Citation Nr: 21008520 Decision Date: 02/17/21 Archive Date: 02/17/21 DOCKET NO. 20-27 304 DATE: February 17, 2021 ORDER Service connection for a skin condition, to include actinic keratosis and basal cell carcinoma, is granted. REMANDED Service connection for a low back condition is remanded. A rating higher than 50 percent for posttraumatic stress disorder (PTSD) is remanded. A rating higher than 50 percent for right hip joint status post joint replacement is remanded. A rating higher than 10 percent for left hip degenerative arthritis is remanded. A compensable rating for right thigh limitation of flexion is remanded. A compensable rating for left thigh limitation of flexion is remanded. A compensable rating for hypertension is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) prior to February 1, 2015 is remanded. FINDING OF FACT The Veteran’s diagnosed actinic keratosis and basal cell carcinoma are at least as likely as not related to his presumed in-service exposure to herbicide agents. CONCLUSION OF LAW The criteria for service connection for a skin condition, to include actinic keratosis and basal cell carcinoma, are met. 38 U.S.C. §§ 1110, 1116, 5107; 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 from January 1966 to January 1968 in the U.S. Army. This matter comes before the Board of Veterans’ Appeals (Board) from October 2016 and March 2017 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a Board hearing before the undersigned Veterans Law Judge in December 2020. A copy of the transcript is of record. This case has been advanced on the Board’s docket pursuant to 38 C.F.R. § 20.900. Initially, the Board notes that the Veteran also appealed the issue of whether the rating reduction from 60 percent to 10 percent for his service-connected coronary artery disease was proper; however, in a March 2020 rating decision, the RO restored the 60 percent rating. Accordingly, the issue has been resolved. Service connection for a skin condition The Veteran contends that his skin cancer is related to in-service exposure to Agent Orange while serving in Vietnam. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). The Veteran has current diagnoses of actinic keratosis and basal cell carcinoma. Additionally, as the Veteran served in the Republic of Vietnam during the applicable period, he is presumed to have been exposed to herbicide agents, including Agent Orange. Accordingly, the first two elements of service-connection have been established. While the Board recognizes that actinic keratosis and basal cell carcinoma are not among the listed diseases and conditions that may be presumptively service-connected based on exposure to herbicide agents under 38 C.F.R. § 3.309(e), that does not preclude the claim for service connection to be established on a direct basis. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). Regarding the third element, nexus, the Veteran submitted two statements from his treating physician. In February 2019, the physician stated that the Veteran suffers from history of chronic actinic keratosis and has a notable history of exposure to Agent Orange. Additionally, the physician opined that his abnormal skin lesions, including his history of basal cell carcinoma could potentially be attributable to his Agent Orange exposure. In December 2020, the Veteran’s physician opined that the Veteran’s long history of chronic actinic keratosis and secondary skin cancer sequalae stemming from the lesions, including squamous cell carcinomas on his face and scalp, are more likely than not related to his exposure to herbicide agents. The physician’s rationale stated that studies have linked the dioxin found in Agent Orange to immune suppression, and he has experience treating other veterans exposed to Agent Orange. The Board finds the opinions to be adequate and highly probative as the physician considered the Veteran’s medical history and provided clear conclusions with supporting data and reasoned explanations. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008). Additionally, there is no medical evidence to the contrary. As such, the Board finds that all elements of service connection for a skin condition are met, and service connection is warranted. REASONS FOR REMAND Service connection for a low back condition The Veteran contends that his low back condition is related to his service-connected bilateral hip disability. Alternatively, the Veteran contends that his low back condition is directly related to service. The Veteran was afforded a VA examination in March 2017; however, the Board finds that the opinion is inadequate for adjudication purposes because the examiner did not address aggravation. Additionally, no examiner has opined as to whether the Veteran’s low back disability is directly related to service. Accordingly, remand is warranted to obtain a new VA examination. Increased rating for PTSD, right hip joint status post joint replacement, left hip degenerative arthritis, right thigh limitation of flexion, left thigh limitation of flexion, and hypertension During the December 2020 Board hearing, the Veteran testified that his service-connected disabilities have worsened since his last VA examinations. Accordingly, remand is necessary to obtain current VA examinations. TDIU During the December 2020 Board hearing, the Veteran asserted that he stopped working due to his service-connected PTSD. Accordingly, the Board has included a TDIU claim as part of his appeal for an increased rating. Rice v. Shinseki, 22 Vet. App. 447 (2009).The Board notes that the Veteran has been in receipt of a TDIU since February 1, 2015. As such, the issue has been characterized as entitlement to a TDIU prior to February 1, 2015. Because a decision on the remanded issue of entitlement to increased rating for PTSD could significantly impact a decision on the issue of entitlement to a TDIU, the issues are inextricably intertwined. Therefore, the claim for a TDIU must be remanded. The matters are REMANDED for the following action: 1. Obtain any outstanding VA treatment records. 2. Schedule the Veteran for an examination with an appropriate clinician regarding the nature and etiology of his claimed low back disability. Following review of the claims file, the examiner must opine as to the following: (a.) Whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s low back disability had its clinical onset during active service or is otherwise related to an in-service injury, event, or disease. (b.) Whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s low back disability was caused (in whole or in part) by his service-connected bilateral hip disability. (c.) Whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s low back disability was aggravated (worsened beyond its natural progression) by his service-connected bilateral hip disability. The examiner should elicit a full history from the Veteran. Consideration should be given to his medical history and lay statements. The examiner should also consider the December 2020 Board hearing testimony describing two events that occurred during service and the documented in-service auto accident. A complete rationale for the opinion should be provided. 3. Schedule the Veteran for appropriate examinations to determine the current severity of his service-connected PTSD, right hip joint status post joint replacement, left hip degenerative arthritis, right thigh limitation of flexion, left thigh limitation of flexion, and hypertension. The claims file should be made available to the examiners for review. All indicated tests and studies should be performed and all findings reported in detail. JOHN Z. JONES Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Kernen, 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.