Citation Nr: 21068875 Decision Date: 11/15/21 Archive Date: 11/15/21 DOCKET NO. 19-18 113 DATE: November 15, 2021 REMANDED Entitlement to service connection for a skin disorder on the feet, to include dermatophytosis and tinea pedis, is remanded. REASONS FOR REMAND The Veteran served on active duty from April 1954 to March 1956. In March 2020, the Veteran provided testimony at a Travel Board hearing before the undersigned Veterans Law Judge (VLJ) in San Antonio, Texas. The Board remanded the claim for further development in June 2020. In December 2020, the Board issued a decision that denied the Veteran's claim. The Veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). In July 2021, the Veteran and the Secretary of VA (parties) filed a Joint Motion for Partial Remand (JMPR) to vacate and remand the claim back to the Board, which was granted by the Court. Entitlement to service connection for a skin disorder on the feet, to include dermatophytosis and tinea pedis, is remanded. The parties to the July 2021 JMPR had found that the Board erred when it failed to provide an adequate statement of reasons or bases when it found that VA was not required to provide a medical examination in this case. The Board found that a VA examination was not warranted because "the evidence does not show that this disability may be associated with the Veteran's service." However, the parties found that the Board failed to address relevant evidence in its analysis. Specifically, at a March 2020 hearing before the Board, the Veteran testified affirmatively to having "things that look like red, round circles with a little silver lining around it" on his feet during service, that he saw a doctor for this condition, that he continues to have this condition today, and that he puts Vicks on it to relieve the itching and redness. The Board notes that efforts have been made to obtain the service treatment records to verify his in-service treatment, however, have been unsuccessful as such were deemed fire-related. During the March 2020 Board hearing, the Veteran has mentioned private post-service treatment. While VA attempted to obtain such records within the June 2020 Board remand, the Veteran has not cooperated in completing the required forms requested as part of the June 2020 Board remand. The Veteran is reminded that the duty to assist a claimant in the development of an application for benefits is a two-way street. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Additionally, a VA regulation requires that the claimant must cooperate in VA's efforts to obtain relevant records from a non-Federal agency. See 38 C.F.R. § 3.159(c)(1)(ii) (stating, "The claimant must cooperate fully with VA's reasonable efforts to obtain relevant records from non-Federal agency or department custodians.). The Veteran will be given the opportunity a second time to provide VA with permission to obtain the records identified at the March 2020 hearing. In performing an internet search, the Board is correcting the name of the nurse practitioner, whose name is Anne Elizabeth Mosiman, and the doctor's office where she works is Dr. Baldemar Covarrubias, which office is located at 5718 Spohn Dr., Corpus Christi, Texas 78414. By providing the correct name and address of the facility where the nurse practitioner works, the Board hopes it will make it easier for the Veteran to provide VA with permission to obtain these treatment records. As the Board found that the Veteran was competent to report a rash on his foot during service and that he was in the water with boots, and his testimony provides an indication that the current disability may be associated with military service, given the "low threshold" in McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006), the Board finds that a VA examination and medical opinion are necessary to adjudicate the claim pursuant to the July 2021 JMPR. The matter is REMANDED for the following action: 1. Request the Veteran complete a VA Form 21-4142, Authorization to Disclose Information to the Department of Veterans Affairs (VA), to allow VA to obtain treatment records from Anne Elizabeth Mosiman, nurse practitioner, from the office of Dr. Baldemar Covarrubias, which office is located at 5718 Spohn Dr., Corpus Christi, Texas 78414. The Veteran is asked to cooperate with this request, as he identified these records at the March 2020 Board hearing. See 38 C.F.R. § 3.159(c)(1)(ii) (stating, "The claimant must cooperate fully with VA's reasonable efforts to obtain relevant records from non-Federal agency or department custodians."). 2. Schedule the Veteran for a VA examination to evaluate the current nature and etiology of his claimed skin disability on the feet. The Veteran's claims file should be made available to be reviewed by the examiner in conjunction with the examination. All appropriate tests, studies, and consultations should be accomplished, and all clinical findings should be reported in detail, to include current symptomatology of a skin disability. The agency of original jurisdiction is asked to provide a copy of the below facts to the examiner. The VA examiner's attention is drawn to the following with citations to the record, when applicable: The Veteran served on active duty from April 1954 to March 1956. The Veteran's Certificate of Release or Discharge from Active Duty (DD-214) indicates that his military occupational specialty (MOS) was a supply handler. The Veteran testified during a March 2020 Board hearing that he had seen a doctor while in service for a skin condition, a ringworm, "things that look like red, round circles with a