Citation Nr: 21075904 Decision Date: 12/21/21 Archive Date: 12/21/21 DOCKET NO. 16-12 943 DATE: December 21, 2021 ORDER The appeal with respect to whether new and material evidence has been received to reopen a previously denied claim for service connection for myopia (claimed as an unspecified bilateral eye condition) is dismissed. The appeal with respect to whether new and material evidence has been received to reopen a previously denied claim for service connection for high cholesterol is dismissed. The previously denied claim of entitlement to service connection for hypertension is reopened; to this limited extent, the appeal of that issue is granted. The previously denied claim of entitlement to service connection for keratosis (claimed as an unspecified skin condition), to include as due to exposure to herbicide agents, is reopened; to this limited extent, the appeal of that issue is granted. REMANDED Whether new and material evidence has been received to reopen a previously denied claim of entitlement to service connection for a headache disability, to include as due to exposure to herbicide agents and/or as secondary to service-connected posttraumatic stress disorder (PTSD) and/or a non-service-connected neck disability, is remanded. Entitlement to service connection for hypertension, to include as due to exposure to herbicide agents and/or as secondary to service-connected PTSD, is remanded. Entitlement to service connection a skin disability, to include hypertrophic actinic keratosis, squamous cell carcinoma, and basal cell carcinoma, to include as due to exposure to herbicide agents, is remanded. Entitlement to service connection for a neck disability, to include as secondary to a non-service-connected headache disability, is remanded. Entitlement to an initial rating in excess of 30 percent for PTSD prior to November 13, 2018, and in excess of 70 percent thereafter, is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU) is remanded. FINDINGS OF FACT 1. At a January 2021 hearing, prior to the promulgation of a Board decision on the matter, the Veteran asked that his appeal with respect to entitlement to service connection for myopia and high cholesterol be withdrawn. 2. In a December 2009 rating decision, the Department of Veterans' Affairs (VA) Regional Office (RO) in Providence, Rhode Island denied the Veteran's claims for service connection for hypertension and keratosis; he was advised of the RO's decision and of his appellate rights. 3. The Veteran appealed the RO's December 2009 rating decision by submitting a timely notice of disagreement (NOD) in February 2010; in August 2011, the RO issued a statement of the case (SOC). 4. The Veteran did not thereafter perfect an appeal of the issues of entitlement to service connection for hypertension or keratosis by filing a substantive appeal as to those issues during the 60-day period following the issuance of the SOC; nor was any new and material evidence received within a year of the mailing of notice of the December 2009 rating decision. 5. New evidence received since the time of the RO's December 2009 decision, when considered with the evidence previously of record, relates to unestablished facts necessary to substantiate the Veteran's claims and raises a reasonable possibility of substantiating the claims. CONCLUSIONS OF LAW 1. The criteria for withdrawal of the appeal with respect to the issues of entitlement to service connection for myopia and high cholesterol have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 2. The RO's December 2009 rating decision denying service connection for hypertension and keratosis is final. 38 U.S.C. § 7105; 38 C.F.R. §§ 20.200, 20.201, 20.302. 20.1103. 3. New and material evidence has been received to reopen the claims for service connection for hypertension and keratosis. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Army from April 1966 to April 1969, to include service in Vietnam. His decorations include the Vietnam Service Medal and the Vietnam Campaign Medal. These matters come to the Board of Veterans' Appeals (Board) on appeal from November 2013, April 2014, and August 2015 rating decisions issued by the VARO in St. Petersburg, Florida. In the November 2013 rating decision on appeal, the RO granted service connection for PTSD and assigned a 30 percent rating therefor, effective September 17, 2009. In June 2019, while the current appeal was pending, the agency of original jurisdiction (AOJ) increased the rating for PTSD to 70 percent, effective November 13, 2018. In January 2021, the Veteran and his spouse testified at a virtual Board hearing before the undersigned Veterans Law Judge. A transcript of that hearing has been associated with the record. The Board notes that while the Veteran filed a claim for service connection for keratosis, the claims file indicates that he has been diagnosed not only with hypertrophic actinic keratosis, but also with squamous and basal cell carcinoma. The scope of a claim is to be construed based on the reasonable expectations of a non-expert claimant, and the evidence developed during the claims process. The factors to consider are the appellant's description of his claim; the symptoms he describes; and all the information he submits, or VA obtains in support of