Citation Nr: 21076076 Decision Date: 12/22/21 Archive Date: 12/22/21 DOCKET NO. 11-15 769 DATE: December 22, 2021 ORDER Service connection for a gastrointestinal disorder, diagnosed as gastroesophageal reflux disease (GERD), esophagitis, and a hiatal hernia, is granted. REMANDED Entitlement to service connection for bilateral eye disorders is remanded. Entitlement to service connection for a skin disorder, to include skin cancer, a growth on the left leg, and a fatty tumor on the back, is remanded. FINDING OF FACT The Veteran's gastrointestinal disorder, diagnosed as GERD, esophagitis, and a hiatal hernia, had its onset in service. CONCLUSION OF LAW The criteria for service connection for a gastrointestinal disorder, diagnosed as GERD, esophagitis, and a hiatal hernia, have been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 1154(a), 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the Army from July 1966 to June 1968, including service in the Republic of Vietnam from June 1967 to June 1968. This matter is before the Board of Veterans' Appeals (Board) on appeal of a June 2010 rating decision of a Department of Veterans Affairs (VA) Regional Office, that denied service connection for bilateral eye disorders (listed as eye infections); a gastrointestinal disorder, to include acid reflux (listed as acid reflux); and for a skin disorder, to include skin cancer, a growth on the left leg, and a fatty tumor on the back (listed as skin cancer of the face, a lump/growth on the left leg, and a fatty tumor on the back). In March 2017, the Veteran appeared at a Board videoconference hearing before the undersigned Veterans Law Judge. In July 2017 and March 2019, the Board remanded the issues of entitlement to service connection for bilateral eye disorders; a gastrointestinal disorder, to include acid reflux; and for a skin disorder, to include skin cancer, a growth on the left leg, and a fatty tumor on the back, for further development. In November 2021, the Veteran, along with his wife and a friend, testified at a second hearing before the same Veterans Law Judge. Gastrointestinal Disorder, to include Acid Reflux Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table). Determinations as to service connection will be based on review of the entire evidence of record, to include all pertinent medical and lay evidence, with due consideration to VA's policy to administer the law under a broad and liberal interpretation consistent with the facts in each individual case. 38 U.S.C. § 1154(a); 38 C.F.R. § 3.303(a). Secondary service connection may be granted for a disability that is proximately due to, the result of, or aggravated by an established service-connected disability. 38 C.F.R. § 3.310 (2015); see also Allen v. Brown, 7 Vet. App. 439 (1995). A veteran who served in the Republic of Vietnam during the Vietnam era is presumed to have been exposed during such service to certain herbicide agents (e.g., Agent Orange). In the case of such a veteran, service incurrence for the following diseases will be presumed if they are manifest to a compensable degree within specified periods, even if there is no record of such disease during service: chloracne or other acneform diseases consistent with chloracne, type 2 diabetes, Hodgkin's disease, chronic lymphocytic leukemia, multiple myeloma, non-Hodgkin's lymphoma, acute and sub-acute peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx, and trachea), and soft-tissue sarcomas. 38 U.S.C. § 1116; 38 C.F.R. §§ 3.307 (a)(6), 3.309(e). Effective August 31, 2010, ischemic heart disease (including, but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina), is included as a disease associated with herbicide exposure under 38 C.F.R. § 3.309 (e). (Under 38 C.F.R. § 3.309 (e), the term ischemic heart disease does not include hypertension or peripheral manifestations of arteriosclerosis such as peripheral vascular disease or stroke, or any other condition that does not qualify within the generally accepted medical definition of Ischemic heart disease. 38 C.F.R. § 3.309 (e) (Note 3.). On January 1, 2021, the National Defense Authorization Act for Fiscal Year 2021 has added three disorders to the list of diseases presumptively associated with exposure to herbicide agents. Specifically, it amended 38 U.S.C. § 1116(a)(2), to include parkinsonism, bladder cancer and hypothyroidism. 38 C.F.R. §§ 3.307(a)(6)(ii), 3.309(e). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and recurrence of symptoms. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case-by-case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d at 1377 (Fed. Cir. 2007) (holding that "[w]hether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board"). The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C. § 7104(a) (West 2002). Moreover, the United States Court of Appeals for Veterans Claims (Court) has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See Id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See Id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). Service connection is in effect for a psychiatric disorder, diagnosed as posttraumatic stress disorder (PTSD) and an unspecified anxiety disorder; diabetes mellitus; right shoulder impingement syndrome (right shoulder impingement syndrome, arthropathy); bilateral hearing loss; and for tinnitus. The Veteran contends that he has a gastrointestinal disorder, to include