollections of his experiences when he handled bodies and body parts and was under attack; and, when triggered by media coverage of war, he has also occasionally visualized episodes of being under attack. He has tried to avoid public reminders of the war and has avoided talking about his experiences. The report further indicated that the Veteran exhibited persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness, exhibiting emotional and sexual distance from his wife. He was also unable to tolerate crowded public places or congested traffic and had increasingly becoming withdrawn from activities with his family over the past few years. Additionally, the Veteran exhibited persistent symptoms of increased arousal, including through being "hyperalert" in social and public settings, scanning areas for escape routes and exits. He also exhibited symptoms of being easily startled by noises and commotion, and symptoms of a having disturbed quantity and quality of sleep for the past several years. Based on the VA psychiatrist's report and specific PTSD diagnosis, the Board concludes that the Veteran met the DSM-IV criteria at the time of that psychiatric evaluation. Further, the evidence indicates that the Veteran continued to exhibit the substantially similar symptomatology through to the time of the current appeal period. Social worker reports dated through May 2012, and VA primary care consultation reports dated through January 2014, continued to note his PTSD diagnosis. Additionally, a private October 2013 opinion concluded that the Veteran had a PTSD diagnosis of record, and that he continued to exhibit a PTSD diagnosis, as exhibited by his record of ongoing treatment for his symptoms and continuing diagnoses made by VA providers. Although a December 2014 VA mental disorders examination report indicated that the Veteran did not meet the diagnostic criteria for PTSD based on his claimed in service stressors, the examiner did not consider the Veteran's consistently reported stressor of having been exposed to rocket and mortar fire when placed on guard duty, or otherwise explain why the reported stressors considered during examination were insufficient to support a PTSD diagnosis. Regardless, affording the Veteran the benefit of the doubt, where the December 2008 VA psychiatric evaluation report indicated that the Veteran met the Veteran's stressors satisfied the diagnostic criteria, the Board finds that reading the evidence as a whole, the Veteran has met the diagnostic criteria for PTSD. As for the Veteran's in-service stressors, he has consistently reported that he had to process and handle body parts of servicemembers that had been killed and wounded in combat, and that he was exposed to rocket and mortar attacks when serving on guard duty. His DD Form 214 pertaining to his period of service ending in March 2004 indicated that he participated in both Operation Iraqi Freedom and Operation Enduring Freedom, and that he had served in imminent danger pay areas in Turkey, Kyrgyzstan, and Afghanistan. Additionally, in a February 2004 post-deployment survey, following deployment to Afghanistan, he specifically reported that he had felt that he was in great danger of being killed during his deployment. Based on the foregoing, the Board finds the Veteran's reports regarding his in-service traumatic experiences to be credible and consistent with the places, types, and circumstances of his service. See 38 C.F.R. § 3.304(f)(3). Moreover, this evidence points to the Veteran's stressors being based on a fear of hostile military or terrorist activity, where he was confronted with an event or circumstances that involved actual or threatened death or serious injury, or a threat to the physical integrity of himself or others, such as from actual or potential incoming artillery, rocket, or mortar fire; and his response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. Finally, where the VA psychiatrist that conducted the December 2008 evaluation noted the Veteran's reported stressors, and intrinsically based the PTSD diagnosis on those stressors, without discussion of other potential stressors in the Veteran's life, the Board finds that the evidence reasonably indicates that the Veteran's PTSD is etiologically related to his active service, to specifically include his in-service stressors. This conclusion is supported by the October 2013 private clinical evaluation which noted the Veteran's reported stressors, treatment and history of PTSD diagnosis, and concluded that his PTSD was at least as likely as not related to his military service. Thus, the Board finds that the required nexus between the Veteran's in-service stressors and his diagnosed PTSD has been satisfied. See Davidson, 581 F.3d 1313; 38 C.F.R. § 3.304(f). To the extent that the favorable opinions diagnosing PTSD as related to the Veteran's service, to specifically include his reported in-service stressors, are based on the Veteran's own reports, the Board emphasizes that VA is not free to ignore a medical opinion or pertinent medical findings, or to reject such a medical opinion based on its own medical judgment, even if the opinion is based, in part, on lay assertions. See Owens, 7 Vet. App. at 9, 433, Obert, 5 Vet. App. 30, and Colvin, 1 Vet. App. 171. Here, the Veteran's in-service stressors have been reasonably verified, and the favorable opinions/diagnoses specifically link the diagnosis to the in-service stressors. Based on the foregoing, the Board concludes that the evidence is at least in equipoise on certain elements of the claim. In such circumstances, the regulations dictate that reasonable doubt is to be resolved in the Veteran's favor. As the benefit-of-the-doubt rule is for application, the Board finds that service connection for PTSD is warranted. 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. at 53-56, 38 C.F.R. § 3.102. 