the claim. See Brokowski, 23 Vet. App. at 86-87; Clemons v. Shinseki, 23 Vet. App. 1 (2009). The Board has recharacterized and broadened the claim regarding service connection for a skin disability, as noted above, based on the information obtained in support of it. In August 2019, the Veteran submitted a formal application for a TDIU, stating that his service-connected PTSD prevented him from securing or maintaining substantially gainful employment. The United States Court of Appeals for Veterans Claims (Court) has held that if a claimant or the record reasonably raises the question of whether a veteran is unemployable due to a disability for which an increased rating is sought, then part and parcel of that claim for increased rating is whether a TDIU is warranted as a result of that disability. Rice v. Shinseki, 22 Vet. App. 447 (2009). The Board acknowledges that the AOJ denied the Veteran's claim for a TDIU in a March 2021 rating decision. However, at his January 2021 hearing, the Veteran again expressly raised the issue of a TDIU per Rice. Therefore, the Board finds that the issue of entitlement to a TDIU is also on appeal. Dismissal 1. The appeal with respect to entitlement to service connection for myopia is dismissed. 2. The appeal with respect to entitlement to service connection for high cholesterol is dismissed. The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 19.55. Withdrawal may be made by the appellant or by his or her authorized representative. Id. Appeal withdrawals must include the name of the veteran, the name of the claimant or appellant if other than the veteran (e.g., a veteran's survivor, a guardian, or a fiduciary appointed to receive VA benefits on an individual's behalf), the applicable VA file number, and a statement that the appeal is withdrawn. If the appeal involves multiple issues, the withdrawal must specify that the appeal is withdrawn in its entirety or list the issue(s) withdrawn from the appeal. Id. In this case, on the record at his January 2021 hearing, prior to the promulgation of a Board decision on the matter, the Veteran requested, through his representative, that his appeal with respect to entitlement to service connection for myopia and high cholesterol be withdrawn. That request has since been reduced to writing in a transcript, received by the Board, which includes the Veteran's name and his VA file number. Under the circumstances, the Board finds that the requirements for a proper withdrawal have been satisfied. See, e.g., Tomlin v. Brown, 5 Vet. App. 355 (1993). As the Veteran has withdrawn his appeal of these issues, there remain no allegations of error of fact or law for appellate consideration with respect to those issues. Accordingly, the Board does not have jurisdiction to review the issues and the appeal of these issues must be dismissed. New and Material Evidence 3. New and material evidence has been received to reopen the previously denied claim of entitlement to service connection for hypertension. 4. New and material evidence has been received to reopen the previously denied claim of entitlement to service connection for keratosis, to include as due to exposure to herbicide agents. The Veteran first filed a claim for service connection for hypertension and keratosis in September 2009. A December 2009 rating decision denied the claims. He was notified of the decision, and of his appellate rights, by letter dated later that same month. The Veteran appealed the denial by submitting a timely NOD in February 2010. Thereafter, in August 2011, the AOJ issued a SOC regarding those issues. While the Veteran submitted a timely VA Form 9 in August 2011 as to other issues that were addressed in the December 2009 rating decision, he did not perfect his appeal of the issues of entitlement to service connection for hypertension or keratosis within the 60-day period of the issuance of the SOC. In addition, no new and material evidence was received during the one-year period following the mailing of notice of the December 2009 rating decision. See 38 C.F.R. § 3.156(b). As a result, the RO's decision as to those issues became final. 38 U.S.C. § 7105; 38 C.F.R. §§ 20.200, 20.201, 20.302. 20.1103. Generally, a claim that has been denied in a final rating decision may not thereafter be reopened and allowed. 38 U.S.C. § 7105. The exception to this rule is 38 U.S.C. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. New and material evidence means evidence not previously submitted to agency decision makers; which relates, either by itself or when considered with previous evidence of record, to an unestablished fact necessary to substantiate the claim; which is neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and which raises a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). To reopen a previously disallowed claim, new and material evidence must be presented or secured since the last final disallowance of the claim on any basis. The Court has interpreted the language of 38 C.F.R. § 3.156(a) as creating a low threshold and has characterized the phrase "raises a reasonable possibility of substantiating the claim" as "enabling rather than precluding reopening." Shade v. Shinseki, 24 Vet. App. 11 (2010). For purposes of determining whether new and material