acid reflux, that is related to service, to include as due to Agent Orange exposure. He specifically maintains that he has had gastrointestinal problems since his period of service. He reports that he had sharp pains, with regurgitation, during service, as well as heartburn since service. The Veteran states that he tried to obtain Tums and Rolaids during service, but that those medications were hard to get. The Veteran essentially contends that she suffered from gastrointestinal problems, to include acid reflux, during service and since service. He further asserts that he has a gastrointestinal disorder, to include acid reflux, as a result of his service-connected PTSD and an unspecified anxiety disorder. The Veteran served on active duty in the Army from July 1966 to June 1968, including service in the Republic of Vietnam from June 1967 to June 1968. The Veteran served in the Republic of Vietnam. Therefore, his exposure to Agent Orange is conceded. The Veteran's service treatment records do show treatment for any gastrointestinal problems, to include acid reflux. Post-service private and VA treatment records, including VA examination reports, show treatment for variously diagnosed gastrointestinal problems, including GERD; bilateral inguinal hernias; status post a right inguinal hernia, times two, and a left inguinal hernia repair; esophagitis; and for a hiatal hernia. A June 2019 lay statement from the Veteran's wife indicates that she had known the Veteran all of her life. She stated that they went to school together, and that when the Veteran came home from Vietnam, they dated for three years and then got married. The Veteran's wife indicated that they had been married for forty-eight years. She reported that when the Veteran came home from the Army, he had lost so much weight that he could not wear his clothes. The Veteran's wife maintained that the Veteran was not able to eat regular food, and that even though chili was his favorite food, he could not eat it. She stated that the Veteran would not put onions on his hamburgers because the onions would hurt his stomach. The Veteran's wife indicated that the Veteran started carrying Tums in his pocket. She related that even though the Veteran was currently on medication, he still had to keep a bottle of antacid pills available. She reported that the Veteran had undergone five hernia repairs. The Board notes that although exposure to Agent Orange is conceded due to the Veteran's service in Vietnam, his claimed gastrointestinal disorder, to include acid reflux, is not among the diseases listed as presumptively associated with Agent Orange exposure. Thus, the Veteran is not entitled to service connection on a presumptive basis. 38 C.F.R. § 3.309(e). The Veteran may, nonetheless, establish service connection if the evidence shows that his claimed gastrointestinal disorder, to include acid reflux, was, in fact, caused by exposure to Agent Orange or some other incident of service. See Combee v. Brown, 34 F.3d at 1039 (Fed. Cir. 1994). The Board notes that the evidence of record includes opinions, as to the etiology of the Veteran's claimed gastrointestinal disorder, to include acid reflux, pursuant to an October 2017 statement from P. A., FNP.; a December 2017 VA esophageal conditions examination report; an October 2019 VA hernias examination report; and an October 2019 VA esophageal conditions examination report. The Board finds that those statements, and opinions, are inadequate and not probative. For example, a statement from P. A., FNP., indicates that he reviewed the Veteran's obtainable medical records, laboratory results, pathology reports, test results, and specialty notes from dermatology and urology. The Board notes, however, that there is no indication that P. A., FNP., reviewed the Veteran's entire claims file. Although claims file review is not necessary, the probative value of a medical opinion is based on its reasoning and its predicate in the record so that the opinion is fully informed. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Additionally, the Board observes that P. A., FNP., indicated that the Veteran's remaining issues on appeal could be candidly linked to his unfortunate exposure to Agent Orange, as he honorably served in the Army during the Vietnam War, and he had suffered medical conditions and diseases that were congruent with known Agent Orange exposures making the basis of the opinion prudent. The Board notes, however, that the P. A., FNP., did not provide much rationale for linking the Veteran's claimed gastrointestinal disorder, to include acid reflux, to Agent Orange exposure in service, other than to refer to a 1975 report from the Centers for Disease Control that animals exposed to Agent Orange suffered gastric ulcers. The Board notes that an examiner, pursuant to the December 2017 VA esophageal conditions examination report, following a review of the claims file, found that the Veteran's diagnosed GERD and inguinal hernias were not related to his period of service, to include his presumed Agent Orange exposure. The Board notes, however, that the examiner did not address whether the Veteran's service-connected psychiatric disorder, diagnosed as PTSD and an unspecified anxiety disorder, or any other service-connected disabilities such as diabetes mellitus, caused or aggravated the Veteran's GERD and inguinal hernias. In El-Amin v. Shinseki, 26 Vet. App. 