Citation Nr: 21072669 Decision Date: 12/06/21 Archive Date: 12/06/21 DOCKET NO. 17-07 632 DATE: December 6, 2021 ORDER Service connection for tinnitus is granted. Service connection for an acquired psychiatric disability, to include posttraumatic stress disorder (PTSD), depression, anxiety, mood disorder, and adjustment disorder, is denied. REMANDED Entitlement to service connection for bilateral hearing loss is remanded. Entitlement to service connection for a skin disability, to include tinea versicolor and tinea cruris, is remanded. FINDINGS OF FACT 1. The Veteran's tinnitus began immediately following and has continued since active service and is etiologically related to his military noise exposure. 2. The Veteran does not have a current diagnosis of PTSD; symptoms of an acquired psychiatric disability other than PTSD were not continuous or recurrent in service and have not been continuous or recurrent since service separation; and there is no medical nexus between the current psychiatric disability and active service. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in favor of the Veteran, the criteria for service connection for tinnitus have been met. 38 U.S.C. §§ 101, 1101, 1110, 1131, 5103(a), 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304. 2. The criteria for service connection for an acquired psychiatric disability, to include PTSD, depression, anxiety, mood disorder, and adjustment disorder, have not been met. 38 U.S.C. §§ 101, 1101, 1110, 1131, 5103(a), 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran, who is the Appellant in this case, had active service from January 1984 to May 1984 and December 1990 to July 1991, with additional Reserve service until 1993. This matter comes before the Board of Veterans' Appeals (BVA or Board) from a March 2015 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). On his February 2017 VA Form 9, the Veteran requested a videoconference hearing before the Board. The hearing was scheduled for June 3, 2021, at the St. Louis RO, and notice of the hearing date and place was provided to the Veteran. However, the Veteran did not report for the hearing, and no request for postponement was received and granted prior to the hearing date. Under 38 C.F.R. § 20.704(d), when a veteran fails to appear for a scheduled hearing and no request for postponement is received, the claim is processed as though the request for hearing had been withdrawn. Therefore, this case will be processed as though the request for a hearing was withdrawn, and the Board can now proceed to appellate review. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (1) competent evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) competent evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The United States Court of Appeals for Veterans Claims (Court) has held that "Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). Where a veteran who served for ninety days or more during a period of war (or during peacetime service after December 31, 1946) develops certain chronic diseases, such as organic diseases of the nervous system (e.g., tinnitus), to a degree of 10 percent or more within one year from separation from service, such diseases may be presumed to have been incurred in service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. See 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). In this case, as discussed below, the medical evidence of record demonstrates tinnitus. Where the veteran asserts entitlement to service connection for a chronic disease but there is insufficient evidence of a diagnosis in service, service connection may be established under 38 C.F.R. § 3.303(b) by demonstrating a continuity of symptomatology since service or diagnosis within the presumptive period after service, but only if the chronic disease is listed under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331, 1338-39 (Fed. Cir. 2013); 38 C.F.R. § 3.307 (service connection authorized for chronic diseases diagnosed within the presumptive period). With specific regard to continuity of symptomatology, for the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. If a condition, such as tinnitus, noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). The psychiatric disability at issue is not among the "chronic diseases" listed under 38 C.F.R. § 3.309(a); therefore, 38 C.F.R. § 3.309(b) (requiring continuity of a condition after service if chronicity is not found in service) does not apply to that disorder. See Walker, 708 F.3d 1331. Service connection may also 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). 