evidence has been received, the credibility of the evidence is to be presumed unless the evidence is inherently incredible or consists of statements that are beyond the competence of the person or persons making them. See Justus v. Principi, 3 Vet. App. 510, 513 (1992); Meyer v. Brown, 9 Vet. App. 425, 429 (1996); King v. Brown, 5 Vet. App. 19, 21 (1993). The December 2009 rating decision denied service connection for hypertension and keratosis, in part, because the evidence did not suggest that there was a relationship between the conditions and the Veteran's service. The evidence before VA at the time of the prior final rating decision consisted, in part, of the Veteran's service treatment records (STRs), VA treatment records, and the Veteran's lay statements. The Board finds that new and material evidence has been received with respect to the claimed conditions. Regarding hypertension, while that disability is not currently among the diseases which have been presumptively linked to herbicide exposure under 38 C.F.R. § 3.309(e), the Board takes notice that the National Academy of Sciences (NAS) recently upgraded the likelihood of an association between hypertension and exposure to herbicides, to include Agent Orange, from "limited or suggestive" evidence of an association to "sufficient" evidence of an association. See Veterans and Agent Orange: Update 11 (2018) (available at http://nationalacademies.org/ hmd/reports/2018/veterans-and-agent-orange-update-2018.aspx). The NAS report indicates that there may be a positive association between exposure to herbicide agents and hypertension, which relates to a previously unestablished fact and raises a reasonable possibility of substantiating the claim. It is therefore new and material. Regarding a skin disability, the Veteran submitted five medical articles in February 2021 regarding a possible link between certain skin conditions, including actinic keratosis and some skin cancers, and exposure to herbicide agents and/or sunlight. These articles indicate that there may be a positive association between the Veteran's conditions and his exposure to herbicide agents and/or sunlight during his service, which relates to a previously unestablished fact and raises a reasonable possibility of substantiating the claim. It is therefore new and material. The claims are reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. REASONS FOR REMAND 1. Entitlement to service connection for hypertension, to include as due to exposure to herbicide agents and/or as secondary to service-connected PTSD, is remanded. The Veteran contends that his hypertension was incurred in or caused by service. As noted, a 2018 NAS report indicates that there may be a positive association between exposure to herbicide agents and hypertension, which has raised the theory that the Veteran's hypertension is due to exposure to herbicide agents in service. The Veteran also contended at his January 2021 hearing that the disability is secondary to his service-connected PTSD in that chronic stress is a common cause of hypertension. His representative stated that he would submit medical articles regarding the association between PTSD and hypertension. Under applicable law, a Veteran who served on active duty in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, is presumed to have been exposed to an herbicide agent, absent affirmative evidence to the contrary. See 38 C.F.R. § 3.307(a)(6)(iii). As an initial matter, the Board notes that the Veteran has a current diagnosis of hypertension, as demonstrated by an August 2013 VA treatment record. The first element of service connection has therefore been established. As noted, he is also currently service-connected for PTSD. The Veteran also served in Vietnam during the requisite time period. His exposure to herbicide agents is therefore presumed. The second element of service connection regarding an in-service event has therefore been established as well. Regarding the link, or nexus between the Veteran's presumed in-service exposure to herbicide agents and his hypertension, the Board notes that the Veteran has not yet been afforded a VA examination and/or opinion with respect to hypertension. As noted, hypertension is not currently among the diseases which have been presumptively linked to herbicide exposure, but the recent findings of the NAS indicate that there is sufficient evidence of an association. Given the presence of a current diagnosis, the Veteran's presumed in-service exposure to herbicide agents, and the recent NAS findings, the Board finds that a VA examination and opinion regarding direct service connection should be provided. Inasmuch as the Veteran is currently service-connected for PTSD, an opinion regarding secondary service connection is also warranted. The Board notes that while the Veteran's representative stated at the January 2021 hearing that he would submit medical articles regarding the association of PTSD and hypertension, to date, no such articles have been received. While several articles were submitted regarding other issues on appeal, none regarding hypertension are currently present in the claims file. Updated records of any VA treatment should also be procured. See Bell v. Derwinski, 2 Vet. App. 611 (1992) (VA medical records are in constructive possession of the agency). 