3. Erectile Dysfunction The Veteran has specifically contended that his claimed ED was incurred as a result of his claimed PTSD. First addressing the matter of current disability, an August 2013 VA reproductive examination report specifically diagnosed ED. On the question of medical etiology of the Veteran's diagnosed ED, in the June 2014 private evaluation report, the private clinician opined that the Veteran's ED was at least as likely as not related to, secondary to, and/or aggravated by his PTSD, and prescribed PTSD medication. In providing this opinion, the clinician assessed the Veteran's ED, and noted that he had been prescribed anti-depressant medications for his PTSD. The clinician noted that medical literature noted a strong correlation between all anti-depressant medications and sexual dysfunction, including ED. In this regard, 30-70 percent of patients that took sertraline and paroxetine were noted to experience sexual dysfunction. Specifically, the medications caused physiological decreased libido, ED, and delayed orgasm. The clinician further cited to multiple medical treatises in support of this opinion. Additional evidence of record points to an etiological connection between the Veteran's psychiatric medications and his ED. Specifically, a November 2012 psychiatric contact report noted the Veteran's report that his medication interfered with his sexual performance. Additionally, the Veteran's VA treatment records reflect his use of sertraline during the appeal period. The Board finds the foregoing private opinion to be of significant probative value. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). The clinician who provided the opinion demonstrated significant familiarity with the Veteran's medical history, including his history of ED, and his reported symptomatology. The clinician fully considered the evidence together with her expertise and medical research. The opinion, therefore, constitutes competent, probative evidence tending to support an award of secondary service connection for the diagnosed ED on a causation basis. 38 C.F.R. § 3.310(a); Allen, 7 Vet. App. 439. While the examiner that conducted an August 2013 VA examination indicated that she could not resolve the issues of whether the Veteran's ED was at least as likely as not proximately due to or the result of his medication, the examiner noted that it was beyond the scope of her expertise to provide an opinion on this matter. Thus, reading the private clinician's opinion as a whole, and in the context of the evidence of record, the Board finds that the opinion is of sufficient probative weight to warrant a finding that the Veteran's current ED is at least as likely as not etiologically related to his now service-connected PTSD. See Acevedo, 25 Vet. App. at 294. Accordingly, in view of the totality of the evidence, and with resolution of reasonable doubt on this appeal in the Veteran's favor, the Board concludes that the criteria for service connection for ED, as secondary to service-connected PTSD, are met. REASONS FOR REMAND Service connection for a neck disability The Veteran contends that he injured his neck during an in-service motor vehicle accident (MVA). His STRs reflect that he was involved in a MVA around June 1995 and that he reported having stiffness in his neck at that time. Additionally, review of the Veteran's VA treatment records reflects multiple complaints of neck pain dated through April 2020. In spite of evidence of in-service neck injury, evidence of current neck pain/disability, and the Veteran's contention that his neck disability was the result of his in-service injury, he has not been afforded a VA examination to determine the nature and etiology of his claimed neck disability. Thus, remand is required to afford the Veteran such VA examination. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159; McLendon v. Nicholson, 20 Vet. App. 79 (2006). Service connection for a low back disability With respect to the Veteran's claimed low back disability, he was afforded a VA examination in August 2013, at which time he was diagnosed with recurrent musculoskeletal lumbar strain. The examiner provided the opinion that current back disability was less likely than not caused by or a result of his military service. In providing the opinion, however, the examiner only referenced a diagnosed lumbar strain in 1974, and appeared to conclude that his current condition was most consistent with simple back pain for which conservative care of four to six weeks was recommended. Notably, the examiner did not address the Veteran's November 2012 statement, wherein the Veteran specifically argued that he had continued pain in the low back area throughout his military career, and that he had chronic problems with back pain ever since it began during his active service. Additionally, the examiner did not reference multiple other clinical reports in the Veteran's STRs which noted ongoing problems with back pain dating through at least August 1978, which was assessed to be musculoskeletal in origin, and which extended four years after the noted lumbar strain diagnosis. Accordingly, remand of this claim is warranted in order to afford the Veteran a new VA examination to obtain an opinion as to the nature and etiology of his claimed low back disability based on consideration of current diagnosis and review of all pertinent evidence of record. Cf. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). Service connection for chronic coughing/pulmonary disorder With respect to the Veteran's claimed pulmonary disorder, he has contended that his symptoms may be associated with an undiagnosed illness or medically unexplained chronic multisymptom illnesses (MUCMI) associated with his service in Southwest Asia. Initially, and in this regard, the Board notes that the Veteran's VA clinical treatment records indicate that he underwent a pulmonary procedure, which apparently included pulmonary function testing (PFT) in July 2013, but that the full record of his pulmonary procedure does not appear to have been associated with the claims file. The entry in the VA treatment records indicates that a full PFT report can be obtained by accessing the PFT from the "Imaging" menu after selecting the "Tools" menu. Remand of this claim is warranted to ensure that a full copy of the July 2013 PFT report is associated with the claims file. 38 C.F.R. § 3.159(c)(2). Further, although the record indicates that the Veteran may not have a current pulmonary disorder diagnosis, to the extent that he has contended that his pulmonary/chronic cough symptoms may be associated with an undiagnosed illness or MUCMI, and that such undiagnosed illness or MUCMI may include signs or symptoms involving the respiratory system, on remand, he should be afforded a VA Gulf War examination. Service connection prostate cancer With respect to the Veteran's claimed prostate cancer, the record contains conflicting evidence as to whether he has been diagnosed with cancer. VA clinical treatment records reflect a history of prostate cancer, but also indicate that had a high grade prostatic intraepithelial neoplasia. The record reflects, however, that he has received treatment for his prostate condition from a private primary care provider, Dr. G. Records from this private provider, however, have not been requested. See 38 C.F.R. § 3.159(e)(2). Further, in light of the Veteran's contentions that he had prostate cancer as a result of his active duty and evidence of prostate disability during the appeal period, the Board finds that remand of this claim is warranted to afford the Veteran a VA examination to determine the nature and etiology of his claimed prostate condition. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159; McLendon, 20 Vet. App. 79. Service connection for a skin disorder The Veteran was afforded a VA skin diseases examination in August 2013. The examiner noted that the Veteran had prior skin diagnoses, including acne, tinea versicolor and PFB. However, the examiner determined that, because there was no objective evidence of skin condition on examination, an etiology opinion could not be provided. Notably, in a November 2012 statement, the Veteran contended that he still used antifungal medicine and hydrocortisone cream to control his skin conditions. Also, at a February 2019 VA clinical consultation, he reported that his acne continued to be intermittent. Thus, given the nature of skin disabilities to cycle through active periods and periods of flare-ups, as well as the evidence that the Veteran may have had skin conditions at other points during the appeal period other than at the time of the August 2013 VA examination, the Board finds that a remand is warranted to afford him a new VA skin conditions examination to determine the nature and etiology of any skin condition that has been present during the pendency of his appeal. Accordingly, these matters are hereby REMANDED for the following action: 1. Obtain the complete report from the Veteran's July 2013 pulmonary testing, including PFT results. Follow the procedures set forth in 38 C.F.R. § 3.159(c) regarding requesting records from Federal facilities. All records and/or responses received should be associated with the Veteran's claims file. 2. Ask the Veteran to provide authorization, on VA Form 21-4142, to obtain his outstanding private treatment records, including from his private primary care provider, Dr. G., to include specifically records pertaining to treatment for his prostate condition. Make two requests for all authorized records, unless it is clear after the first request that a second request would be futile. 3. Then, schedule the Veteran for an appropriate VA examination for his claimed neck and low back disabilities. Any and all indicated studies and tests deemed necessary by the examiner should be completed. The claims file and a copy of this REMAND should be made available to the examiner for review. After review of the record and completion of the examination (including any necessary tests and studies), the VA examiner should: (a.) Clearly identify any and all neck disabilities and low back disabilities (to include recurrent musculoskeletal lumbar strain) currently present, or present at any point pertinent to the current claim (even if now asymptomatic or resolved). (b.) Then, for each such current disability, the examiner should provide an opinion as to whether it is at least as likely as not (i.e., a 50 percent probability or greater), that the disability had its onset during service, or is otherwise medically-related to the Veteran's service, to include specifically, for the neck disability, the Veteran's in-service motor vehicle accident, and for the low back disability, his multiple reported incidents of low back pain and diagnoses of pain of musculoskeletal origin during service. In addressing the above, the examiner must consider and discuss all pertinent medical evidence and lay evidence of record, to include the Veteran's specific assertions as to the nature, onset, and continuity of his claimed neck and low back pain symptomatology since in-service injury. If lay assertions in any regard are discounted, the examiner should clearly so state, and explain why. A clear rationale must be provided for all opinions, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 4. Also after completion of directives "1" and "2" above, arrange for the Veteran to undergo a VA Gulf War examination for his claimed chronic coughing/pulmonary disorder by an appropriate examiner. Any and all indicated studies and tests deemed necessary by the examiner should be accomplished. The claims file and a copy of this REMAND should be made available to the examiner