Citation Nr: 21072852 Decision Date: 12/13/21 Archive Date: 12/13/21 DOCKET NO. 17-12 658 DATE: December 13, 2021 REMANDED Entitlement to an increased rating for deviated septum, traumatic, is remanded. Entitlement to service connection for skin disability is remanded. REASONS FOR REMAND The Veteran served active duty in the United States Air Force from December 1981 to January 1987. This matter comes to the Board of Veterans' Appeals (Board) on appeal of a February 2015 rating decision of the Department of Veteran Affairs (VA) Regional Office (RO). In July 2019, the Board remanded the issues on appeal for additional development, and the case has since been returned for further appellate review. A remand by the Board confers on the claimant a legal right to substantial compliance with the remand order. Stegall v. West, 11 Vet. App. 268 (1998). Upon thorough review of the evidence, the Board concludes remand of each claim is necessary to further develop the issues and achieve substantial compliance, as discussed below. Id. at 271; 38 C.F.R. § 20.904 (a). First, the Board finds the VA examinations are inadequate and remand is necessary in order to adjudicate each of the Veteran's claims. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). In July 2019, the Board determined the VA examinations of record were inadequate to adjudicate either claim and therefore remanded to provide new examinations and obtain fully reasoned medical opinions. 1. Entitlement to an increased rating for deviated septum, traumatic is remanded. Regarding the Veteran's increased rating claim, he was provided a VA examination in July 2020 to assess the severity of his disability, with a January 2020 evaluation also submitted. He seeks a rating of 10 percent as he is currently in receipt of a non-compensable rating for traumatic deviated septum under Diagnostic Code (DC) 6502. Pursuant to the Schedule of Ratings for the Respiratory System, a 10 percent disability rating is assigned under DC 6502 when there is 50 percent obstruction of the nasal passage on both sides or complete obstruction on one side. 38 C.F.R. § 4.97. The Veteran contends he experiences nasal obstruction of at least 50 percent that is affected by environmental factors, such as humidity, smells, season, or time of day. Third Party Correspondence, 04/13/2020, pg. 3/4. He contends he has difficulty breathing, snoring, and nightly congestion that is only mitigated by several medications, which was not considered in evaluating the severity of his disability. The July 2019 remand instructed an examiner to address these contentions when assessing whether the Veteran experiences nasal passage obstruction. A July 2020 examiner indicated an absence of 50 percent or more obstruction of both nasal passages or a total obstruction of one. The examiner noted additional diagnoses related to his in-service deviated septum as allergic rhinitis and larynx or pharynx conditions, but similarly concluded the Veteran's allergic rhinitis did not result in a 50 percent obstruction of both nasal passages or a total obstruction of one. However, the examination report does not note consideration of the Veteran's lay statements and it is unclear whether the above contentions were considered in evaluating the severity of his conditions. Additionally, imaging studies of the sinuses have not been performed since 2015 and further clarification of the Veteran's larynx or pharynx conditions should be provided. The Board also noted the January 2015 examiner indicated the Veteran's deviated septum was not the result of trauma and requested clarification on this discrepancy, in conjunction with the Veteran's above contentions. The July 2020 examination report notes a diagnosis of traumatic deviated nasal septum; however, the examiner indicates the condition is non-traumatic elsewhere in the report. Therefore, it is unclear whether the examiner fully considered the medical evidence in conjunction with the Veteran's contentions as instructed by the Board's remand. As such, remand is necessary as the examination does not substantially comply with the prior remand directives or provide sufficient, detailed information for the Board to adjudicate the claim based on the facts. See Ardison v. Brown, 6 Vet. App. 405, 407 (1994). 2. Entitlement to service connection for skin disability is remanded. Regarding service connection for the Veteran's skin condition, he was provided VA examinations in July 2020 and June 2021, with a January 2020 evaluation also submitted to the record. Relying on these examinations, the RO denied the Veteran's claim based on a lack of service treatment records linking his current disability to service. However, the VA opinions do not discuss evidence regarding treatment for a skin condition during service tending to support the Veteran's contentions. See Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993). Additionally, the Board's July 2019 remand expanded the claim to include all related diagnoses, including mild spongiotic dermatitis, subacute cutaneous lupus erythematosus, and Sjogren's syndrome. See Clemmons v. West, 206 F.3d 1401, 1403 (Fed. Cir. 2000). As such, the Board instructed the RO to obtain adequate medical opinions and specified opinions were needed for each of the Veteran's skin diagnoses. The July 2020 and June 2021 examiners concluded the Veteran's skin condition was less likely than not incurred in or caused by service. The Veteran contends his disorder is the result of two years active-duty service in Saudi Arabia. Specifically, he asserts direct exposure to chemicals and excessive sunlight without sunscreen caused symptoms of a skin disease to manifest while in-service that have continued since. The June 2021 examiner provided an opinion only as to the Veteran's cutaneous lupus erythematosus, reasoning the Veteran's service records were silent on diagnosis and treatment for the condition on active duty. However, this is an improper basis in providing a negative nexus opinion. See Buchanan v. Nicholson, 451 F.3d 1331, 1336, n. 1 (Fed. Cir. 2006). Additionally, without further explanation, this conclusion is contrary to the evidence. See e.g. Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993). The Veteran asserts, despite his post-service diagnosis, symptoms of a skin condition manifested during service, including lesions, red bumps, itching, and hair loss on the scalp. Review of service treatment records confirm many complaints of skin problems on the face, back, chest, and neck, and several records throughout service note papulopustules, chronic acne, warts, and lesions. See STR, 12/22/2014, pgs. 14, 21, 22, 28, 32, 35, 41, 46/48. A January 1987 separation examination notes skin disease requiring topical cream. STR, 12/22/2014, pg. 9/48. However, a July 1981 examination does not indicate skin problems or symptoms at the Veteran's entry on active duty. STR, 12/22/2014, pg. 12/23. The Veteran reports chronic itching during service that was treated conservatively with topical ointments but continued to experience red spots, itching, and bald spots now requiring ointments and prescription medication. The July 2020 examiner indicated spongiotic dermatitis may be caused by contact with chemicals or fungal infection, among other factors, and notes the causes of Sjogren's Syndrome and systemic lupus erythematosus (SLE) are not known but include environmental factors such as ultraviolet light, viruses, or bacterial infections. The examiner reasoned current medical literature does not yield conclusive evidence supporting an etiology related to service and the Veteran's service record is insufficient to determine a nexus. However, the examiner did not discuss whether the Veteran's in-service complaints were manifestations of or otherwise related to any currently diagnosed skin disorder. As such, an examiner must provide a discussion of the evidence tending to show an in-service onset such that the Board may make a fully informed decision. Further, as the claim was expanded to include any acquired skin condition, an opinion is needed on the individual diagnoses of spongiotic dermatitis, systemic lupus erythematosus, and Sjogren's syndrome. As a VA examiner stated exposure to ultraviolet light, chemicals, and other environmental factors are known causes of each of the disorders, an examiner must reconcile each diagnosis with his contentions, as well as the in-service evidence discussed above. Additionally, a review of the Veteran's military personnel records reflect that he was stationed in Saudi Arabia. As such, a VA examiner must address whether the Veteran's exposure to sun while stationed in Saudi Arabia caused any of his currently diagnosed skin disabilities. Based on the above, remand is necessary to obtain, (1) an adequate examination regarding the severity of the Veteran's traumatic deviated septum with consideration of the Veteran's contentions of obstruction, and (2) an adequate medical nexus opinion regarding his skin disorder with full consideration of the in-service evidence. Accordingly, the matters are REMANDED for the following action: 1. Obtain any outstanding VA or private treatment records relevant to the Veteran's disabilities and associate them with the claims file. 2. After the above development, schedule the Veteran for a VA examination to determine the current nature and severity of his service-connected deviated septum. The record and a copy of this remand must be made available to and reviewed by the examiner. The examination must include all physical and diagnostic testing deemed necessary by the examiner in conjunction with this request. The examiner should report all manifestations and functional impairment related to the Veteran's service-connected deviated septum. (a.) The VA examiner should address the Veteran's contentions that he has difficulty breathing, snoring, and nightly congestion that is only mitigated by several medications. (b.) The VA examiner should also address whether the Veteran's deviated septum is traumatic. 3. Forward the record and a copy of this remand to the examiner who conducted the June 2021 VA skin examination, or if the examiner is unavailable, another suitably qualified examiner, for completion of an addendum opinion. If the examiner determines that another in-person examination of the Veteran is required to provide the below-requested information, then such an examination should be scheduled. Following review of the record, the examiner should express an opinion as to: (a.) Provide a diagnosis for any skin disability demonstrated since service, found on current examination or in the record. The Board notes that the Veteran has been diagnosed with several skin disabilities, including, spongiotic dermatitis, systemic lupus erythematosus, and Sjogren's syndrome. (b.) For each skin disability, provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) the Veteran's symptoms of skin disability are related to an event, injury, or disease, to include the extensive notations of skin problems during his active service. (c.) The examiner is further asked to address whether the Veteran's exposure to sun while stationed in Saudi Arabia at least as likely as not caused any of his current skin conditions. The examiner is asked to provide the underlying reasons for all opinions expressed, and is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as against it. B. G. LeMoine Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Tabitha Chapman, Associate 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.