2. Entitlement to service connection a skin disability, to include hypertrophic actinic keratosis, squamous cell carcinoma, and basal cell carcinoma, to include as due to exposure to herbicide agents, is remanded. The Veteran contends that his skin disability was incurred in or caused by service, to include as due to exposure to herbicide agents. Specifically, he contended at his January 2021 hearing that the disability was due to exposure to herbicide agents while he was in Vietnam. He also testified that he brushed up against things, including spider webs, in the jungle in Vietnam, and that he was exposed to significant amounts of sunlight and had no sun protection. He further testified that he noticed itching during his service in Vietnam. In February 2021, the Veteran submitted several articles regarding a possible association between skin disorders and his in-service exposures. As an initial matter, and as noted, the Veteran has current diagnoses of hypertrophic actinic keratosis, squamous cell carcinoma, and basal cell carcinoma. An April 2013 left hand biopsy showed well differentiated squamous cell carcinoma arising from hypertrophic actinic keratosis. A June 2012 VA treatment record shows that a skin biopsy was consistent with residuals of basal cell carcinoma. The first element of service connection has therefore been established. As noted, the Veteran's exposure to herbicide agents by virtue of his service in Vietnam is presumed. While his contention that he was exposed to things in the jungle and to sunlight in Vietnam are also consistent with his service, the Board notes that his STRs are silent for any complaints of, treatment for, or diagnoses related to a skin disorder during service, to include a disorder that causes itching. Regardless of the absence of evidence regarding a skin disability in the STRs, the second element of service connection has been established because the Veteran is presumed to have been exposed to herbicide agents in service. Regarding the link, or nexus, between the Veteran's skin disabilities and an in-service event, the Veteran submitted four medical articles in February 2021. The first is dated in September 1992 and indicates that basal cell carcinoma is the most common malignant tumor in whites, occurs in areas exposed to sunlight, and that sunlight-induced skin changes called actinic keratoses often precede or accompany basal cell carcinoma. The second is dated in January 2014 and indicates that the risk of developing non-melanotic invasive skin cancer is increased even four decades after exposure to herbicide agents. The third is dated in November 2014 and addresses the effect of exposure to herbicide agents on non-melanoma skin cancer regression rates. The fourth is dated in March 2020 and also indicates that even 40 years after exposure, there remains a greater chance for non-melanotic skin cancer developing in veterans who were exposed to herbicide agents. To date, the Veteran has not been afforded a VA examination in connection with his claim. In light of the Veteran's current diagnoses, his presumed exposure to herbicide agents while serving in Vietnam, and the medical articles indicating that there may be a link between his skin disorders and that exposure and/or exposure to sunlight, the Board finds that a VA examination and/or opinion is warranted. McLendon v. Nicholson, 20 Vet. App. 79 (2006). 3. Entitlement to service connection for a neck disability, to include as secondary to a non-service-connected headache disability, is remanded. The Veteran contends that his neck disability was incurred in or caused by service. Specifically, at his January 2021 hearing he testified that his neck disability was incurred in service when he was in a helicopter that crashed and threw him out of the vehicle. He stated that he did not seek medical treatment during service, as it did not seem to be serious at the time, but that it is a problem that has kept coming back. He also contends that his neck disability is secondary to his non-service-connected headaches. In support of that contention, he submitted a medical article in February 2021 which is dated in 2015. The article indicates that neck pain is a very common feature of migraine attacks and is more likely to be part of a migraine attack than a prodromal migraine symptom. As an initial matter, the Board notes that the Veteran has a current neck disability. A September 2014 MRI shows multilevel multifactorial moderate thecal sac stenosis with mild cord compression and multilevel severe neural foraminal stenosis. The first element of service connection has therefore been established. Regarding an in-service event, the Board notes that an October 2013 VA examination for PTSD confirms that the Veteran's stressor of being in a helicopter crash while serving in Vietnam is the stressor upon which his diagnosis of PTSD is based. However, STRs are silent for any complaints of, treatment for, or a diagnosis related to a neck disability. Still further, there is no evidence of a link, or nexus, between the Veteran's neck disability and the in-service event. The Board finds that a VA examination based on the theory of direct service connection is therefore not warranted at this time. See