for review. After review of the record and completion of the examination (including any necessary tests and studies), the VA examiner should: (a.) determine whether the Veteran's complaints pertaining to chronic coughing/pulmonary disorder are associated with a known clinical diagnosis, and if so, whether any such diagnosis is related to or consists of a distinct and identifiable disability. (b.) For any symptoms pertaining to the Veteran's complaints of chronic coughing/pulmonary disorder that are determined not to be associated with a known clinical diagnosis, the examiner should specify the relevant symptoms that have not been attributed to a known clinical diagnosis and should provide an opinion as to whether it is at least as likely as not (i.e. a 50 percent or greater probability) that the symptom(s) represent an objective indication of chronic disability resulting from an undiagnosed illness related to the Veteran's service in Southwest Asia; (c.) For any symptoms pertaining to the Veteran's complaints that are associated with a diagnosed illness, the examiner should provide an opinion as to whether it is at least as likely as not (i.e. a 50 percent or greater probability) that any such illness constitutes a medically unexplained chronic multisymptom illness without conclusive pathophysiology or etiology (related to the Veteran's service in Southwest Asia), that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. For each distinct and identifiable disability associated with Veteran's complaints of chronic coughing/pulmonary disorder, the examiner should provide an opinion as to whether it is at least as likely as not (i.e., a 50% or greater probability) that the disability onset during service; or is otherwise medically-related to the Veteran's service. In addressing the above, the examiner must consider and discuss all relevant medical and other objective evidence of record and all lay assertions, to include the Veteran's assertions as to the nature, onset, and continuity of relevant symptoms. In this regard, the examiner is advised that the Veteran is competent to report his symptoms and history, and his assertions in this regard must be considered in formulating the requested opinions. If lay assertions in any regard are discounted, the examiner should clearly so state, and explain why. A clear rationale for all opinions must be provided, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 5. Also after completion of directives "1" and "2" above, schedule the Veteran for an appropriate VA examination for his claimed prostate cancer. Any and all indicated studies and tests deemed necessary by the examiner should be accomplished. The claims file and a copy of this REMAND should be made available to the examiner for review. After review of the record and completion of the examination (including any necessary tests and studies), the VA examiner should: (a.) clearly identify all prostate conditions, to include any cancer, currently present, or present at any point pertinent to the current claim (even if now asymptomatic or resolved). (b.) For each such condition, the examiner should opine as to whether it is at least as likely as not (i.e., a 50% probability or greater), that the condition onset during service, or is otherwise medically-related to the Veteran's service. In addressing the above, the examiner must consider and discuss all pertinent medical evidence and lay evidence of record, to include assertions as to the nature, onset, and continuity of the claimed prostate condition. If lay assertions in any regard are discounted, the examiner should clearly so state, and explain why. A clear rationale must be provided for all opinions, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 6. Also, schedule the Veteran for an appropriate VA examination for his claimed skin condition. Any and all indicated studies and tests deemed necessary by the examiner should be accomplished. The claims file and a copy of this REMAND should be made available to the examiner for review. After review of the record and completion of the examination (including any necessary tests and studies), the VA examiner should: (a.) clearly identify all skin conditions, to include PFB, tinea versicolor, and acne, currently present, or present at any point pertinent to the current claim (even if now asymptomatic or resolved). (b.) Then for each such skin condition, the examiner should provide an opinion as to whether it is at least as likely as not (i.e., a 50% probability or greater), that the condition had its onset during service, or is otherwise medically-related to the Veteran's service, including as a result of any skin condition(s), including tinea versicolor, PFB, rash, and acne, noted in the Veteran's STRs. In addressing the above, the examiner must consider and discuss all pertinent medical evidence and lay evidence of record, to include assertions as to the nature, onset, and continuity of the claimed skin condition. If lay assertions in any regard are discounted, the examiner should clearly so state, and explain why. A clear rationale must be provided for all opinions, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. No action is required of the Veteran until he is notified by VA. However, he is advised of his obligation to cooperate in ensuring the duty to assist is satisfied. Kowalski v. Nicholson, 19 Vet. App. 171 (2005). His failure to report for any scheduled VA medical examination may impact determinations made. 38 C.F.R. § 3.655. The Veteran also is advised that he has the right to submit additional evidence and argument with respect to these matters. Kutscherousky v. West, 12 Vet. App. 369 (1999). This appeal must be afforded prompt treatment. THERESA M. CATINO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Michael Wilson, 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.