136 (2013), a decision issued by the United States Court of Appeals for Veterans Claims (Court), the Court vacated a decision of the Board where a VA examiner did not specifically opine as to whether a disability was aggravated by a service-connected disability. The Board also notes that the examiner did not discuss a report from the Compass Community Health Care Center, which relates diagnoses including GERD, and refers to an examiner statement that the aggravating factors of the Veteran's GERD included anxiety. The Board further observes that the examiner did not specifically address the Veteran's reports of gastrointestinal problems during service and since service. The Board observes that the Veteran is competent to report gastrointestinal problems during service and since service. See Davidson, 581 F.3d at 1313. The Board notes that an examiner, pursuant to an October 2019 VA hernias examination report, related diagnoses of an inguinal hernia, and status post a right inguinal hernia repair times two, and a left inguinal hernia repair. The examiner indicated that the Veteran's bilateral inguinal hernia, status post repair times two, with a left inguinal hernia repair times one, were less likely than not incurred in, or caused by, the Veteran's period of service. The examiner stated that there was no medical evidence that inguinal hernias were caused by Agent Orange exposure, and there was no peer-reviewed medical evidence in medical literature that shows a cause or related relationship between Agent Orange exposure and inguinal hernia. It was noted that there was no evidence that the Veteran had complaints of inguinal hernias while in service, which were diagnosed twenty-eight years after his discharge from service. The examiner further stated that the P. A., FNP., did not discuss the illnesses what illnesses he was opining in favor of, jut that he believed all of the Veteran's health conditions were caused by his Agent Orange exposure. The Board observes that the examiner did not specifically address the Veteran's reports of gastrointestinal problems during service and since service. See Davidson, 581 F.3d at 1313. The examiner also did not discuss whether the Veteran's service-connected psychiatric disorder, diagnosed as PTSD and an unspecified anxiety disorder, or any other service-connected disabilities such as diabetes mellitus, caused or aggravated the Veteran's GERD and inguinal hernias. See El-Amin v. Shinseki, 26 Vet. App. at 136. The Board observes that the examiner, pursuant to the October 2019 VA esophageal conditions examination report, who also conducted the October 2019 VA hernias examination, related diagnoses of GERD, esophagitis, and a hiatal hernia. The examiner, following a review of the claims file, indicated that the Veteran's diagnoses of GERD, "gastritis," and hiatal hernias, were less likely than not (less than 50 percent probability) incurred in, or caused by, the gastrointestinal disorder, to include acid reflux, during service. The examiner reported that the Veteran's service treatment records were silent in regard to GERD symptoms or complaints, and that he reported that his first episode was at least a year after his discharge, when he was treated in an emergency room for his acid reflux. The examiner also maintained that there was no peer-reviewed medical evidence currently available in the medical literature that shows a causal relationship between Agent Orange and GERD. The examiner further stated that there was no evidence that the Veteran's mental health (PTSD and an unspecified anxiety disorder), or his diabetes mellitus, caused his GERD or hiatal hernia. The examiner further stated that the P. A., FNP., did not discuss the illnesses what illnesses he was opining in favor of, jut that he believed all of the Veteran's health conditions were caused by his Agent Orange exposure. The Board observes that the examiner did not specifically address the Veteran's reports of gastrointestinal problems during service and since service. See Davidson, 581 F.3d at 1313. The examiner also did not discuss whether the Veteran's service-connected psychiatric disorder, diagnosed as PTSD and an unspecified anxiety disorder, or any other service-connected disabilities such as diabetes mellitus, aggravated the Veteran's GERD and inguinal hernias. The examiner solely stated that such disorders did not cause his GERD and hiatal hernias. See El-Amin v. Shinseki, 26 Vet. App. at 136. The Board observes that the Veteran is currently diagnosed with a gastrointestinal disorder, diagnosed as GERD, esophagitis, and a hiatal hernia. The Board finds the Veteran's reports of gastrointestinal problems during and since his period of service to be credible. See Jandreau v. Nicholson, 492 F.3d 1372 (2007) (holding that lay evidence can be competent and sufficient to establish a diagnosis of a condition when a lay person is competent to identify the medical condition, or reporting a contemporaneous medical diagnosis, or the lay testimony describing symptoms at the time supports a later diagnosis by a medical professional). The Board also finds the reports from the Veteran's wife, of the Veteran having gastrointestinal problems when he came home from the Army, to be credible. Resolving any doubt in the Veteran's favor, the Board finds that the evidence is at least in equipoise as to whether the Veteran's gastrointestinal disorder, diagnosed as GERD, esophagitis, and a hiatal hernia, commenced during his period of service. In light of the evidence, the Board cannot conclude that the preponderance of the evidence is against granting service connection for a gastrointestinal disorder, diagnosed as GERD, esophagitis, and a hiatal hernia. Therefore, service connection for a gastrointestinal disorder, diagnosed as GERD, esophagitis, and a hiatal hernia, is warranted. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. As the Board has granted direct service connection in this matter, it need not address other theories of service connection. REASONS FOR REMAND The remaining issues on appeal are entitlement to service connection for bilateral eye disorders, and for a skin disorder, to include skin cancer, a growth on the left leg, and a fatty tumor on the back. As discussed above, the Board has granted service-connection for a gastrointestinal disorder, diagnosed as GERD, esophagitis, and a hiatal hernia. The Veteran is now service-connected for PTSD and an unspecified anxiety disorder; diabetes mellitus; right shoulder impingement syndrome (right shoulder impingement syndrome, arthropathy); bilateral hearing loss; tinnitus; and for a gastrointestinal disorder, diagnosed as GERD, esophagitis, and a hiatal hernia. This case was remanded in March 2019, partly to schedule the Veteran for an appropriate VA examination to determine the onset and etiology of his claimed bilateral eye disorders. The examiner was to diagnoses all current bilateral eye disorders, to include eye syndrome; senile cataracts; choroidal nevus; blepharitis; and conjunctivitis, etc. The examiner was also to provide a medical opinion as to whether it was at least as likely as not that any currently diagnosed bilateral eye disorders, to include dry eye syndrome; senile cataracts; choroidal nevus; blepharitis; and conjunctivitis, etc., were related to, and/or had their onset during, the Veteran's period of service, to include his presumed in-service Agent Orange exposure. The March 2019 Board remand also directed that the examiner specifically acknowledge and discuss the Veteran's reports of treatment for right and left eye problems during service and since service, and comment on an October 2017 positive opinion from P. A., FNP. The examiner was further directed to opine as to whether the Veteran's service-connected diabetes mellitus, or any other service-connected disabilities, caused or aggravated any currently diagnosed bilateral eye disorders, to include dry eye syndrome; senile cataracts; choroidal nevus; blepharitis; and conjunctivitis, etc. Pursuant to the March 2019 Board remand, the Veteran was afforded a VA eye conditions examination in October 2019. There is a notation that the Veteran's claims file was reviewed. The diagnoses were dry eye syndrome in both eyes; posterior blepharitis in both eyes; nuclear sclerotic cataracts in both eyes; choroidal nevus in the right eye; a history of conjunctivitis; and diabetes, without retinopathy or macular edema in both eyes. The examiner reported that the Veteran did not have diabetic retinopathy in either eye, and that his visual acuity was slightly reduced in both eyes secondary to dry eye syndrome, and it was no related o diabetes. The examiner stated that the Veteran had some contraction of the bilateral visual fields that was stable to his previous visual field performed in December 2017. The examiner maintained that such was less likely than not due to diabetes because diabetes did not cause visual field constriction in the absence of any other diabetic changes such as tractional retinal detachments or retinopathy. The examiner indicated that the Veteran had mild nuclear cataracts in both eyes, which were less likely than not due to his service-connected diabetes. The examiner stated that the Veteran's type of cataract, nuclear sclerotic, was a normal age-related physiologic change and had not been shown to be directly associated with diabetes. The examiner reported that the Veteran had dry eye syndrome, as well as associated posterior blepharitis. It was noted that some studies show that Agent Orange exposure could cause changes to meibomian glands in children and fetuses, but that there were no direct studies, or peer-reviewed literature, that show direct links between Agent Orange exposure and dry eye syndrome and posterior blepharitis. The examiner stated that the Veteran's wife reported that such had been a longstanding condition since his twenties, which made it less likely than not that the Veteran's dry eye syndrome and posterior blepharitis were incurred during his time in the service or caused by his Agent Orange exposure. The examiner indicated that the Veteran also had a choroidal nevus in his right eye, and that nevi were freckles inside the eye that could be present at birth or develop through life as a result of ultraviolet exposure in the same way freckles develop on the skin. The examiner stated that there was no evidence prior to the Veteran's entrance into the service that nevi were present, and that, therefore, they were at least as likely as not to have been incurred during that time in service, but that such was a condition that was commonly found in the general population, which was no known to cause any functional or visual impairment. The examiner reported that an October statemen from P. A., FNP., states that all of the Veteran's