Citation Nr: 21068409 Decision Date: 11/10/21 Archive Date: 11/10/21 DOCKET NO. 17-20 708 DATE: November 10, 2021 REMANDED Issue of entitlement to service connection for a fungal infection of the groin, also claimed as jock itch, is remanded. Issue of entitlement to service connection for left pectoral area cellulitis, also claimed as boil under left arm, is remanded. Issue of entitlement a total disability rating based on individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1966 to April 1968. This appeal to the Board of Veterans' Appeals (Board) arose from an April 2015 rating decision issued by the Department of Veterans Affairs (VA). See June 2015 Notice of Disagreement (NOD); April 2017 Statement of the Case (SOC); April 2017 Substantive Appeal (VA Form 9). The Veteran testified at a February 2017 hearing before a Decision Review Officer. February 2017 Hearing Testimony. The Veteran requested a hearing before a Veterans Law Judge but then withdrew his request. April 2017 VA Form 9; October 2020 VA Form 27-0820. The Board notes that the Veteran did not perfect his appeal to the Board for the issues of entitlement to increased ratings for diabetes mellitus and hypertension, and to service connection for a left leg boil. See April 2017 SOC; April 2017 VA Form 9. The issues are, thus, no longer in appellate status or before the Board. 1. Issue of entitlement to service connection for a fungal infection of the groin, also claimed as jock itch, is remanded. 2. Issue of entitlement to service connection for left pectoral area cellulitis, also claimed as boil under left arm, is remanded. Additional evidence was added to the claims file since the last adjudication by the agency of original jurisdiction (AOJ), including a December 2020 VA examination for skin diseases. A September 2021 letter from the Board asked the Veteran if he wished to waive AOJ review of the additional evidence. The Veteran did not respond within 45 days from the date of the letter. The Board, thus, finds that this appeal needs to be remanded to the AOJ for readjudication. The Board also finds that additional development by a VA examiner is needed to clarify whether the Veteran's asserted groin area fungal infection and left pectoral area cellulitis are current disabilities and, if so, whether they are secondary to his service-connected diabetes mellitus. A March 2017 VA examination report for skin disease indicates that the Veteran had diagnoses in 2017 for tinea cruris and left pectoral furuncle, but the report also indicates that there is no finding of actual treatment for these skin conditions other than a September 2011 treatment note describing a thigh lesion. It is unclear from the VA examiner's findings if the Veteran's fungal infection of the groin and left pectoral area cellulitis are current disabilities. The March 2017 VA examiner then opined that the Veteran's skin conditions are less likely than not proximately due to or the result of his diabetes mellitus because the medical literature suggests that diabetes mellitus may create a predisposition to both bacterial and fungal infections, but the examiner felt it is not enough for a "greater than 50% cause/effect relationship." See March 2017 VA Examination Medical Opinion. However, the VA examiner provided insufficient rationale as to why the medical literature is not enough to support a cause/effect relationship. In addition, the question for the VA examiner is whether the Veteran's skin conditions are at least as likely as not secondary to his diabetes mellitus, a 50 percent or greater probability. The March 2017 VA examiner appears to have imposed a higher burden with a "greater than 50%" standard. The VA examiner also did not address whether the Veteran's skin conditions are aggravated by his diabetes mellitus. See id. Another VA examination is, thus, needed. Lastly, the Veteran's representative also contended that the Veteran's skin conditions are due to his in-service exposure to herbicide agents. June 2015 NOD. The VA examiner should also address this theory of entitlement. 3. Issue of entitlement to a TDIU is remanded. Because a decision on the remanded issues of entitlement to service connection for a fungal infection of the groin and for left pectoral area cellulitis could significantly impact a decision on the issue of entitlement to a TDIU, the issues are inextricably intertwined. A remand of this claim is required. The matters are REMANDED for the following action: 1. Schedule a VA examination to determine the nature and cause of the Veteran's skin conditions, to include tinea cruris and left pectoral furuncle. A detailed explanation (rationale) is requested. The medical professional should respond to the following: (a) Identify any evidence that the Veteran has or has had a skin disease recent to and since his August 2011 claim. The VA examiner should specifically consider and discuss the March 2017 VA examination for skin disease, which noted 2017 diagnoses for tinea cruris and left pectoral furuncle. (b) For each identified skin disease, is it at least as likely as not (a 50 percent or greater probability) that it began in or is otherwise related to the Veteran's military service? The examiner should consider the contention in the June 2015 NOD that the Veteran's boils are due to his in service exposure to herbicide agents. The examiner is advised that a negative opinion cannot be based solely on the fact that the identified skin condition is not on the list of disease that are presumptively associated with exposure to herbicide agents. (c) For each identified skin disease, the examiner should also provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that it is proximately due to or the result of his service connected diabetes mellitus. The examiner should consider and discuss the Veteran's assertion during the February 2017 DRO hearing and March 2017 VA examination for skin disease that he has had boils and fungal infections since his diabetes diagnosis in the 1990s. The examiner should also specifically consider and discuss the medical literature cited in the March 2017 VA examination about the predisposition diabetics have to skin infections. (d) For each identified skin disease, the examiner should also provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that it is aggravated (any increase in severity beyond its natural progression) by his service-connected diabetes. The examiner should consider and discuss the Veteran's assertion during the February 2017 DRO hearing and March 2017 VA examination for skin disease that he has had boils and fungal infections since his diabetes diagnosis in the 1990s. The examiner should also specifically consider and discuss the medical literature cited in the March 2017 VA examination about the predisposition diabetics have to skin infections. R. FEINBERG Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Lin 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.