Citation Nr: 21066885 Decision Date: 11/02/21 Archive Date: 11/02/21 DOCKET NO. 17-11 620 DATE: November 2, 2021 ORDER 1. Entitlement to service connection for an age-related cataract, to include as secondary to service-connected diabetes mellitus, is denied. 2. Entitlement to an effective date of April 22, 2013, but no earlier, for entitlement to service connection for diabetes mellitus is granted. REMANDED 3. Entitlement to service connection for residuals of an inner ear infection, including slight facial droop, is remanded. 4. Entitlement to service connection for a psychiatric disorder, to include posttraumatic stress disorder (PTSD) and to include as secondary to service-connected diabetes mellitus and/or medications related to his service-connected disabilities, is remanded. 5. Entitlement to service connection for chronic allergies is remanded. 6. Entitlement to service connection for migraine headaches is remanded. 7. Entitlement to service connection for a chronic widespread rash on the shoulders, chest, and abdomen is remanded. 8. Entitlement to service connection for athlete's foot is remanded. 9. Entitlement to service connection for obstructive sleep apnea is remanded. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that cataracts are caused or aggravated by the service-connected diabetes mellitus or are otherwise related to an in-service injury or disease, and refractive error is not a disability for which service connection may be granted. 2. While on active duty, the Veteran was diagnosed with diabetes mellitus and filed a claim for service connection in November 2011,which was during his active service. The Veteran was discharged from that period of active duty on April 21, 2013. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for age-related cataract, to include as secondary to service-connected diabetes mellitus, have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310, 4.9 (2020). 2. The criteria for entitlement to an effective date of April 22, 2013, but no earlier, for the grant of service connection for diabetes mellitus have been met. 38 U.S.C. § 5110 (2012); 38 C.F.R. §§ 3.151, 3.155, 3.400 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1986 to March 1990, from January to July 2005, from January to May 2006, from October 2007 to February 2008, and from May 2008 to April 2013. The Veteran testified at a virtual hearing before the undersigned Veterans Law Judge in February 2021. A transcript of the hearing was prepared and associated with the claims file. The record was left open for 30 days to submit the DD Form 214 from the period of active duty from May 2008 to April 2013, which was received. Concerning the claim for service connection for a psychiatric disorder, claimed as PTSD and diagnosed as an adjustment disorder with mixed anxiety and depressed mood, in Clemons v. Shinseki, the United States Court of Appeals for Veterans Claims (Court) noted the Board should consider alternative current disorders within the scope of the filed claim. Clemons v. Shinseki, 23 Vet. App. 1 (2009). The Board has reviewed the case at hand and finds that Clemons is applicable here. The RO has separately denied, and the claim has been certified to the Board as, a claim for service connection for PTSD. In light of Clemons, the Board has framed the issue as entitlement to service connection for a psychiatric disorder, claimed as PTSD, as reflected on the title page. The claim for entitlement to service connection for athlete's foot was previously denied in a final rating decision dated in June 1990. As such, the issue had been adjudicated by the AOJ as to whether new and material evidence had been receipt date to reopen the claim. The AOJ had reopened the claim and denied the claim on the merits. However, the evidence associated with the claims file since the issuance of the previously noted rating decision includes additional service treatment records (STRs). Such records were previously unavailable and include treatment records as well as re-enlistment examinations and reports of medical history. As a result, the Board will adjudicate the issue on a de novo basis rather than on the basis of whether new and material evidence has been received. See 38 C.F.R. § 3.156(c). Service Connection 1. Entitlement to service connection for an age-related cataract, to include as secondary to service-connected diabetes mellitus, Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. 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 is also warranted for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Such secondary service connection is warranted for any increase in severity of a nonservice-connected disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(b). The Veteran testified at the February 2021 hearing that he had always had good vision until he was diagnosed with diabetes mellitus. He testified that since his diabetes mellitus diagnosis, he has had to wear readers, and thus, he believes his vision issues are caused or aggravated by his diabetes mellitus. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the claim for service connection for cataracts and refractive error. The reasons follow. As to evidence of a current disability, September 2016 and September 2017 VA treatment records document that the Veteran has a diagnosis of a cataract and refractive error. Therefore, the facts establish that the first element of a service connection claim is met. Initially, the Board notes that service connection for refractive error is not warranted because the declining vision is correctable refractive error and is not a disability for the purposes of service connection. 38 C.F.R. §§ 3.303(c), 4.9. Myopia, astigmatism, and presbyopia are all considered to be forms of refractive error. M21-1, III.iv.4.B.1.d. Actual pathology, other than refractive error, is required to support impairment of visual acuity. M21-1, III.iv.4.B.1.b. As to evidence of a disease or injury in service, the STRs do not show that the Veteran sustained a disease or injury to the eyes during service. For example, in June 1986, February 1990, June 1995, September 1995, and August 2000 Reports of Medical History, the Veteran specifically denied having or having had any vision correction and endorsed that he had vision in both eyes. The June and September 1995 and August 2000 examinations also documented that clinical evaluations of the eyes, pupils, ophthalmoscopic, and ocular motility were all normal. At a November 2011 VA examination, the Veteran specifically denied having any issues with his eyes or vision, and an eye examination was clinically normal. The first documentation in the claims file of a cataract is in September 2016 VA treatment records, approximately three years after the Veteran's discharge from active service. Additionally, the Veteran himself does not contend that his cataract or refractive error had an onset in service. Rather, he testified that he had always had good vision and good health until he was diagnosed with diabetes mellitus. Thus, the preponderance of the evidence is against a finding that the second element of a direct service-connection claim is met. Without evidence of a disease or injury in service, the criteria for a direct service-connection claim are not met. Despite not meeting the requirements for service connection on a direct basis, the Board will still address whether the Veteran meets the requirements for service connection on a secondary basis. However, the preponderance of the evidence is against finding that the diagnosed cataract is at least as likely as not caused or aggravated by the service-connected diabetes mellitus. VA treatment records from September 2016 and September 2017 both document that the Veteran has an age-related cataract. The September 2017 VA treatment provider documented that the Veteran did not have a diagnosis of diabetic retinopathy, and this optometry consult was provided as a routine diabetic eye examination. The Board finds that the September 2017 VA treatment records are highly probative, as the examiner was addressing the full nature of the Veteran's eye disability to specifically assess whether the diagnosed diabetes mellitus was impacting his vision or causing diabetic retinopathy. Following this full clinical assessment, the treatment provider specifically noted that the Veteran did not have a diagnosis of diabetic retinopathy and noted that the diagnosed cataract was related to the Veteran's age. The treatment provider also noted that the Veteran did not have any other diagnoses related to his eyes, including glaucoma, blindness, or macular degeneration. This is evidence against a nexus between the current bilateral eye disability and service-connected diabetes mellitus. There is no competent evidence to weigh against this medical opinion. Thus, the Board finds that the preponderance of the evidence is against finding a nexus between the current cataract and the service-connected diabetes mellitus. The Board acknowledges the Veteran's testimony that he believes his cataract is related to his diabetes mellitus because the cataract had an onset around the time of his diagnosis of diabetes mellitus. The Board must analyze the credibility and probative value of the evidence, account for the evidence it finds persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the Veteran. Kahana v. Shinseki, 24 Vet. App. 428, 433 (2011). This includes weighing the credibility and probative value of lay evidence against the remaining evidence of record. See King v. Shinseki, 700 F.3d 1339 (Fed. Cir. 2012); Kahana, 24 Vet. App. at 43334. A lay person is competent to report to the onset and continuity of his symptomatology. Id. at 438. Moreover, lay evidence may be competent and sufficient evidence of a diagnosis or nexus if (1) the particular condition at issue is the type of condition that is within the competence or common knowledge of a lay person, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 137677 (Fed. Cir. 2007). The Board must determine on a case-by-case basis whether a particular condition is the type of condition that is within the competence of a lay person. See Kahana, 24 Vet. App. at 433, n. 4. In this case, while the Veteran is competent to report symptoms that he has experienced, such as issues with his vision since he was diagnosed with diabetes mellitus, he