1. Service connection for tinnitus is granted. The Veteran contends that his tinnitus is related to noise exposure during active service. Specifically, he was exposed to the noise of helicopters and static on the radio for hours during his second period of active service as a combat signaler. The RO conceded acoustic trauma for this period of service, and the Board also finds that such exposure occurred. His DD Form 214 for his second period of active service shows that his Military Occupational Specialty (MOS) was combat signaler for more than 7 years, which includes his Reserve service. For the reasons discussed below, the Board finds that the evidence is at least in equipoise as to whether the Veteran's tinnitus began during and has continued since his active service, and, resolving reasonable doubt in the Veteran's favor, finds that service connection for tinnitus is warranted. At a December 2016 VA audiological examination, the Veteran reported intermittent "ringing" in his ears since 1993. The VA examiner opined that the tinnitus was not related to active service because there were no complaints of tinnitus during active service and the Veteran reported inception of symptoms in 1993, 2 years after separation from active service. However, the Board notes that his Reserve service, during which time he continued to work in communications, ended in 1993. Thus, the examiner did not appear to consider the additional 2 years of noise exposure during Reserve service, nor did the examiner discuss the DD Form 214 noted above which demonstrates more than 7 years of duty as a combat signaler. The Veteran has competently and credibly stated that he has experienced ringing in his ears beginning immediately after his Reserve service and continuing to the present, and that, following service separation, he did not have occupational noise exposure. The Board finds that such continuity of symptomatology from active service establishes a nexus to active service. The Board acknowledges the negative nexus opinion of the March 2015 VA examiner. However, the RO deemed this opinion to be inadequate as the examiner did not appear to consider the Veteran's second period of active service during which the conceded acoustic trauma occurred, and the Board agrees with this assessment. Resolving reasonable doubt in favor of the Veteran, the Board finds that the evidence is at least in equipoise as to whether the Veteran's tinnitus began during and has been continuous since active service, and that, therefore, the Veteran's tinnitus is related to his military noise exposure, and service connection is warranted. 2. Service connection for an acquired psychiatric disability, to include posttraumatic stress disorder (PTSD), depression, anxiety, mood disorder, and adjustment disorder, is denied. The Veteran contends that his current psychiatric disability is related to events during active service. Specifically, he avers that he was exposed to dead bodies while service in Kuwait, and that he has had nightmares and sleep disturbances related to such exposure. His DD Form 214 from his second period of active service shows that he had service in Southwest Asia. For the reasons discussed below, the Board finds that the weight of the evidence is against a finding that the Veteran has a diagnosis of PTSD, and against a finding of a medical nexus between the current psychiatric disability and active service. Reviewing the most relevant evidence of record, service treatment records for both periods of active service are negative for any signs, symptoms, reports, findings, treatment, or diagnoses of any psychiatric conditions. The June 1991 separation examination report indicates a normal psychiatric evaluation, and the Veteran denied depression or excessive worry and nervous trouble on his Report of Medical History. Following separation from active service, in January 2015, the Veteran sought to establish care with VA, stating that he had not seen a doctor since 1993. He stated that he was "alright" until he served overseas in support of Operation Desert Storm; he reported that he had anxiety attacks and woke up at night with flashbacks. Later in January 2015, he was seen at the mental health clinic and reported ongoing depressive and anxiety symptoms, this time in the context of recently finding out his children were taken by DFS. It was noted that he had no previous formal psychiatric history. He stated that he was already "very depressed," and this incident put him "out of commission." He reported experiencing significant depressive symptoms, including depressed mood, decreased energy, disrupted sleep (only 4 hours/night), and intermittent feelings of hopelessness. He also described being "stressed out over many things," felt "on edge" all the time, and having occasional panic attacks. The clinician noted that he had recently been released from jail, with a distant history of sexual abuse of a minor. He met the criteria for major depressive disorder and was prescribed medication. In April 2015, the Veteran again discussed the situation involving his children being in state custody; however, he stated that he was not anxious about this, but, rather, he was experiencing "post syndrome" from seeing dead bodies in Kuwait. The clinician assessed unspecified anxiety disorder. The Veteran was afforded a VA PTSD examination in May 2016. The examiner concluded that the Veteran's symptoms did not meet the diagnostic criteria for PTSD under DSM-5 criteria, but instead diagnosed Unspecified Anxiety Disorder. The examiner explained that although the Veteran reported having experienced a Criterion