Citation Nr: 21008072 Decision Date: 02/11/21 Archive Date: 02/11/21 DOCKET NO. 10-36 036 DATE: February 11, 2021 REMAND Entitlement to service connection for a skin disability is remanded. Entitlement to service connection for a right hand disability is remanded. Entitlement to service connection for a left foot disability is remanded. Entitlement to service connection for a right foot disability is remanded. REASONS AND BASES FOR REMAND The Veteran served on active duty from September 1958 to September 1962 and from March 1967 to May 1972. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a July 2009 Department of Veterans Affairs (VA) regional office (RO) rating decision. By way of background, the RO denied service connection for the disabilities on appeal in a July 2009 rating decision, and the Veteran perfected an appeal to the Board in July 2010. In July 2015 and November 2016, the Board remanded the issues on appeal for further development, specifically to obtain private and VA treatment records as well as medical examinations and opinions. In September 2017, the Board remanded the issues on appeal again, noting that the examinations obtained in accordance with the July 2015 and November 2016 remands were not adequate. Additional examinations were obtained, and the case was returned to the Board in October 2018. In November 2018, the Board again found that the examinations and opinions of record were inadequate and remanded the issues for new examinations and opinions. The requested opinions were obtained, and the appeal was once again recertified to the Board in May 2020. In July 2020, the Board again remanded the claims for further VA examination. Regarding the Veteran’s claim for entitlement to service connection for a skin disability, the Board found that the October 2019 VA examination was inadequate as it failed to render an etiological opinion for all skin disabilities of record. As for the right hand, and bilateral foot disabilities, the Board found the October 2019 VA examination inadequate as it failed to opine whether the Veteran’s herbicide exposure directly caused these disabilities. Addendum VA medical opinions were obtained, and the matter returns to the Board. Furthermore, the Board notes that when a Veteran makes a claim for entitlement to service connection for a disability, he is seeking service connection for symptoms regardless of how those symptoms are diagnosed or labeled. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). Therefore, the Board has recharacterized the claims on appeal to comport with the record. See id. 1. Entitlement to service connection for a skin disability is remanded. 2. Entitlement to service connection for a right hand disability is remanded. 3. Entitlement to service connection for a left foot disability is remanded. 4. Entitlement to service connection for a right foot disability is remanded. While the Board regrets further delay, remand is necessary to obtain addendum VA examinations and medical opinions regarding the Veteran’s claims for entitlement to service connection for skin, right hand, and bilateral foot disabilities. As discussed in more detail below, each VA examination suffers from the same defect—the VA examiner’s failure to provide an etiological opinion for each individual skin, right hand, and bilateral foot disabilities. As such, remand is necessary regarding each claim. Skin Disability The Veteran generally contends that his skin disability, however diagnosed, is related to his service—and specifically—his exposure to herbicides while in Vietnam. The Veteran’s DD 214 verifies that he served in Vietnam from September 1971 until February 1972. Therefore, the presumption on herbicide exposure attaches. In the latest July 2020 remand, the Board required the addendum VA examiner to provide an etiology regarding all the Veteran’s skin disabilities, to include those listed in the previous July 2010, July 2015, November 2016, October 2017, and October 2019 VA examinations. The Board specifically required opinions for chloracne, squamous cell carcinoma, basal cell carcinoma, actinic keratosis, and tinea unguium. The August 2020, September 2020, and October 2020 addendum opinions provided etiological opinions regarding the specifically requested disabilities. However, the September 2020 addendum opinion also identified that the Veteran was additionally diagnosed with asymptomatic seborrheic keratosis, lentigines with no atypical features, actinic dermatitis/poikiloderma, and xerosis per a July 2019 dermatology consult. Unfortunately, none of the VA examiners provided etiological opinions regarding these additional disabilities diagnosed by the July 2019 dermatology consult and identified by the September 2020 addendum VA examiner. See McLain v. Nicholson, 21 Vet. App. 319, 321 (2007) (holding that service connection may be granted for a disability that manifests at any point during the pendency of a claim, even if it subsequently resolves prior to resolution of the claim). For this reason, remand is necessary so that a new VA addendum examination can be obtained which addresses all diagnosed skin disabilities of record. On remand, the addendum VA examiner must