is not competent to directly link the current disability to his diabetes mellitus, as medical expertise is required. In this regard, the question of causation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran's own opinion is nonprobative evidence. A VA examination was scheduled in September 2016, which the Veteran did not attend. The Veteran has not receipt date any justification for missing this examination. Furthermore, as the Board finds that the opinion provided by the September 2017 and September 2017 VA treatment providers as to the etiology of the cataracts is probative, a VA examination is not necessary. In reaching the above conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, that doctrine is not applicable where, as here, there is not an approximate balance of positive and negative evidence. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Thus, the claim for service connection for a cataract and refractive error is denied. 2. Entitlement to an effective date prior to September 30, 2015 for the grant of service connection for diabetes mellitus Except as otherwise provided, the effective date of an award of compensation based on an original claim shall be fixed in accordance with the facts found but shall be no earlier than the date of receipt of the application. 38 U.S.C. § 5110(a). The statutory provision is implemented by regulation, which provides that the effective date for an evaluation and award of compensation based on an original claim will be the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 C.F.R. § 3.400. If, the claim is received within one year after separation from service, service connection will be granted from the day following separation from active service or the date entitlement arose, whichever is later. 38 C.F.R. § 3.400(b)(2). In this case, the record shows that the Veteran was diagnosed with diabetes mellitus in May or October 2010, which is during a period of active service. In November 2011, while on active duty, the Veteran filed VA Form 21-0819, VA/DOD Joint Disability Evaluation Board Claim. This claim was not decided for the purposes of VA compensation upon the Veteran's release from active service in April 2013. In September 2015, the Veteran filed another claim for compensation, including a claim for diabetes mellitus, which was granted in a March 2016 rating decision. An effective date of September 2015 was assigned. The Veteran was diagnosed with diabetes during active service with an onset as early as May 2010 and filed a claim for service connection while on active duty. Thus, when resolving all doubt in the Veteran's favor, the Board finds that April 22, 2013, the day following the Veteran's separation from active service for the period dated from May 23, 2008 to April 21, 2013, is the earliest possible effective date for service connection for diabetes mellitus. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400(b)(2). In other words, the day following service discharge is the earliest date allowed by law for the award of service connection. REASONS FOR REMAND 3. Entitlement to service connection for residuals of an inner ear infection, including slight facial droop The Veteran has not been provided a VA examination in relation to his claim for residuals, including a slight facial droop, from an inner ear infection. At the February 2021 hearing, the Veteran testified that he had an incident of Bell's palsy following an inner ear infection in service. He reported that he was given medication to help the droop, but he also testified that when he was tired, he still experiences a droop on one side of his face, causing him to sound as though he is slurring words. He also testified that he does not feel the muscles in his face are as strong as they used to be, and, as he ages, the residuals are becoming worse. The Board finds this to be credible evidence that the Veteran has a possible current disability. STRs from November 2007, during a period of active service, document that the Veteran reported a plugged and painful ear with periodic vertigo due to a eustachian tube dysfunction. In a later visit to the emergency room, also in November 2007, it was documented that he had Bell's palsy and continued to report vertigo. As the STRs establish that an event, injury, or disease occurred in service and the Veteran testified to competent evidence of a current disability or persistent or recurrent symptoms of a disability which may be associated with the Veteran's service, the Board finds the McLendon criteria have been met and a VA examination must be provided. McLendon v. Nicholson, 20 Vet. App. 79 (2006). 