eye conditions were secondary to Agent Orange exposure, but that there was no evidence in peer-reviewed literature to support such statements. The Board observes that the examiner found that the Veteran had mild nuclear cataracts in both eyes, which were less likely than not due to his service-connected diabetes. The examiner also reported that the Veteran had dry eye syndrome, as well as associated posterior blepharitis, and that some studies show that Agent Orange exposure could cause changes to meibomian glands in children and fetuses, but that there were no direct studies, or peer-reviewed literature, that show direct links between Agent Orange exposure and dry eye syndrome and posterior blepharitis. The examiner stated that the Veteran's wife reported that such had been a longstanding condition since his twenties, which made it less likely than not that the Veteran's dry eye syndrome and posterior blepharitis were incurred during his time in the service or caused by his Agent Orange exposure. The Board observes that the examiner solely addressed whether the Veteran's diagnosed mild nuclear sclerotic cataracts in both eyes were associated with his service-connected diabetes mellitus. The examiner did not specifically address whether the Veteran's mild nuclear sclerotic cataracts were aggravated by his service-connected diabetes mellitus, or any other service-connected disabilities. The examiner also did not address whether the Veteran's diagnosed dry eye syndrome, as well as associated posterior blepharitis, were caused or aggravated by his service-connected diabetes mellitus, or any other service-connected disabilities. In El-Amin v. Shinseki, 26 Vet. App. 136 (2013), a decision issued by the United States Court of Appeals for Veterans Claims (Court), the Court vacated a decision of the Board where a VA examiner did not specifically opine as to whether a disability was aggravated by a service-connected disability. The Board also observes that the examiner did not address whether the Veteran's diagnosed mild nuclear sclerotic cataracts were directly due to service, to include his presumed Agent Orange exposure. The Board further notes that the examiner did not address the Veteran's reports of treatment for right eye and left eye problems during and since service. See Davidson, 581 F.3d at 1313. Therefore, the Board finds that the examiner's opinions are inadequate in this matter. The March 2019 Board remand also indicated that the Veteran should be afforded a VA examination to determine the onset and etiology of his claimed skin disorder, to include skin cancer, a growth on the left leg, and a fatty tumor on the back. The examiner was to diagnose all current skin disorders, to include basal cell carcinoma; a complex cyst of the left thigh; and a lipomatous lesions of the back, etc. The examiner was also to opine as to whether it was at least as likely as not that any currently diagnosed skin disorders, to include basal cell carcinoma; a complex cyst of the left thigh; and a lipomatous lesions of the back, etc., were related to, and/or had their onset during, his period of service, to include his presumed in-service Agent Orange exposure. The March 2019 Board remand further directed that the examiner specifically acknowledge and discuss the reports by the Veteran of skin problems during service and since service, and comment on an October 2017 positive opinion from P. Akins, FNP. Pursuant to the March 2019 Board remand, the Veteran was afforded a VA skin diseases examination in October 2019. There is a notation that the Veteran's claims file was reviewed. The diagnoses were basal cell carcinoma; actinic keratoses; a rash; a complex cyst of the left thigh, status post a cystectomy, with a biopsy showing a lipoma; and a lipoma on the back. The examiner indicated that the Veteran's diagnosed basal cell carcinoma; rash; lipoma of the left thigh, status post excision; and lipoma of the back, were less likely than not incurred in, or caused by, service. The examiner reported that there was no peer-reviewed medical evidence that notes a causal relationship between basal cell carcinoma and Agent Orange, or lipomas and Agent Orange. It was noted that lipomas were fatty cells lumped together that were benign. The examiner stated that the cause of lipomas was not fully understood, and that they tended to run in families, so genetic factors likely played a role. The examiner indicated that basal cell carcinomas had multiple risk factors, to include chronic sun exposure, not one episode of moderate to severe sunburn, but repeated episodes of sun exposure or frequent tanning bed use. It was noted that fair-skinned people had a higher risk, and that increasing age was a risk. The examiner maintained that there was currently no peer medical evidence in the medical literature that demonstrated Agent Orange exposure caused basal cell carcinoma. The examiner reported that the Veteran's first diagnosis and treatment was almost twenty years after his discharge from the service. The examiner stated that there was no mention of a skin condition on the separation examination. It was noted that the Veteran's medical record revealed a couple occasions of being treated for a rash, but there was no descriptor of the rash or diagnosis provided for the rash. The examiner stated that there was no evidence of chronic, progressive, complaints of a rash noted in the