review the claims file in conjunction with the VA examination. To assist the addendum examiner, the Board will provide a list of evidence that must be considered and discussed when rendering these opinions. However, the Board reminds the addendum examiner that this list is not exhaustive and that the entire claims file must be considered and discussed. Right Hand Disability Left Foot Disability Right Foot Disability The Veteran claims that his right hand and bilateral lower foot disabilities are related to service, to include his in-service exposure to herbicide while serving in Vietnam. In response to the latest Board remand, the September 2020 VA examiner identified that the Veteran was diagnosed with right upper extremity neuropathy, right lower extremity neuropathy, left lower extremity neuropathy, and Raynaud’s disease. Regarding the Veteran’s neuropathy, although he is presumed exposed to herbicides while serving in Vietnam, the VA examiner opined that these disabilities are less likely than not related to service as there was no documentation of peripheral neuropathy in his service treatment records and because onset of these disabilities were decades after service. The VA examiner also explained that peripheral neuropathy has been associated with acute or subacute exposure to herbicides, “which is not the case here.” As for the Veteran’s Raynaud’s disease, the VA examiner opined that the it is less likely than not —even “extremely unlikely”—related to service as there is no evidence of this disability in his service treatment records, and because it developed more than 40 years after exposure in service. However, the VA examiner also identified that the Veteran was diagnosed with additional right upper and bilateral lower extremity disabilities. Specifically, the Board notes that the September 2020 addendum VA examiner identified that a July 2015 VA examination diagnosed the Veteran with right thumb degenerative arthritis of the 1st MCP joint and a March 2011 VA treatment record diagnosed the Veteran with bilateral plantar fasciitis. As the Veteran has been diagnosed with additional right hand and bilateral foot disabilities, and because no VA examiner has rendered an etiological opinion regarding such, remand is necessary before final adjudication. See McLain v. Nicholson, 21 Vet. App. 319, 321 (2007) (holding that service connection may be granted for a disability that manifests at any point during the pendency of a claim, even if it subsequently resolves prior to resolution of the claim). The addendum VA examiner must review the claims file in conjunction with the VA examination. To assist the addendum examiner, the Board will provide a list of evidence that must be considered and discussed when rendering these opinions. However, the Board reminds the addendum examiner that this list is not exhaustive and that the entire claims file must be considered and discussed. These matters are REMANDED for the following action: 1. Obtain any outstanding VA or private treatment records. 2. Thereafter obtain an addendum VA examination from a dermatologist (or similarly qualified examiner) to determine the nature and etiology of the Veteran’s skin disabilities. An in-person examination (or telehealth interview or similar action, if an in-person examination is not feasible) need not be scheduled unless it is deemed necessary by the examiner or otherwise required by the evidence. The examiner must review the claims file in its entirety and that review should be noted in the examination report. The VA examiner should provide separate, fully-articulated medical opinions with respect to the following: (a) Identify all currently diagnosed skin disabilities, to include chloracne, squamous cell carcinoma, actinic keratosis, tinea unguium, basal cell carcinoma, asymptomatic seborrheic keratosis, lentigines with no atypical features, actinic dermatitis/poikiloderma, and xerosis. (b) Is it at least as likely as not that the Veteran’s chloracne was incurred in service or is otherwise causally related to the Veteran’s active service therein, to include his presumed in-service exposure to herbicides? (c) Is it at least as likely as not that the Veteran’s squamous cell carcinoma was incurred in service or is otherwise causally related to the Veteran’s active service therein, to include his presumed in-service exposure to herbicides? (d) Is it at least as likely as not that the Veteran’s actinic keratosis was incurred in service or is otherwise causally related to the Veteran’s active service therein, to include his presumed in-service exposure to herbicides? (e) Is it at least as likely as not that the Veteran’s tinea uguium was incurred in service or is otherwise causally related to the Veteran’s active service therein, to include his presumed in-service exposure to herbicides? (f) Is it at least as likely as not that the Veteran’s basal cell carcinoma was incurred in service or is otherwise causally related to the Veteran’s active service therein, to include his presumed in-service exposure to herbicides? (g) Is it at least as likely as not that the Veteran’s asymptomatic seborrheic keratosis was incurred in service or is otherwise causally