Citation Nr: 21066352 Decision Date: 10/29/21 Archive Date: 10/29/21 DOCKET NO. 14-42 669 DATE: October 29, 2021 ORDER Service connection for a skin disorder, to include atopic dermatitis, eczematous dermatitis, ectopic dermatitis, pruritic scalp, and urticaria is denied. REMANDED The issue of service connection for a right upper extremity nerve disorder, to include idiopathic peripheral neuropathy and carpal tunnel syndrome, to include as secondary to service-connected diabetes mellitus type II is remanded. The issue of service connection for a left upper extremity nerve disorder, to include idiopathic peripheral neuropathy and carpal tunnel syndrome, to include as secondary to service-connected diabetes mellitus type II is remanded. FINDING OF FACT The Veteran's skin disorder was not caused by service. CONCLUSION OF LAW The criteria to establish service connection for a skin disorder have not been met. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(d). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the U.S. Army from August 1967 to April 1969, to include service in the Republic of Vietnam. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2014 rating decision of the Houston, Texas Regional Office (RO). In October 2018, the Veteran was afforded a hearing before the undersigned Veterans Law Judge (VLJ) sitting at the RO. During the hearing, the VLJ engaged in a colloquy with the Veteran toward substantiation of the claims. Bryant v. Shinseki, 23 Vet. App. 488, 496-97 (2010). A hearing transcript is in the record. In August 2021, the Board remanded the appeal to the RO for additional action. The RO has not substantially complied with the Board's remand directives as to the claims of service connection for a right upper extremity nerve disorder and left upper extremity nerve disorder. Stegall v. West, 11 Vet. App. 268 (1998). Service Connection Skin Disorder Service connection may be granted for a current disability arising from a disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110. Service connection may be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of an in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The Veteran asserts that his skin disorder was caused by exposure to Agent Orange during service in Vietnam. The Veteran is diagnosed with a current skin disorder. His military personnel records (MPRs) show that the Veteran served in the Republic of Vietnam. Under the law, the Veteran is presumed to have been exposed to Agent Orange; however, the Veteran's skin disorder is not a presumptive disease associated with exposure to herbicide agents or listed as a chronic disease. 38 C.F.R. §§ 3.309(a), (e). The disputed issue is whether the Veteran's skin disorder was caused by exposure to Agent Orange. The claim will be denied. Service treatment records (STRs) do not show complaints or contemporaneous reports concerning the Veteran's skin. In his April 1969 separation medical history report, the Veteran answered "no" to the question of whether he then had, or once had skin diseases. In the Veteran's April 1969 separation medical examination report, the service medical examiner noted no skin abnormalities. The STRs are highly probative evidence because they were generated with the specific view of recording the events they describe. In this respect, they are akin to official records, which generally enjoy a high degree of probative value in the law. Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (observing that although formal rules of evidence do not apply before the Board, recourse to the Federal Rules of Evidence may be appropriate if it assists in the articulation of the reasons for the Board's decision). A September 1970 VA examination did not note skin symptoms. To the extent that the Veteran asserts that he has had a continuing skin disorder since his military service, the VA examiner's finding is probative evidence that the Veteran did not have symptoms of a skin disorder approximately 15 months after service separation. 38 C.F.R. § 3.159(a); Curry v. Brown, 7 Vet. App. 59 (1994) (noting that contemporaneous evidence has greater probative value than history as reported by the Veteran). In an April 2014 statement, the Veteran reported an itching sensation on both arms since service. The Veteran is competent to report his observable symptoms. 38 C.F.R. § 3.159(a). However, the Veteran is not credible in his report of an itching sensation since service because STRs do not show complaints or contemporaneous reports concerning the Veteran's skin, the Veteran answered "no" to the question of whether he then had, or once had skin diseases at service separation, the service medical examiner noted no skin abnormalities at service separation, and the September 1970 VA examination revealed no skin symptoms. Curry, 7 Vet. App. at 59. In his July 2014 notice of disagreement, the Veteran reported an itching sensation on his entire body. In non-VA treatment records dated November 2016, January 2017, March 2017, October 2017, March 2018, and September 2018, a physical skin examination revealed normal findings. In his October 2018 Board hearing, the Veteran testified that his itching sensation "probably goes back 20-some years" or since approximately 1998 many years after the Veteran was discharged from active duty. In an October 2018 VA treatment record, a physical examination revealed no skin discoloration. The Veteran was assessed with "basal cell cancer status-post removed stable." In non-VA treatment records dated November 2018 and March 2019, a physical skin examination revealed normal findings. In an April 2019 VA treatment record, a physical examination revealed no skin discoloration. An October 2019 VA treatment record reflects the Veteran's report of a low back rash. A physical examination revealed a 3x3 centimeter erythematous flat patch on the lower lumbar region. The Veteran was diagnosed with atopic dermatitis and it was noted that the atopic dermatitis was present for approximately one month. In a July 2019 non-VA treatment record, a physical skin examination revealed normal findings. The January 2020 VA examination was found inadequate by the November 2020 Board remand. Therefore, the January 2020 VA examination is of low probative value. A February 2020 VA treatment record noted a history of basal cell carcinoma on the left check treated in 1997. The Veteran reported an itchy scalp and a small red patch that appeared on his low back six weeks prior and spread to his trunk. A physical examination revealed erythematous, edematous, and slightly scaly papules and plaques on his back, flank, and scalp without erythema or scale. The Veteran was diagnosed with eczematous dermatitis and pruritic scalp. A May 2020 VA treatment record noted atopic dermatitis as an active problem. The January 2021 VA examiner diagnosed the Veteran with ectopic dermatitis and urticaria. The May 2021 VA negative etiology opinion was found inadequate by the August 2021 Board remand. Therefore, the VA opinion is of low probative value. In an August 2021 addendum, the VA examiner opined that the Veteran's skin disorder was not caused by exposure to Agent Orange during service in Vietnam because the Veteran had a history of eczematous dermatitis and basal cell carcinoma that were removed and such skin disorders result from a combination of immune system activation, genetics, environmental triggers, and stress. The VA addendum is highly probative because the examiner had an accurate and complete understanding of the Veteran's medical history and provided a medical conclusion with sufficient rationale. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). A preponderance of the evidence is against a finding that the Veteran's skin disorder was caused by exposure to Agent Orange. The Veteran is not credible as to his account of an itching sensation since service separation. The August 2021 VA examiner opined that the Veteran's skin disorder was not caused by exposure to Agent Orange. Significantly, no competent medical provider has opined otherwise. Therefore, service connection is not warranted, and the claim is denied. REASONS FOR REMAND The remaining matters are remanded for the following actions: 1. BACKGROUND FOR THE RO ADJUDICATOR In August 2021, the Board remanded the claims of service connection for a right and left upper extremity nerve disorder for an adequate VA etiology opinion because the May 2021 VA examiner (1) in providing a negative etiology opinion as to direct service connection, did not consider the Veteran's relevant medical history, clinical data, and competent statement of numbness and tingling and (2) did not provide an opinion as to whether the Veteran's right and left upper extremity nerve disorder was aggravated by service-connected diabetes mellitus type II. Bloom v. West, 12 Vet. App. 185, 187 (1999); El-Amin v. Shinseki, 26 Vet. App. 136 (2013). The August 2021 addendum was inadequate because the VA examiner provided an opinion as to aggravation for the Veteran's right and left lower extremity nerve disorder but did not provide an etiology opinion as to direct service connection and aggravation as to secondary service connection for the Veteran's right and left upper extremity nerve disorder. Stegall, 11 Vet. App. at 268. THE REMAND DIRECTIVES FOLLOW: 2. Return the file to the VA examiner who provided the August 2021 medical opinion for a file review and an addendum opinion. If the examiner is not available, have the file reviewed by a similarly qualified examiner. Another examination is not required; however, if the VA examiner indicates that he or she cannot respond to the Board's questions without examination of the Veteran, another examination should be afforded to the Veteran. All relevant medical and non-medical records must be made available for review of pertinent documents. The examination report should specifically state that such a review was conducted. THE EXAMINER IS ADVISED that the law requires medical opinions must be both fully informed and explained. The Courts have held that the Board must evaluate any medical opinions by review of multiple factors, including but not limited to whether the examiner conducted a personal interview of the Veteran and review of the claims folder including electronic "Virtual VA" filings; conducted clinical testing and explained findings, and most importantly whether the examiner fully explained his or her findings and opinion. THE EXAMINER IS ALSO ADVISED THAT BY LAW, THE MERE STATEMENT THAT THE CLAIMS FOLDER WAS REVIEWED AND OR THAT THE EXAMINER HAS EXPERTISE IN THE SUBJECT MATTER IS NOT ADEQUATE TO FIND THAT THE EXAMINATION IS SUFFICIENT. Right and left upper extremity nerve disorder: the examiner MUST PROVIDE THE FOLLOWING OPINIONS WITH A COMPREHENSIVE EXPLANATION: (1) Was the Veteran's right upper extremity nerve disorder, to include idiopathic peripheral neuropathy and carpal tunnel syndrome caused by exposure to Agent Orange during service? Why or why not? (2) Was the Veteran's right upper extremity nerve disorder caused or aggravated by service-connected diabetes mellitus type II? Why or why not? (3) Was the Veteran's left upper extremity nerve disorder, to include idiopathic peripheral neuropathy and carpal tunnel syndrome caused by exposure to Agent Orange during service? Why or why not? (4) Was the Veteran's left upper extremity nerve disorder caused or aggravated by service-connected diabetes mellitus type II? Why or why not? Although the examiner must review the VBMS file, his or her attention is drawn to the following: In the Veteran's April 1969 separation medical examination report, the service medical examiner noted no neurological abnormalities. In his April 1969 separation medical history report, the Veteran answered "no" to the question of whether he then had, or once had neuritis. In a September 1970 VA examination not focused on the Veteran's bilateral upper extremity nerve disorder, the Veteran did not report symptoms of neuropathy. In an April 2014 statement, the Veteran reported numbness in both upper extremities since service. A November 2016 non-VA treatment record reflects the Veteran's diagnoses of bilateral upper extremity idiopathic peripheral neuropathy and carpal tunnel syndrome. A September 2018 non-VA treatment record reflects the Veteran's diagnosis of limb numbness. In his October 2018 Board hearing, the Veteran reported that the severity of his bilateral upper extremity numbness was "minor" until approximately four years prior. In an October 2018 VA treatment record, a review of systems revealed no tingling or numbness and it was noted that the Veteran's neuropathy was stable. A July 2019 non-VA treatment record reflects the Veteran's report of numbness and tingling in both upper extremities. An abdomen and pelvis radiograph revealed idiopathy neuropathy and the Veteran was diagnosed with idiopathic neuropathy. In an October 2019 VA treatment record, it was noted that the Veteran's diagnosis of neuropathy was stable. (CONTINUED ON NEXT PAGE) 3. The RO adjudicator is requested to ensure that the examination is fully responsive to the questions in paragraph 2, subparagraphs (1) through (4) above. If the examination is not fully responsive and fully explained, please request another addendum. Then readjudicate the issues on appeal. If the benefits sought on appeal remain denied, the Veteran should be provided a supplemental statement of the case (SSOC). An appropriate period should be allowed for response before the case is returned to the Board. Vito A. Clementi Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Cohen, Counsel The Board's action is binding only in this case and does not establish VA policy or legal precedent.