4. Entitlement to service connection for a psychiatric disability, to include PTSD and to include as secondary to service-connected diabetes mellitus and/or medications related to his service-connected disabilities The Veteran was initially provided a VA psychiatric examination in May 2016. The examiner opined that the Veteran did not meet the criteria for PTSD, but the examiner did diagnose the Veteran with an adjustment disorder with mixed anxiety and depressed mood. However, the examiner opined that the adjustment disorder was less likely than not incurred in active duty, as the issues with anxiety and depression had popped up over the last two years as a result of loss of employment and reported incidents of racial discrimination. The Board finds this opinion is inadequate as the examiner did not address the in-service incidents of depression and other psychiatric symptoms that are documented in the claims file. Specifically, in a February 1990 Report of Medical History, the Veteran reported a positive history of depression or excessive worry. Furthermore, in March 2013, just prior to his discharge from his final period of active service, the Veteran specifically endorsed having little interest or pleasure in doing things, and he endorsed feeling down and/or depressed over the previous year. Furthermore, the examiner did not provide a rationale for the provided opinion. An addendum opinion is necessary to address these incidents of symptoms of depression in service and address whether the current psychiatric disorder is at least as likely as not related to these reports. Additionally, at the February 2021 hearing, the Veteran asserted that the stress of his service-connected diabetes mellitus and all of the medications he has to take are also causing him stress. Thus, an opinion as to whether or not the Veteran's diabetes mellitus and/or medications taken for diabetes mellitus or his other service-connected disabilities caused or aggravates his adjustment disorder with mixed anxiety and depressed mood. 5. Entitlement to service connection for chronic allergies The Veteran has not been provided a VA examination in relation to the claim for service connection for chronic allergies. At the February 2021 hearing, the Veteran testified that he did not have allergies prior to service, but that he noticed, when he moved from Philadelphia to San Diego and then from San Diego to Norfolk, he had allergies and that they became worse when he was in Washington. He reports that he now takes Allegra for allergies and that he has year-round symptoms. A review of the claims file does not clearly show whether the Veteran has a diagnosis of allergies, but the Veteran has a history of reporting that he has allergy symptoms and/or takes medication for allergies. In May 2016, the Veteran reported that he had not been using his CPAP machine due to congestion related to his allergies. On his June 2016 Notice of Disagreement, the Veteran reported that his allergies were being treated with medication. The STRs are also unclear as to whether or not the Veteran was diagnosed with allergies or experienced allergy symptoms in service. In March 1989, the Veteran reported experiencing a runny nose, sneezing, and sinus irritation. In May 1996, between periods of active service, National Guard Records document that the Veteran had a history of allergies, was currently experiencing symptoms of a stuffy nose, coughing, wheezing, and difficulty breathing, and was diagnosed with allergic rhinitis. On an August 2000 Report of Medical History, the Veteran documented having or having had hay fever, which he further described as having allergies during the summer. In April 2007 private records, between periods of active service, it was documented that the Veteran had no known allergies but was reporting that he had allergies and increased nasal congestion. A diagnosis of allergic rhinitis was provided. Despite these reports that suggest some type of allergies, other STRs specifically document that the Veteran did not have allergies. In a June 1995 Report of Medical History, the Veteran specifically denied having allergies. In February 2006, the Veteran reported that he was allergic to food, tomatoes, and milk. However, as the STRs document evidence establishing that an event, injury, or disease occurred in service or at least an in-service flare-up of symptoms, and the Veteran testified to competent evidence of a current disability or persistent or recurrent symptoms of a disability that may be associated with the Veteran's service, the Board finds the McLendon criteria have been met and a VA examination was warranted. McLendon v. Nicholson, 20 Vet. App. 79 (2006). 6. Entitlement to service connection for migraine headaches The Veteran has not been provided a VA examination in relation to his claim for service connection for migraine headaches. At the February 2021 hearing, the Veteran testified that he experienced ongoing migraines. He testified that his migraines began between 1989 and 1990 and got worse in approximately 2007. Private treatment records from October 2013, just a few months after the Veteran's discharge from active service document that the Veteran has longstanding health issues, including migraine headaches. The Veteran's STRs document that he experienced migraine headaches in November 2007, during a period of active service, consistent with the Veteran's testimony. As the STRs document at least one instance of competent evidence of a current disability or persistent or recurrent symptoms of a disability, and the Veteran's testimony and private treatment records from the period immediately following the Veteran's last period of active service contain competent evidence of a current disability or persistent or recurrent symptoms of a disability that may be associated with the Veteran's service, the Board finds the McLendon criteria have been met, and a VA examination is warranted in connection with this claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006). 