medical record, and that the Veteran's service treatment records were silent for a rash condition. The Board observes that the examiner indicated that there was no evidence of chronic, progressive, complaints of a rash noted in the medical record, and that the Veteran's service treatment records were silent for a rash condition. The Board observes, however, that the examiner did not specifically address the Veteran's reports of skin problems during service and since service. See Davidson, 581 F.3d at 1313. Additionally, the Board notes that the examiner indicated that basal cell carcinomas had multiple risk factors, to include chronic sun exposure, not one episode of moderate to severe sunburn, but repeated episodes of sun exposure or frequent tanning bed use. The Board observes that at a November 2021 Board hearing, the Veteran specifically testified that he had sun exposure, with sunburns on his face and arms, while serving in Vietnam. He also maintained that he was unable to receive treatment for skin problems while serving in Vietnam. In light of the above, the Board finds that the Veteran has not been afforded VA examinations, with the opportunity to obtain responsive etiological opinions, following a thorough review of the entire claims file, as to his claims for service connection for bilateral eye disorders and for a skin disorder, to include skin cancer, a growth of the left leg, and a fatty tumor of the back, all to include as due to Agent Orange exposure. Such examinations must be accomplished on remand. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also Stefl v. Nicholson, 21 Vet. App. 120, 125 (2007); Stegall v. West, 11 Vet. App. 268, 271 (1998). The matters are REMANDED for the following action: 1. Ask the Veteran to identify all medical providers who have treated him for right and left eye problems and skin problems, since September 2019. After receiving this information and any necessary releases, obtain copies of the related medical records which are not already in the claims folder. Document any unsuccessful efforts to obtain the records, inform the Veteran of such, and advise him that he may obtain and submit those records himself. 2. Notify the Veteran that he may submit lay statements from himself and from other individuals who have first-hand knowledge, and/or were contemporaneously informed of his in-service and post-service symptoms regarding his claimed bilateral eye disorders, and skin disorder, to include skin cancer, a growth on the left leg, and a fatty tumor on the back. He should be provided an appropriate amount of time to submit this lay evidence. 3. Schedule the Veteran for an appropriate VA examination (or telehealth interview, review of the record, etc., if an in-person examination is not feasible) to determine the onset and etiology of his claimed bilateral eye disorders. The examiner must diagnose all current bilateral eye disorders, to include dry eye syndrome; senile cataracts; choroidal nevus; blepharitis; and conjunctivitis, etc. The examiner must opine as to whether it is at least as likely as not that any currently diagnosed bilateral eye disorders, to include dry eye syndrome; senile cataracts; choroidal nevus; blepharitis; and conjunctivitis, etc., are related to and/or had their onset during the Veteran's period of service, to include his presumed in-service Agent Orange exposure. The examiner must specifically acknowledge and discuss the Veteran's competent reports of treatment for right and left eye problems during service and since service, and in particular dry eye problems since service. The examiner must further opine as to whether the Veteran's service-connected diabetes mellitus, or any other service-connected disabilities, caused or aggravated any currently diagnosed bilateral eye disorders, to include dry eye syndrome; senile cataracts; choroidal nevus; blepharitis; and conjunctivitis, etc. 4. Schedule the Veteran for an appropriate VA examination (or telehealth interview, review of the record, etc., if an in-person examination is not feasible) to determine the onset and etiology of his claimed skin disorder, to include skin cancer, a growth on the left leg, and a fatty tumor on the back. The examiner must diagnose all current skin disorders, to include basal cell carcinoma; a complex cyst of the left thigh; and a lipomatous lesions of the back, etc. The examiner must opine as to whether it is at least as likely as not that any currently diagnosed skin disorders, to include basal cell carcinoma; a complex cyst of the left thigh; and a lipomatous lesions of the back, etc., are related to, and/or had their onset during, the Veteran's period of service, to include his presumed in-service Agent Orange exposure. The examiner must specifically acknowledge and discuss the competent reports by the Veteran of skin problems during service and since service, to specifically include his reports of sun exposure, with sunburns on his face and arms, while serving in Vietnam. (Continued on the next page) The examiner must further opine as to whether the Veteran's service-connected disabilities, caused or aggravated any currently diagnosed skin disorders, to include basal cell carcinoma; a complex cyst of the left thigh; and a lipomatous lesions of the back, etc. STEVEN D. REISS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. D. Regan, 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.