Citation Nr: 21067072 Decision Date: 11/03/21 Archive Date: 11/03/21 DOCKET NO. 15-00 698A DATE: November 3, 2021 REMANDED Entitlement to service connection for a respiratory disorder, claimed as sarcoidosis, is remanded. Entitlement to service connection for a neurological disorder, claimed as tremors, is remanded. Entitlement to service connection for a skin disorder, claimed as skin lesions, is remanded. REASONS FOR REMAND These matters were previously before the Board of Veterans' Appeals (Board) in July 2019, when they were remanded for further development. The Board acknowledges its prior remand referenced the issues on appeal in a single issue statement; however, as discussed in more detail below, consolidating the symptoms claimed by the Veteran into a single issue statement has resulted in difficulty in obtaining an adequate nexus opinion. For clarity, the Board has now recharacterized the issues on appeal, as noted above, in accordance with the Veteran's testimony during a January 2019 hearing before undersigned, to facilitate obtaining an opinion that more clearly focuses on the separate symptoms claimed by the Veteran. The Board's July 2019 remand directives instructed the Agency of Original Jurisdiction (AOJ) to obtain both a direct and secondary service connection opinion regarding the symptoms claimed by the Veteran. Unfortunately, the September 2021 opinion the AOJ obtained is inadequate to make an informed decision on the Veteran's claims. Initially, the Board notes the author of the September 2021 opinion, T.D., M.D., provided a summary rationale for his conclusions regarding direct service connection, as well as both causation and aggravation in the context of secondary service connection, for all of the symptoms claimed by the Veteran, which makes it difficult to understand the precise basis for each conclusion contained in the report, as well whether there was adequate consideration of the Veteran's lay reports. Further, the claims file contains two versions of the September 2021 opinion authored by T.D., M.D., the first of which clearly indicates a mental health expert should provide the secondary service connection opinion with a second version appearing to have been rewritten to omit any reference to the need of an additional expert. In light of these deficiencies, the Board finds a new opinion is necessary to ensure compliance with its prior remand directives, as well as VA's duty to assist. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination to obtain a new opinion regarding the issue of service connection for a respiratory disorder, claimed as sarcoidosis, preferably with an examiner who has not previously examined the Veteran. The selected examiner must provide an opinion addressing whether the Veteran has a respiratory disorder, to include, but not limited to, sarcoidosis, that is at least as likely as not (50 percent probability or greater) the result of an in-service disease or injury; or proximately due to, or aggravated by, her service-connected post-traumatic stress disorder (PTSD). The secondary service connection opinion must address causation and aggravation separately to be deemed adequate. A mere conclusion regarding aggravation without a separate rationale is not sufficient. The examiner must be advised aggravation means an increase in the severity of the underlying disability beyond its natural progression. If aggravation is found, the examiner should attempt to quantify the degree of additional disability resulting from the aggravation above the baseline level of disability. If the secondary service connection opinion is not provided by a mental health expert, as suggested by T.D., M.D., in his initial September 2021 opinion, the author of the opinion must include a specific discussion of his or her qualifications to address a potential link between the claimed disability and the Veteran's service-connected PTSD. The examiner must be further advised the Veteran is competent to report her symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinion. If the examiner rejects the Veteran's reports, he or she must provide a reason for doing so. The examination report must include a complete rationale for all conclusions contained therein. 2. Schedule the Veteran for an examination to obtain a new opinion regarding the issue of service connection for a neurological disorder, claimed as tremors, preferably with an examiner who has not previously examined the Veteran. The selected examiner must provide an opinion addressing whether the Veteran has a neurological disorder, manifesting in tremors, that is at least as likely as not (50 percent probability or greater) the result of an in-service disease or injury; or proximately due to, or aggravated by, her service-connected PTSD. The secondary service connection opinion must address causation and aggravation separately to be deemed adequate. A mere conclusion regarding aggravation without a separate rationale is not sufficient. The examiner must be advised aggravation means an increase in the severity of the underlying disability beyond its natural progression. If aggravation is found, the examiner should attempt to quantify the degree of additional disability resulting from the aggravation above the baseline level of disability. If the secondary service connection opinion is not provided by a mental health expert, as suggested by T.D., M.D., in his initial September 2021 opinion, the author of the opinion must include a specific discussion of his or her qualifications to address a potential link between the claimed disability and the Veteran's service-connected PTSD. The examiner must be further advised the Veteran is competent to report her symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinion. If the examiner rejects the Veteran's reports, he or she must provide a reason for doing so. In this regard, the examiner must explicitly acknowledge the Veteran's credible lay reports of continuously experiencing tremors since first manifesting involuntary movements and twitching in service, as documented in her service treatment records. The examination report must include a complete rationale for all conclusion contained therein. 3. Schedule the Veteran for an examination to obtain a new opinion regarding the issue of service connection for a skin disorder, claimed skin lesions, preferably with an examiner who has not previously examined the Veteran. The selected examiner must provide an opinion addressing whether the Veteran has a skin disorder, to include, but not limited to, skin lesions, that is at least as likely as not (50 percent probability or greater) the result of an in-service disease or injury; or proximately due to, or aggravated by, her service-connected PTSD. The secondary service connection opinion must address causation and aggravation separately to be deemed adequate. A mere conclusion regarding aggravation without a separate rationale is not sufficient. The examiner must be advised aggravation means an increase in the severity of the underlying disability beyond its natural progression. If aggravation is found, the examiner should attempt to quantify the degree of additional disability resulting from the aggravation above the baseline level of disability. If the secondary service connection opinion is not provided by a mental health expert, as suggested by T.D., M.D., in his initial September 2021 opinion, the author of the opinion must include a specific discussion of his or her qualifications to address a potential link between the claimed disability and the Veteran's service-connected PTSD. The examiner must be further advised the Veteran is competent to report her symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinion. If the examiner rejects the Veteran's reports, he or she must provide a reason for doing so. The examination report must include a complete rationale for all conclusion contained therein. M. HYLAND Veterans Law Judge Board of Veterans' Appeals Attorney for the Board L. S. Kyle, 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.