7. Entitlement to service connection for a chronic widespread rash on the shoulders, chest, and abdomen The Veteran has not been provided a VA examination in relation to his claim for service connection for a chronic widespread rash. At the February 2021 hearing, the Veteran testified that he first noticed a rash when he was serving in the United Kingdom, which was during the period of active duty from January 2005 to July 2005. The Veteran testified that he was told to use the same cream he was provided for his athlete's foot to treat the rash. The Veteran testified that since that time the rash returns approximately once per year, starting with a small spot and spreading up over his chest. Additionally, May 2016 VA records document that the Veteran requested a cream to treat ringworm, and August 2017 and February 2018 VA treatment records document that the Veteran had another flare-up of a rash. The August 2017 records document that the Veteran reported that he had this type of a rash every few years since being in the military. The STRs document that the Veteran reported a rash on his lower chest that itched in January 1988. Though STRs do not document that the Veteran reported a rash during his service in England, the Veteran submitted a prescription, dated June 2005, for Clotrimazole, which is a medication used to treat Athlete's foot, consistent with the February 2021 testimony. Additionally, October 2013 STRs from just a few months after the Veteran's discharge from active service and prior to his discharge from the National Guard document that the Veteran was diagnosed with ringworm, and the Veteran reported that he had the rash for approximately two months. As the STRs document evidence establishing that an event, injury, or disease occurred in service, specifically in January 1988, and the Veteran testified to and VA treatment records from the period on appeal document competent evidence of a current disability or persistent or recurrent symptoms of a disability that may be related to the Veteran's service, the Board finds the McLendon criteria have been met, and a VA examination must be provided. McLendon v. Nicholson, 20 Vet. App. 79 (2006). 8. Entitlement to service connection for athlete's foot The Veteran has not been provided a VA examination in relation to his claim for service connection for athlete's foot, diagnosed as tinea pedis. At the February 2021 hearing, the Veteran testified that he was treated for athlete's foot in service and that he has had flare-ups since that time for which he has been given powders and creams to treat his symptoms. The STRs document that the Veteran was diagnosed with tinea pedis during his active service. September 1986 STRs document a diagnosis of tinea pedis, and the Veteran reported having or having had trouble with his feet, which he noted was a history of athlete's foot, on the February 1990 separation Report of Medical History. A prescription label receipt date by the Veteran and dated June 2006 documents that the Veteran was prescribed Clotrimazole, a medication used to treat athlete's foot. On a November 2011 VA examination report, conducted during the Veteran's last period of active service, it was documented that the Veteran reported having tinea pedis. As the STRs document evidence establishing that an event, injury, or disease occurred in service, and the Veteran provided testimony that would establish evidence of a current disability or persistent or recurrent symptoms of a disability that may be associated with the Veteran's active service, the Board finds the McLendon criteria have been met, and a VA examination must be provided. McLendon v. Nicholson, 20 Vet. App. 79 (2006). Additionally, the Board notes that the November 2011 VA examiner documented that there is a strong association between tinea pedis and diabetes mellitus and that the tinea pedis may be related to the service-connected diabetes mellitus. However, the Board notes that the Veteran was diagnosed with diabetes mellitus decades after the first notations of tinea pedis in the claims file, which was not addressed by the November 2011 VA examiner. Thus, an opinion as to whether the tinea pedis is at least as likely as not caused or aggravated by service-connected diabetes mellitus must also be obtained. 9. Entitlement to service connection for obstructive sleep apnea The Veteran has asserted at his hearing that his obstructive sleep apnea was caused or aggravated by his psychiatric disorder. Thus, the issue of entitlement to service connection for obstructive sleep apnea is inextricably intertwined with the issue of entitlement to service connection for a psychiatric disorder, which has been remanded. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination in connection with the claim for service connection for residuals of an inner ear infection, including a slight facial droop. The examiner must review the claims file. The examiner should note any current diagnosis and document any residuals from the November 2007 in-service incident of Bell's palsy. See VBMS entry with document type, "Medical Treatment Record Non-Government Facility," receipt date 09/30/2015, with "#2" in the subject field, pp. 5-6. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider the symptoms as a "disability" for the purpose of providing the requested opinion below. The examiner is asked to provide a response to the following: Is it at least as likely as not (50 percent probability or greater) that the Veteran has a current disability or symptoms of a disability that is related to service, including the November 2007 incident in which it was documented that the Veteran had Bell's palsy? The examiner is asked to provide a rationale for the opinion given, including providing the medical principles and evidence relied upon for the opinion. If the examiner is unable to provide an opinion without resorting to speculation, he or she should explain why this is so and what, if any, additional evidence would be necessary before an opinion could be rendered. 2. Obtain an addendum opinion from an appropriate clinician in connection with the claim for service connection for a psychiatric disorder, diagnosed as adjustment disorder with mixed anxiety and depressed mood. If the clinician finds that an in-person examination is warranted to provide an informed opinion, an examination should be scheduled. The examiner is asked to opine: (a) Is the diagnosed psychiatric disorder at least as likely as not (50 percent probability or greater) related to an in-service injury, event, or disease? The Veteran had periods of active duty from March 1986 to March 1990; January 2005 to July 2005; January 2006 to May 2006; October 2007 to February 2008; and May 2008 to April 2013. In providing this opinion, the examiner should specifically comment on the February 1990 Report of Medical History in which the Veteran documented a positive history of depression or excessive worry, as well as the March 2013 STRs in which the Veteran endorsed having little interest or pleasure in doing things and feeling down/depressed over the previous year. See VBMS entry with document type, "STR Medical," receipt date 06/06/1990, with "#1" in the subject field, pp. 4-5 (February 1990 Report of Medical History showing a positive history of depression or excessive worry, which he stated involved worrying about personal problems); VBMS entry with document type, "STR," receipt date 03/22/2017, with "#1" in the subject field, p. 17 (March 2013 positive depression screen). (b) If the answer to (a) is negative, is the psychiatric disorder at least as likely as not (50 percent probability or greater) caused by the service-connected diabetes mellitus and/or medications taken to treat his service-connected disabilities? The Veteran has stated that the stress of his service-connected diabetes mellitus and all of the medications he has to take are also causing him stress. (c) If the answers to (a) and (b) are negative, is it at least as likely as not (50 percent probability or greater) that the psychiatric disorder is aggravated by the service-connected diabetes mellitus and/or medications taken to treat his service-connected disabilities? Aggravation is different from causation in that it did not cause the disability but that it caused an increase in severity that is not due to the natural progress of the disability. (d) If the examiner finds that the service-connected diabetes mellitus and/or medications taken to treat his service-connected disabilities aggravates the psychiatric disorder, the examiner is asked to state whether there is medical evidence created prior to the aggravation or at any time between the time of aggravation and the current level of disability that shows a baseline for the psychiatric disorder prior to aggravation. If the examiner is unable to establish a baseline for the psychiatric disorder prior to the aggravation, he or she should state such and explain why a baseline cannot be determined. The examiner is asked to provide a rationale for each opinion given, including providing the medical principles and evidence relied upon for each opinion. If the examiner is unable to provide an opinion without resorting to speculation, he or she should explain why this is so and what, if any, additional evidence would be necessary before an opinion could be rendered. 3. Schedule the Veteran for a VA examination in connection with the claim for service connection for chronic allergies. The examiner must review the claims file. The examiner should note any current diagnosis. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion below. The examiner is asked to provide a response to the following: Is any diagnosed disability related to allergies or any residual symptoms causing functional impairment at least as likely as not (50 percent probability or greater) had its onset during a period of active duty? The Veteran had periods of active duty from March 1986 to March 1990; January 2005 to July 2005; January 2006 to May 2006; October 2007 to February 2008; and May 2008 to April 2013. The examiner is asked to provide a rationale for the opinion given, including providing the medical principles and evidence relied upon for the opinion. If the examiner is unable to provide an opinion without resorting to speculation, he or she should explain why this is so and what, if any, additional evidence would be necessary before an opinion could be rendered. 