A stressor (exposure to dead bodies while serving in Kuwait) during his service in the military, he did not meet the remaining criteria for a diagnosis of PTSD at this time. The main symptom reported by the Veteran was sleep disturbance. Based on the Veteran's report today, this symptom was not clearly related to his service in Desert Storm or any experiences therein. His ongoing sleep disturbance was reportedly characterized by recurrent episodes of abrupt terror arousals from sleep, often beginning with a panicked scream. He reported anxiety upon waking accompanied by signs of autonomic arousal (e.g., rapid breathing, sweating). He denied that he was able to recall any dream content upon waking (which is typical of sleep terrors). Although these episodes did cause the Veteran distress, they did not reportedly lead to noteworthy functional impairment. Indeed, the Veteran reported positive mood during waking hours and was currently feeling hopeful with regard to the future. With regard to Criterion B, the May 2016 VA examiner explained that the Veteran initially mentioned experiencing nightmares and "flashbacks" since 1993. However, when queried further, the Veteran clarified that multiple times per week, he woke with various physiological anxiety symptoms, but was unable to recall any dream content. As such, this was not considered a trauma-related re-experiencing symptom. Rather, this appeared to be more of a generalized anxiety symptom. The Veteran did not endorse any clear, trauma-related re-experiencing symptoms. The Veteran did not endorse any symptoms related to Criteria C and D. With regard to Criterion E, the Veteran endorsed sleep disturbance; however, this did not appear to be linked to his military experiences (either in a temporal manner or through information provided about symptom content). The May 2016 VA examiner concluded that, based on the content of the Veteran's symptoms and the time of onset of these symptoms (the Veteran reported first experiencing sleep disturbance in 1993, having a lull in this symptom for many years, and experiencing a reoccurrence in the last 6 months), it is less likely than not (less than 50% probability) that his current mental health symptoms (diagnosed as generalized anxiety disorder) are related to or caused by his military service or any stressors experienced therein. VA treatment records from November 2016 document diagnoses of likely adjustment disorder and unspecified depressive disorder, and in February 2017, he was diagnosed with adjustment disorder with mood disturbance. In an August 2017 VA mental disorders examination report, the examiner diagnosed mood disorder unspecified and personality disorder unspecified, expressing disagreement with the adjustment disorder diagnosis documented in VA treatment records and noting that he had a long history of behavioral abnormalities. The examiner noted that previous examinations had ruled out PTSD and opined that it is less likely than not that his mood condition was caused, aggravated, or associated with service. The examiner could not clinically make out the significance of his nightmares since he did not remember them and only inferred their presence from diaphoretic sweating. After a review of all of the evidence, lay and medical, the Board finds that the weight of the evidence is against a finding that the Veteran has a diagnosis of PTSD, and, further, that the weight of the evidence is against a finding that his psychiatric disability, variously diagnosed as depression, anxiety, mood disorder, and adjustment disorder, is related to events that occurred in active service. In addition to the laws and regulations outlined above, service connection for PTSD requires: medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a) (conforming to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). With regard to the first element necessary for a grant of service connection for PTSD (medical evidence of PTSD), the Board finds that the weight of the evidence is against a finding that there was a current diagnosis of PTSD. The first requirement for any service connection claim is competent evidence of existence of a current disability. Brammer, 3 Vet. App. at 225. As discussed above, the May 2016 VA examiner explained in detail why the Veteran's symptoms do not meet the criteria for a diagnosis of PTSD using the DSM-5 criteria. The Board finds this report to be the most probative evidence addressing the question of whether the Veteran has a diagnosis of PTSD, and it is supported by the VA treatment notes, which indicate that the Veteran's treating physicians did not diagnose PTSD. The August 2017 VA examiner also seemed to agree that the criteria for a diagnosis of PTSD were not met. Accordingly, the Board finds that the greater weight of the probative evidence is against finding that the Veteran has a current diagnosis of PTSD. Thus, in specific reference to the PTSD aspect of the appeal, the Board reiterates that in the absence of proof of a present disability there can be no valid claim. Brammer. As a result, the claim for service connection for PTSD