related to the Veteran’s active service therein, to include his presumed in-service exposure to herbicides? (h) Is it at least as likely as not that the Veteran’s lentigines with no atypical features was incurred in service or is otherwise causally related to the Veteran’s active service therein, to include his presumed in-service exposure to herbicides? (i) Is it at least as likely as not that the Veteran’s actinic dermatitis/poikiloderma was incurred in service or is otherwise causally related to the Veteran’s active service therein, to include his presumed in-service exposure to herbicides? (j) Is it at least as likely as not that the Veteran’s xerosis was incurred in service or is otherwise causally related to the Veteran’s active service therein, to include his presumed in-service exposure to herbicides? In providing the above opinion, the VA examiner must address the following evidence: • Service Treatment Records: March 1968 service treatment records indicate that the Veteran had a prior history of boils but has not had any for 8 years. A November 1971 service treatment record shows that the Veteran was seen for a rash on his leg and groin diagnosed as allergic dermatitis. • Post-Service Treatment Records: August 2004 and September 2005 VA treatment records show that the Veteran did not have any skin issues upon physical examination. August 2008 VA treatment records indicate that the Veteran had rashes on his face and hands. A July 2019 dermatology note diagnoses asymptomatic seborrheic keratosis, lentigines with no atypical features, actinik dermatitis, and xerosis. • Lay Statements: In an April 2009 lay statement, the Veteran contended that his skin condition “will not go away.” He further stated that he has lesions that will not heal and believes that it is chloracne as he has “severe problems with blackheads around my mouth and on my nose.” The Veteran stated that he has had these symptoms since the military. • All VA examinations of record to include the July 2015, November 2016, October 2019, August 2020, September 2020, and October 2020 VA medical opinions. 3. Thereafter, obtain an addendum VA examination from an appropriately qualified examiner to determine the nature and etiology of the Veteran’s right hand and bilateral feet disabilities. An in-person examination (or telehealth interview or similar action, if an in-person examination is not feasible) need not be scheduled unless it is deemed necessary by the examiner or otherwise required by the evidence. The examiner must review the claims file in its entirety and that review should be noted in the examination report. The VA examiner should provide separate, fully-articulated medical opinions with respect to the following: (a) Identify all currently diagnosed right hand and bilateral feet disabilities, to include right upper extremity peripheral neuropathy, left or right lower extremity peripheral neuropathy, Raynaud’s disease, right thumb degenerative arthritis of the 1st MCP joint, and bilateral plantar fasciitis. (b) Is it at least as likely as not that the Veteran’s right upper extremity peripheral neuropathy is causally related to the Veteran’s active service, to include exposure to herbicides? (c) Is it at least as likely as not that the Veteran’s left and right lower extremity peripheral neuropathy is causally related to the Veteran’s active service, to include exposure to herbicides? (d) Is it at least as likely as not that the Veteran’s Raynaud’s disease is causally related to the Veteran’s active service, to include exposure to herbicides? (e) Is it at least as likely as not that the Veteran’s right thumb degenerative arthritis of the 1st MCP joint onset in service, within one year of service separation, or is otherwise related to the Veteran’s active service, to include his in-service exposure to herbicides. (f) Is it at least as likely as not that the Veteran’s bilateral plantar fasciitis onset in service, or is otherwise related to the Veteran’s active service, to include his in-service exposure to herbicides. In providing the above opinion, the VA examiner must address the following evidence: • Post-Service Treatment Records: A July 2015 VA examination diagnosed the Veteran with right thumb degenerative arthritis of the 1st MCP joint and a March 2011 VA treatment record diagnosed the Veteran with bilateral plantar fasciitis. • Lay Statements: In April 2020 and November 2020 lay statements, the Veteran contends that an October 1969 flight medical examination, he mentioned the tingling in his fingers and toes and the “odd sensations in the hands and feet I experienced visiting some Northern states while on leave when the nighttime temperatures fell below the warm level.” The Board notes that the Veteran underwent this flight medical examination in November 1969. • All VA examinations of record, to include the July 2015, November 2016, October 2019, August 2020, and September 2020 VA medical opinions. Detailed rationales for all opinions must be provided. The examiner 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. LESLEY A. REIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Finelli, 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.