4. Schedule the Veteran for a VA examination in connection with the claim for service connection for migraine headaches. The examiner must review the claims file. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider the symptoms a "disability" for the purpose of providing the requested opinions below. The examiner is asked to provide a response to the following: Is it at least as likely as not (50 percent probability or greater) that the headaches or migraine headaches (1) began during active service or (2) manifested within one year after discharge from service? The Veteran had periods of active duty from March 1986 to March 1990; January 2005 to July 2005; January 2006 to May 2006; October 2007 to February 2008; and May 2008 to April 2013. The examiner is asked to provide a rationale for each opinion given, including providing the medical principles and evidence relied upon for each opinion. If the examiner is unable to provide an opinion without resorting to speculation, he or she should explain why this is so and what, if any, additional evidence would be necessary before an opinion could be rendered. 5. Schedule the Veteran for a VA examination in connection with the claim for service connection for a chronic, widespread rash. The examiner must review the claims file. The examiner should note any current diagnosis. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion below. The examiner is asked to provide a response to the following: Is any diagnosed disability of a chronic widespread rash or any residuals causing functional impairments at least as likely as not (50 percent probability or greater) related to service? The Veteran had periods of active duty from March 1986 to March 1990; January 2005 to July 2005; January 2006 to May 2006; October 2007 to February 2008; and May 2008 to April 2013. The examiner is asked to provide a rationale for each opinion given, including providing the medical principles and evidence relied upon for each opinion. If the examiner is unable to provide an opinion without resorting to speculation, he or she should explain why this is so and what, if any, additional evidence would be necessary before an opinion could be rendered. 6. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any diagnosed tinea pedis and/or athlete's foot. The examiner must review the claims file. The examiner is asked to opine: (a) Is the diagnosed tinea pedis or athlete's foot at least as likely as not (50 percent probability or greater) related to an in-service injury, event, or disease? The Veteran had periods of active duty from March 1986 to March 1990; January 2005 to July 2005; January 2006 to May 2006; October 2007 to February 2008; and May 2008 to April 2013. (b) If the answer to (a) is negative, is the tinea pedis or athlete's foot at least as likely as not (50 percent probability or greater) caused by the service-connected diabetes mellitus? In a November 2011 VA examination report, the examiner documented that there is a strong association between tinea pedis and diabetes mellitus and that the tinea pedis may be related to the service-connected diabetes mellitus. The Veteran was diagnosed with tinea pedis during his first period of active duty from March 1986 to March 1990 and was first diagnosed with diabetes mellitus in October 2010. See VBMS entry with document type, "VA Examination," receipt date 11/18/2011. (c) If the answers to (a) and (b) are negative, is it at least as likely as not (50 percent probability or greater) that the tinea pedis or athlete's foot is aggravated by the service-connected diabetes mellitus? Aggravation is different from causation in that it did not cause the disability but that it caused an increase in severity that is not due to the natural progress of the disability. (d) If the examiner finds that diabetes mellitus aggravates the tinea pedis or athlete's foot, the examiner is asked to state whether there is medical evidence created prior to the aggravation or at any time between the time of aggravation and the current level of disability that shows a baseline for the tinea pedis or athlete's foot prior to aggravation. If the examiner is unable to establish a baseline for the tinea pedis or athlete's foot prior to the aggravation, he or she should state such and explain why a baseline cannot be determined. The examiner is asked to provide a rationale for each opinion given, including providing the medical principles and evidence relied upon for each opinion. If the examiner is unable to provide an opinion without resorting to speculation, he or she should explain why this is so and what, if any, additional evidence would be necessary before an opinion could be rendered. A. P. SIMPSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Keninger, 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.