McLendon, supra. The Board further finds, however, that the Veteran's claim for service connection for a neck disability is inextricably intertwined with his claim for service connection for headaches, which is being remanded. Harris v. Derwinski, 1 Vet. App. 180 (1991) (issues are inextricably intertwined when a decision on one issue would have a significant impact on another issue). As such, the Board will remand the neck disability claim as well. The Board finds that if the Veteran's headache disability is found to be service-connected, then a VA examination regarding secondary service-connection as to the Veteran's neck disability will be warranted. The Board also notes that the Veteran submitted other medical articles regarding his claim for service connection for a neck disability, but that the other articles indicate that headaches are secondary to neck pain and/or other problems. Inasmuch as the Veteran is not currently service-connected for a neck disability, those articles at present are not relevant to the issues on appeal. 4. Whether new and material evidence has been received to reopen a previously denied claim of entitlement to service connection for a headache disability, to include as secondary to service-connected PTSD and/or a non-service-connected neck disability, is remanded. The Veteran first filed a claim for service connection for headaches in September 2009. A December 2009 rating decision denied the claim. As with his previously denied claims for service connection for hypertension and keratosis, the Veteran timely appealed the December 2009 rating decision as to headaches by filing a timely NOD in February 2010. Thereafter, in August 2011, the AOJ issued a SOC that addressed the Veteran's claim for service connection for headaches. The Veteran did not subsequently perfect his appeal regarding the issue of service connection for headaches by filing a substantive appeal as to that issue within 60 days of the issuance of the SOC. He submitted an application to reopen the claim in August 2013. The Veteran contends that his headaches were incurred in or caused by service. He testified at the January 2021 Board hearing that he started having headaches right towards the end of his service in Vietnam or when he came back from Vietnam, and that he has been having them continuously since his discharge from service. He also contends that they are secondary to his service-connected PTSD and testified at his January 2021 hearing that stress seems to kick off headaches and that it also makes them worse. Finally, he contends that they are secondary to his non-service-connected neck disability. He testified at his January 2021 hearing that he was getting more headaches because his neck disability was getting worse. At the outset, the Board notes that the Veteran's STRs are silent for complaints of, treatment for, or diagnoses related to a headache disability. VA treatment records dated in March 2004, February 2005, April 2007, September 2012, February 2013, August 2013, April 2015, November 2015, May 2016, December 2016, February 2018, and March 2019 were also all negative for headaches. The Veteran is currently service connected, however, for PTSD. In addition, as noted above, one of the issues currently on appeal is entitlement to service connection for a neck disability. The Board is unable to find at the present time that new and material evidence has been received to reopen the previously denied claim for service connection for headaches. However, that claim is inextricably intertwined with his claim for service connection for a neck disability, which is being remanded. See Harris, supra. As such, the Board will remand the headaches claim as well. If the Veteran's neck disability is found to be service-connected, then a VA medical opinion as to whether he has a headache disability secondary to the neck disability will be warranted. The claims file also includes a post-service treatment record from November 2009 which indicates that the Veteran had a diagnosis of headaches and/or migraine headaches at that time, and that they might have been associated with the Veteran's PTSD. The mental status examination portion of the evaluation noted several psychiatric symptoms, and an additional medical observation was that the Veteran had intermittent migraine headaches. The provider diagnosed migraine headaches at that time and included the fact that the Veteran got migraine headaches off and on when he discussed the various psychiatric symptoms that were present. To date, the Veteran has not been afforded a VA examination in connection with his claim for service connection for headaches. If, on remand, new and material is received to reopen the claim for service connection for headaches, a medical opinion should be obtained as to whether he has a chronic headache disability that is secondary to his PTSD, taking into consideration the conflicting evidence as to whether he has a current diagnosis of a chronic headache disability, the fact that at least some evidence (though remote) suggests that there may be a link between a possible headache disability and PTSD, and that he is currently service-connected for PTSD. 5. Entitlement to an initial rating in excess of 30 percent for PTSD prior to November 13, 