Citation Nr: 21064392 Decision Date: 10/20/21 Archive Date: 10/20/21 DOCKET NO. 16-37 000 DATE: October 20, 2021 REMANDED Entitlement to service connection for a skin disorder is remanded. REASONS FOR REMAND The Veteran had active duty service from July 1966 to July 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2015 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). This matter was before the Board in June 2019 and July 2021 and remanded for additional evidentiary development. Entitlement to service connection for a skin disorder is remanded. Throughout the rating period on appeal, the Veteran has been assessed with squamous cell carcinoma, seborrheic keratosis, and multiple angiomas. He asserts his skin disability was incurred in service, including due to Agent Orange and sun exposures in service. The Veteran served in Vietnam and Agent Orange exposure is conceded. The Veteran's service-treatment records (STRs) reveal that he was assessed with pigmented nevus in April 1969 and a plan was made to obtain a specimen for pathology. Post-service treatment records reveal that he complained of a rash for the past year in October 2000. He was subsequently assessed with squamous cell carcinoma in January 2001 and seborrheic keratosis in January 2003. VA examinations were performed in January 2020 and August 2021. The examiner concluded that the Veteran's skin disabilities, including squamous cell carcinoma, seborrheic keratosis, and multiple angiomas, were not related to service, including exposure to herbicides. The examiner reasoned that the Veteran was assessed with pigmented nevus in service, which was removed and sent for pathology. The pathology results were not contained in the Veteran's STRs. The examiner indicated that most squamous cell skin cancers are caused by prolonged exposure to UV [ultraviolet] radiation either from sunlight or tanning beds. The Veteran's separation examination was normal and he did not show a skin complaint until January 2001. Accordingly, chronicity of care could not be established. Moreover, the examiner noted that squamous cell carcinoma, seborrheic keratosis, and multiple angiomas are not included in the list of presumptive diseases related to herbicide exposure. After a review of the evidence, the Board finds that an addendum opinion is warranted. In this regard, the examiner noted that most squamous cell skin cancers are the result of prolonged exposure to UV radiation. The Veteran served in Vietnam and submitted an argument in October 2021 noting studies that show an increased risk factor of sun exposure in military personnel. Moreover, he indicated during his examinations that he did not have excessive sun exposure or exposure to tanning beds post-service. In addition, the examiner noted that the Veteran did not have a skin complaint until January 2001. However, treatment records reveal that he complained of a rash for the past year in October 2000. Lastly, the examiner indicated that his skin disability was not related to service given that his diagnosed skin disabilities are not included on the list of presumptive diseases related to herbicide exposure. However, notwithstanding the presumptive provision, a claimant is not precluded from establishing service connection for disability due to Agent Orange exposure with proof of direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994); Stefl v. Nicholson, 21 Vet. App. 120 (2007). Accordingly, the Board finds that an addendum medical opinion is warranted on remand. The matter is REMANDED for the following actions: 1. Obtain and associate with the claims file the Veteran's updated VA treatment records from July 2020 to the present. 2. After completion of #1, forward the claims file, including a copy of this remand, to the January 2020 and August 2021 examiner for an addendum medical opinion. (If the examiner is not available the file should be forwarded to another appropriate clinician for an opinion. A new VA examination should be scheduled only if deemed necessary by the examiner). The claims file, including this remand, must be reviewed by the examiner and such review should be noted in the examination report. The examiner should respond to the following: Is it at least as likely as not (probability of at least 50 percent) that the Veteran's skin disability or disabilities, including squamous cell carcinoma, seborrheic keratosis, and/or multiple angiomas, are etiologically related to active service, including his conceded exposure to Agent Orange and/or sun exposures in Vietnam and generally in service? The examiner is instructed to provide an opinion as to the relationship of his conceded Agent Orange exposure regardless of whether the skin disability or disabilities are listed on VA's presumptive list. The examiner must provide a comprehensive rationale for each opinion provided. The examiner must discuss the October 2021 argument, included the cited studies, noting the increased risk factor of sun exposure and military personnel. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports are to be considered in formulating any opinion. If any opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner does not have the knowledge or training. As appropriate, the AOJ should conduct additional development or supplement the record. Eric S. Leboff Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Merrick 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.