is denied. The Board recognizes that the Court has held that the presence of a chronic disability at any time during the claim process can justify a grant of service connection, even where the most recent diagnosis is negative. McClain v. Nicholson, 21 Vet. App. 319 (2007) (the presence of a disability at any time during the claim process can justify a grant of service connection, even where the most recent diagnosis is negative). However, where the overall record fails to support a current diagnosis of the claimed disability, as is the case here, that holding would not apply. Next, as noted above, the Board finds that the weight of the evidence is against a grant of service connection for the Veteran's psychiatric disability, variously diagnosed as depression, anxiety, mood disorder, and adjustment disorder. After a review of the evidence of record, lay and medical, the Board finds that the weight of the evidence demonstrates that an acquired psychiatric disability did not have its onset during active service. As noted above, service treatment records are silent as to any psychiatric symptoms, providing highly probative evidence against such a finding. Next, the Board finds that symptoms of a psychiatric disability were not continuous or recurrent since service separation in July 1991. Following service separation in July 1991, the evidence of record shows no mention of psychiatric symptoms until 2015, as described above. The absence of post-service complaints, findings, diagnosis, or treatment for more than 20 years after service separation until 2015 is one factor that tends to weigh against a finding of continuous symptoms of a psychiatric disability after service separation. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (the lack of contemporaneous medical records is one fact the Board can consider and weigh against the other evidence, although the lack of such medical records does not, in and of itself, render the lay evidence not credible). Other evidence of record showing that symptoms of an acquired psychiatric disability were not continuous or recurrent since service includes the Veteran's own statements made at the May 2016 VA examination that he began experiencing symptoms in 1993, then had a lull in symptoms for many years, with reoccurrence of the symptoms 6 months prior to the May 2016 examination. This history provided by the Veteran is highly probative evidence against a finding of continuous psychiatric symptoms since active service. Regarding the Veteran's claim of continuous or recurrent symptoms of the claimed psychiatric disorder since service, the Board finds that, while the Veteran was competent to report the onset of his psychiatric symptoms, his more recent assertions made in the context of the current disability claim of continuous or recurrent psychiatric symptoms since service are outweighed by the other, more contemporaneous, lay and medical evidence of record, both in service and after service, and are not reliable. See Charles v. Principi, 16 Vet. App. 370 (2002). The Board finds that the Veteran's assertion of continuous or recurrent psychiatric symptoms after service is not accurate because it is outweighed by other evidence of record that includes the more contemporaneous service treatment records which are negative for psychiatric symptoms and show normal psychiatric evaluation at the time of separation; the history of symptoms provided by the Veteran at the May 2016 VA examination, as outlined above; and the lack of any report of psychiatric symptoms until 2015, more than 20 years after service separation. As such, the Board finds that the evidence does not sufficiently support continuous or recurrent psychiatric symptomatology since service so as to warrant a grant of service connection. Finally, the Board finds that the weight of the competent medical evidence weighs against a finding of a medical nexus between the current psychiatric disability and active service. In this regard, the Board finds that the May 2016 VA nexus opinion, discussed above, is the most probative evidence of record. The VA opinion is competent and probative medical evidence because it is factually accurate and is supported by an adequate rationale. The VA examiner was informed of the pertinent evidence, reviewed the Veteran's claims file, and fully articulated the opinion in the report, citing to specific treatment records in support of his conclusions. There are no contrary competent medical opinions of record. The Board acknowledges the Veteran's belief that his psychiatric disability is related to active service. However, his statements alone do not establish a medical nexus. Indeed, as noted above, while the Veteran is competent to provide evidence regarding matters that can be perceived by the senses, he has not been shown to be competent to render medical opinions on questions of etiology. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Barr v. Nicholson, 21 Vet. App. 303 (2007) (lay testimony is competent to establish the presence of observable symptomatology). As such, as a layperson, he is without the appropriate medical training and expertise to offer an opinion on a medical matter, including the diagnosis, etiology, or causation of a specific disability. The question of diagnosis and causation, in this case, involves complex medical issues that the Veteran is not competent to address. Jandreau, 492 F.3d 1372. For these reasons, the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to service connection for bilateral hearing loss is remanded. The Veteran contends that his current bilateral hearing loss disability is related to the acoustic trauma he experienced during active service; as discussed above, acoustic trauma during active service has been conceded. The Veteran has been afforded 2 VA audiological examinations; unfortunately, both are inadequate. The March 2015 VA examiner relied solely upon normal audiometric findings during active service in providing a negative nexus opinion. See Hensley v. Brown, 5 Vet. App. 155, 157 (1993) (the absence of hearing loss during service and at separation from service is not fatal to a claim for service connection and may not serve as the sole basis for a negative opinion). The December 2016 VA examiner incorrectly stated that the Veteran did not have a hearing loss disability for VA purposes, despite audiogram results from that examination showing otherwise. The examiner then cited to the 2005 Institute of Medicine (IOM) report entitled Noise and Military Service: Implications for Hearing Loss and Tinnitus, stating that this report concluded that there was no scientific basis on which to conclude that a hearing loss that appeared many years after noise exposure could be causally related to that noise exposure if hearing was normal immediately after the exposure, and noted that the Veteran's hearing was normal at service separation. The examiner did not explain why the conceded in-service noise exposure in this particular Veteran's case did not contribute to his hearing loss, which he noticed 15 years earlier. In light of the inadequate VA opinions, the Board finds that a new VA examination is necessary to obtain an opinion regarding the etiology of the Veteran's bilateral hearing loss. 2. Entitlement to service connection for a skin disability, to include tinea versicolor and tinea cruris, is remanded. The Veteran contends that he has a skin disability, claimed as a rash, that began during active service. Service treatment records show that in July 1985, he reported possible jock itch which started 7 days earlier; he had blackish patches on both thighs near the groin area, was diagnosed with tinea cruris, and prescribed a topical cream. In June 1990, the Veteran reported itching on his back, groin, now spreading to his chest. On physical examination, the clinician observed patches of lesions measuring 5 by 6 centimeters on the Veteran's back, white in color with slight scaling present. The assessment was tinea versicolor, and a special shampoo was recommended. In September 2015, the Veteran reported a skin rash and itching since 1993 after returning from the Gulf War. He displayed reddened plaques to the posterior neck and dorsal surface of right hand with associated itching, pain, and burning at times. He denied using any new soap or lotion to rule out contact dermatitis. He saw the nurse practitioner on in August 2015 for the same reason and Benadryl 25 mg BID and Eucerin cream were prescribed. He stated that Benadryl helped him at night and the cream had not helped him since a week ago. In an addendum note, the clinician noted a long history of pruritic dermatitis on the dorsal surface of the right hand and posterior neck. At a November 2016 VA skin examination, the examiner diagnosed tinea versicolor (1990), and tinea corpus, manus, and pedis (2015). The examiner observed mild abrasion of the skin secondary to his scratching, but no other lesions. The examiner concluded that the fact that the claimed skin conditions were not in evidence at time of the current examination suggested no relationship to the skin condition in service. VA treatment records from March 2018 show treatment for a gluteal rash which was believed to be a fungal infection. In light of the VA treatment records showing the presence of and treatment for recurrent skin conditions, the Board finds that the November 2016 VA examination is inadequate and that a remand is necessary. When there is a history of remission and recurrence of a condition, VA's duty to assist encompasses the obligation to evaluate a condition during an active, rather than inactive, phase. See Ardison v. Brown, 6 Vet. App. 405, 407-08 (1994) (concluding that examination during a remission phase did not accurately reflect the elements of a disability that caused the Veteran to miss three to four months of work at a time); but cf. Voerth v. West, 13 Vet. App. 117, 122-23 (1999) (holding that a condition that became inflamed approximately twice a year for a few days did not require examination during a flare-up). As such, a remand is necessary to schedule an examination during an episode of flare-up of the rash if possible. In this regard, as noted in Ardison, skin disorders