2018, and in excess of 70 percent thereafter, is remanded. As noted, the Veteran's PTSD has been rated as 30 percent disabling prior to November 13, 2018, and as 70 percent disabling thereafter. He contends that a higher rating is warranted, particularly for the earlier portion of the appeal period. The Board notes that there appear to be missing private treatment records from the earlier portion of the appeal period. A February 2014 record from the Pompano Beach Vet Center indicates that the Veteran was treated for a few years prior to that date at the Rhode Island Vet Center. At present, the claims file does not contain records from the Rhode Island Vet Center. As those records could have a bearing on the outcome of the Veteran's claim, a remand to obtain them is warranted. See, e.g., 38 C.F.R. § 3.159(e)(2) (if VA becomes aware of the existence of relevant records before deciding a claim, VA will, among other things, request that the claimant provide a release for the records). 6. Entitlement to a TDIU is remanded. As noted, the Veteran filed a formal application for a TDIU in August 2019. While a March 2021 rating decision denied the claim, the Board finds from the Veteran's January 2021 hearing testimony and other evidence of record that he is seeking entitlement to a TDIU based on his service-connected PTSD. That issue is inextricably intertwined with the other issues that are being remanded. See Parker, Harris, supra. Accordingly, the TDIU issue will be remanded as well. These matters are REMANDED for the following action: 1. Invite the Veteran and/or his representative to submit any medical articles in their possession regarding a possible association between PTSD and hypertension. 2. Ask the Veteran to identify and provide a release for records of private treatment from the Rhode Island Vet Center, and to identify and provide a release for relevant records of treatment from any other private care providers who may possess new or additional evidence pertinent to the issues remaining on appeal. If he provides the necessary release(s), assist him in obtaining the records identified, following the procedures set forth in 38 C.F.R. § 3.159. Any new or additional (i.e., non-duplicative) evidence received should be associated with the record. If any of the records sought are not available, the record should be annotated to reflect that fact and the Veteran and his representative should be notified. 3. Obtain copies of records pertaining to any VA treatment the Veteran has received since the time that such records were last procured, following the procedures set forth in 38 C.F.R. § 3.159. The evidence obtained should be associated with the record. 4. If, and only if, after the foregoing development has been completed to the extent possible, new and material is received to reopen the claim for service connection for headaches, arrange to have the Veteran scheduled for a VA headaches examination with an appropriate VA clinician. The examiner should review the record. All indicated tests should be conducted and the results reported. After examining the Veteran and reviewing the record, together with the results of any testing deemed necessary, the examiner should indicate whether the Veteran has had a chronic headache disability at any time since August 2013 (when he filed his claim to reopen his previously denied claim for service connection for headaches). If the examiner finds that the Veteran has had a chronic headache disability at any time since August 2013, he or she should offer an opinion as to whether it is at least as likely as not (i.e., whether it is 50 percent or more probable) that the disability had its onset in, or is otherwise attributable to, service. In so doing, the examiner should consider the November 2009 VA treatment record showing a diagnosis of migraine headaches, as well as the March 2004, February 2005, April 2007, September 2012, February 2013, August 2013, April 2015, November 2015, May 2016, December 2016, February 2018, and March 2019 VA treatment records which are affirmatively negative for headaches. The examiner should also consider the Veteran's January 2021 hearing testimony that he developed headaches in service and that they have continued since. If the examiner finds that the Veteran has had a headache disability at any time since August 2013, but that it is unlikely that it had its onset in, or is otherwise attributable to, service, he or she should offer a further opinion as to whether it is at least as likely as not that the disability was a) caused or b) aggravated (i.e., permanently or temporarily worsened beyond its natural progression) by the Veteran's service-connected PTSD and/or non-service-connected neck disability. In so doing, the examiner should consider and address the November 2009 VA treatment record in which the examiner appears to have included migraine headaches as a possible psychiatric symptom. The examiner should also consider the Veteran's January 2021 hearing testimony to the effect that stress kicks off his headaches and/or makes them worse. A complete medical rationale for all opinions expressed must be provided. 