little silver lining around it," as described by his representative. See VBMS entry with document type, "Hearing Transcript," receipt date 03/10/2020, on pages 3-6. The Veteran stated that the rash was on his feet but did not remember if he had it anywhere else, because "it's been 50, 60 years." He testified to getting into "the water in Korea [with boots on]" in 1956 but "can barely remember." Id. The Veteran reported he still had the problem currently and it "comes and goes." He reported he had seen a doctor for it but not recently. He stated he applied Vicks to relieve itching and redness. Id at pages 11-12. A March 2001 VA treatment record shows that diabetes was the only diagnosis on the Veteran's active problem list. The examiner performed a physical examination and documented overgrown nails when evaluating the extremities. There was no skin diagnosis entered. See VBMS entry with document type, "CAPRI," receipt date 06/22/2018, with "#1" in the subject field, pp. 150-151. An August 2001 VA treatment record shows that the Veteran's active problem list included diabetes, joint pain involving the shoulder, and hyperlipidemia. See VBMS entry with document type, "CAPRI," receipt date 06/22/2018, with "#1" in the subject field, p. 146. A December 2003 VA treatment record shows the Veteran's active problem list included diabetes, joint pain involving the shoulder, hyperlipidemia, elevated liver function tests, diverticulosis, and hemorrhoids. All of these diagnoses were added to the Veteran's active problem list in 2001. The Veteran presented for diabetes foot care. The examiner documented the Veteran had dystrophic, discolored, elongated nails. Under assessment, the examiner checked diabetes mellitus, debridement, and onychomycosis. One of the options was "Tinea Pedis," and the examiner did not check that box, which the Board construes means that the Veteran did not have tinea pedis at that time. See VBMS entry with document type, "CAPRI," receipt date 06/19/2020, with "#1" in the subject field, pp. 143-144. A June 2005 VA treatment record shows the Veteran underwent a comprehensive foot examination that day. The examiner documented that both feet were normal without evidence of skin breaks, deformity, trauma, erythema, dependent rubor, edema, corns, excessive callus or nail abnormality. See VBMS entry with document type, "CAPRI," receipt date 06/22/2018, with "#1" in the subject field, p. 107. A July 2006 VA treatment record shows that a physical examination of the Veteran's extremities revealed no clubbing, cyanosis, or pedal edema. See VBMS entry with document type, "CAPRI," receipt date 06/22/2018, with "#1" in the subject field, p. 95. An October 2006 VA treatment record shows that a physical examination of the Veteran's extremities revealed no edema or ulcers. See VBMS entry with document type, "CAPRI," receipt date 06/22/2018, with "#1" in the subject field, p. 91. An April 2007 VA treatment record shows the Veteran was there for diabetes foot care. The examiner documented the Veteran had dystrophic, discolored, elongated nails. Under the assessment, the examiner checked diabetes mellitus, debridement, onychomycosis, and tinea pedis. This is the first diagnosis of tinea pedis documented in the VA treatment records. See VBMS entry with document type, "CAPRI," receipt date 06/22/2018, with "#1" in the subject field, p. 83. Following this treatment, a diagnosis of tinea pedis was documented regularly in 2009 and 2010 when the Veteran was seen for diabetic foot care. See VBMS entry with document type, "CAPRI," receipt date 06/22/2018, with "#1" in the subject field, pp. 13 (November 2010), 16 (September 2010), 18 (August 2010), 25 (April 2010), 30 (November 2009), 40 (July 2009). Tinea Pedis was added to the Veteran's active problem list in June 2011. VA is in the process of obtaining private treatment records that the Veteran identified. Thus, they may have been added to the file after October 2021. The examiner's review of the record is NOT restricted to the evidence listed above. This list is provided to assist the examiner in locating potentially relevant evidence. The examiner is asked to answer the following questions based upon the evidence of record and sound medical principles: a. Please list the Veteran's diagnosed skin disabilities on the feet. b. For each skin disability offered, is it at least as likely as not (50 percent or greater likelihood) related to the Veteran's service from April 1954 to March 1956? Please state upon what facts, medical principles, and/or medical literature the opinion is based. The examiner should consider and address the Veteran's testimony from the March 2020 Board hearing. (Locations in VBMS file laid out above). Please explain your answers by citing to supporting clinical data and/or medical literature, as deemed appropriate. A full rationale must be provided for all medical opinions given. If the examiner is unable to provide an opinion without resorting to mere speculation, he or she should explain why this is so. The examiner shall then explain whether the inability to provide a more definitive opinion is the result of a need for more information and indicate what additional evidence is necessary, or whether he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). 3. After all available evidence has been associated with the record, review the evidence, and determine if further development is warranted. The AOJ should take any additional development as deemed necessary. A. P. SIMPSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Cheng, 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.