are frequently subject to remission and recurrence. Id. Therefore, the lack of symptoms at the time of a VA examination does not preclude service connection. If an examination cannot be scheduled during a period of flare-up, the VA examiner should offer an opinion as to whether the Veteran has a recurrent chronic skin disorder that is related to active service, including the skin conditions documented in his service treatment records. The matters are REMANDED for the following action: 1. Obtain a VA opinion (or examination if deemed necessary) from an appropriate specialist to address the nature and etiology of the Veteran's bilateral hearing loss disability. Any and all indicated evaluations, studies, and tests deemed necessary by the examiner should be accomplished, and a rationale for any opinion expressed should be provided. The claims file must be made available to the examiner for review of the history in conjunction with the examination, and the examination report should reflect that such review was accomplished. (a.) The examiner should offer the following opinion: Is it at least as likely as not (i.e., to at least a 50/50 degree of probability) that the Veteran's bilateral hearing loss disability was incurred during or caused by active service, to include as a result of his conceded acoustic trauma during active service as a combat signaler? The examiner is advised that the Veteran is competent to describe symptoms that are observable by a lay person, such as noticing difficulty hearing. If the examiner rejects the Veteran's reports regarding his symptoms, the examiner must provide a reason for doing so. In addition, the examiner is advised that they must not rely solely on the absence of hearing loss in service in providing a negative nexus opinion. If any medical studies/reports are relied upon, the examiner must also explain why, in this particular case, the conceded in-service acoustic trauma did not contribute to the Veteran's current hearing loss disability. Note: The term "at least as likely as not" does not mean merely within the realm of medical possibility, but rather that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of causation as it is to find against it. All opinions are to be accompanied by a rationale consistent with the evidence of record. A discussion of the pertinent evidence, relevant medical treatises, and generally accepted medical principles is requested. If the examiner cannot provide an opinion without resorting to speculation, he or she shall provide complete explanations stating why this is so. In so doing, the examiner shall explain whether any inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. 2. Obtain a VA opinion (or examination if deemed necessary) from an appropriate specialist to address the nature and etiology of the Veteran's skin disability. This medical evaluation, to the extent that it is reasonably possible, should be performed during a time when the skin condition is in an active state, that is, during a flare-up. See Ardison v. Brown, 6 Vet. App. 405 (1994). Any and all indicated evaluations, studies, and tests deemed necessary by the examiner should be accomplished, and a rationale for any opinion expressed should be provided. The claims file must be made available to the examiner for review of the history in conjunction with the examination, and the examination report should reflect that such review was accomplished. (a.) The examiner should first identify any and all skin conditions, including those documented in his service treatment records and post-service treatment records, as well as those identified on current examination. If the skin condition is not in an active state, the examiner should review the post-service VA treatment records which show diagnosis of and treatment for various skin conditions, as outlined above. (b.) The examiner should offer the following opinion: Is it at least as likely as not (i.e., to at least a 50/50 degree of probability) that the Veteran's skin disability was incurred during or caused by active service, to include as related to the skin conditions documented in his service treatment records? The examiner is advised that the absence of an active skin condition on current examination cannot serve as the basis for a negative nexus opinion. Note: The term "at least as likely as not" does not mean merely within the realm of medical possibility, but rather that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of causation as it is to find against it. All opinions are to be accompanied by a rationale consistent with the evidence of record. A discussion of the pertinent evidence, relevant medical treatises, and generally accepted medical principles is requested. If the examiner cannot provide an opinion without resorting to speculation, he or she shall provide complete explanations stating why this is so. In so doing, the examiner shall explain whether any inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. Cynthia M. Bruce Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Sherrard, 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.