5. Also arrange to provide the record on appeal to a VA clinician for the purpose of assessing the etiology of the Veteran's hypertension. The examiner should review the record. After reviewing the record, the examiner should offer an opinion as to whether it is at least as likely as not (i.e., whether it is 50 percent or more probable) that the Veteran's hypertension had its onset in, or is otherwise attributable to, service, to include as due to his presumed in-service exposure to herbicide agents. In so doing, the examiner must specifically address the November 2018 Veterans and Agent Orange: Update 11, citing a recent NAS report indicating that there is "sufficient" evidence of an association between hypertension and herbicide exposure. If it is the examiner's conclusion that it is unlikely that the Veteran's hypertension is related to service, the examiner should offer a further opinion as to whether it is at least as likely as not that the Veteran's hypertension has been (a) caused or (b) aggravated by his service-connected PTSD. In so doing, the examiner should consider the Veteran's contention that chronic stress is a common cause of hypertension. The examiner should also consider any additional medical articles regarding a possible link between PTSD and hypertension that are submitted by the Veteran, if any. The need for an in-person and/or telephonic or video interview of the Veteran is left to the discretion of the examiner selected to offer the requested opinion(s). A complete medical rationale for all opinions expressed must be provided. 6. Also arrange to provide the record on appeal to a qualified VA examiner for the purpose of assessing the nature and etiology of the Veteran's skin disabilities. The examiner should review the record. After reviewing the record, the examiner should identify any skin disabilities that have been present since August 2013 (when the Veteran filed an application to reopen his previously denied claim for service connection for keratosis). For each identified disability, the examiner should offer an opinion as to whether it is at least as likely as not (i.e., whether it is 50 percent or more probable) that the disability had its onset in, or is otherwise attributable to, service, to include as due to his presumed in-service exposure to herbicide agents. In so doing, the examiner should note that an April 2013 VA treatment record shows diagnoses of well differentiated squamous cell carcinoma arising from hypertrophic actinic keratosis and that a June 2012 VA treatment record shows a diagnosis of residuals of basal cell carcinoma. The examiner should also consider the Veteran's contention that he was exposed to things, including spider webs, in the jungle and to sunlight while serving in Vietnam, and that his exposure to herbicide agents in-service is presumed. Finally, the examiner should consider the September 1992, January 2014, November 2014, and March 2020 medical articles which indicate that there may be an association between certain skin disorders, including certain types of skin cancer, and exposure to herbicide agents and/or sunlight. The need for an in-person and/or telephonic or video interview of the Veteran is left to the discretion of the examiner selected to offer the requested opinion. A complete medical rationale for all opinions expressed must be provided. 7. If, and only if, the Veteran's headache disability is found to be service-connected, arrange to provide the record on appeal to a qualified VA clinician for the purpose of assessing the etiology of the Veteran's neck disability. The examiner should review the record. After reviewing the record, the examiner should offer an opinion as to whether it is at least as likely as not that the Veteran's neck disability had its onset in, or is otherwise attributable to, service. In so doing, the examiner should consider the Veteran's contention that he injured his neck at the same time he was involved in a helicopter crash while serving in Vietnam. If the examiner finds that it is unlikely that the Veteran's neck disability had its onset in, or is otherwise attributable to, service, he or she should offer a further opinion as to whether it is at least as likely as not that the Veteran's neck disability was a) caused or b) aggravated (i.e., permanently or temporarily worsened beyond natural progression) by his (service-connected) headache disability. In so doing, the examiner should consider the 2015 medical article submitted in February 2021 indicating that neck pain is a very common feature of migraine attacks and is more likely to be part of a migraine attack than a prodromal migraine symptom. The need for an in-person and/or telephonic or video interview of the Veteran is left to the discretion of the examiner selected to offer the requested opinion. A complete medical rationale for all opinions expressed must be provided. 8. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs (to include obtaining an updated PTSD examination, if warranted), the issues remaining on appeal should be readjudicated based on the entirety of the evidence. If any benefit sought remains denied, the Veteran and his representative should be issued a supplemental SOC. An appropriate period of time should be allowed for response. DAVID A. BRENNINGMEYER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Oldroyd, 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.