Citation Nr: 21009994 Decision Date: 02/23/21 Archive Date: 02/23/21 DOCKET NO. 07-24 384A DATE: February 23, 2021 REMANDED Entitlement to service connection for type II diabetes mellitus is remanded. Entitlement to a compensable evaluation for bilateral foot tinea pedis prior to May 22, 2019, is remanded. Entitlement to a compensable evaluation for palmoplantar keratoderma (previously diagnosed as bilateral foot tinea pedis) on or after May 22, 2019, is remanded. Entitlement to an evaluation in excess of 10 percent for left hip contusion and strain with residuals is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. REASONS FOR REMAND The Veteran serviced on active duty from January 1991 to September 1991. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from August 2006, June 2016, and November 2016 rating decisions. The Board remanded the case for further development in May 2015 and January 2018. The case has since been returned to the Board for appellate review. Regarding the service-connected skin disability, in an August 1994 rating decision, the Regional Office (RO) granted service connection for tinea pedis and assigned a noncompensable evaluation effective from March 31, 1993, pursuant to 38 C.F.R. § 4.118, Diagnostic Code 7813 for dermatophytosis. In a February 2020 rating decision, the RO changed the Diagnostic Code assigned for the Veteran’s service-connected skin disability based on findings from an August 2019 VA examination. In so doing, the RO assigned a noncompensable evaluation for palmoplantar keratoderma effective from May 22, 2019, pursuant to 38 C.F.R. § 4.118, Diagnostic Code 7824 for diseases of keratinization. In an August 2019 VA examination report, the examiner opined that the Veteran’s longstanding skin disability was more consistent with palmoplantar keratoderma. In so finding, she stated that it was questionable whether tinea pedis was a correct diagnosis because the Veteran showed no improvement after years of treatment for a curable condition. The examiner also stated that palmoplantar keratoderma is a different condition than tinea pedis and dermatitis of the scrotum. The Veteran has contended that the symptoms of his service-connected skin disorder spread from his feet to his groin. His VA medical records document that he was prescribed topical medication for symptoms skin disorders of the groin and feet. A July 2019 VA dermatology record also noted that the Veteran was advised to put his socks on before his underwear to prevent a recurrence of tenia cruris. However, the August 2019 VA examiner did not address whether any skin conditions of the groin were manifestations or complications of the Veteran’s service-connected skin disability. Therefore, a remand is necessary. Regarding the service-connected left hip disability, the Veteran was afforded a VA examination in August 2019. The examiner stated that passive range of motion testing for the hips could not be performed or was not medically appropriate. However, the examiner did not provide an explanation for his conclusions, as directed by the Board in January 2018. Therefore, a remand is necessary to obtain an additional VA examination. Stegall v. West, 11 Vet. App. 268, 271 (1998). The August 2019 examiner also stated that he was unable to provide a retrospective medical opinion regarding range of motion findings with precision based on the available evidence. However, the examiner did not clearly explain why he was unable to provide a retrospective opinion, as directed by the Board in January 2018. Therefore, a remand is necessary to obtain an additional VA medical opinion. Stegall v. West, 11 Vet. App. 268, 271 (1998). Moreover, the Agency of Original Jurisdiction (AOJ) obtained information regarding the Veteran’s service from the VA/Department of Defense Identity Repository (VADIR), which indicated that the Veteran served in the United States Army Reserve from September 1992 to September 1997. In a September 2018 report of general information, the Veteran reported that his reserve unit informed him that copies of his records were maintained at the Records Management Center (RMC). A June 1993 request for information noted that the Veteran’s health and dental records were forwarded to the United States Army Reserve Personnel Center in St. Louis, Missouri. The Veteran’s active duty service treatment and personnel records are associated with the claims file. However, it is unclear whether there are any outstanding Reserve service records. Therefore, the AOJ should ensure that proper development has been conducted to obtain any outstanding records from such service. In addition, in March 2020, the Veteran reported having supportive evidence from “two other medical treatment facilities.” However, he did not clearly identify the medical facilities. In April 2018, the RO requested that the Veteran identify any VA and private treatment providers. The Board reminds the Veteran that the “duty to assist is not always a one-way street.” A veteran is expected to cooperate in the efforts to adjudicate the claim, and his failure to do so would subject him to the risk of an adverse adjudication based on an incomplete and underdeveloped record. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Thus, on remand, the AOJ should afford the Veteran an additional opportunity to identify any outstanding treatment records. The record also reflects that the Veteran was awarded vocational rehabilitation subsistence allowance for training at a university. See February 2020 correspondence. However, the Veteran’s rehabilitation plan is not associated with the claims file. Therefore, the AOJ should associate the Veteran’s vocational rehabilitation records with the claims file. The Board further finds that the issue of entitlement to TDIU is inextricably intertwined with the increased rating and service connection claims. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (noting that two issues are inextricably intertwined when the adjudication of one issue could have significant impact on the other issue). The matters are REMANDED for the following action: 1. The AOJ should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for the disorders on appeal that are not already of record. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should also obtain any outstanding VA medical records. 2. The AOJ should obtain the Veteran’s vocational rehabilitation file and associate it with the claims file. 3. The AOJ should contact the Records Management Center (RMC), the Veteran’s Reserve unit, or any other appropriate location, to request any outstanding service treatment records and service personnel records for any service in the United States Army Reserve from September 1992 to September 1997. If any requested records are not available, the AOJ should clearly document the claims file to that effect and notify the Veteran of any inability to obtain the records, in accordance with 38 C.F.R. § 3.159(e). 4. After completing the foregoing development, the Veteran should be afforded a VA examination to ascertain the current severity and manifestations of his service-connected left hip disability. The examiner is requested to review all pertinent records associated with the claims file. It should be noted that the Veteran is competent to attest to factual matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should state this with a fully reasoned explanation. The examiner should report all signs and symptoms necessary for rating the disability. In particular, the examiner should provide the range of motion in degrees for the Veteran’s left and right hips. In so doing, the examiner should test the Veteran’s range of motion in active motion, passive motion, weight-bearing, and nonweight-bearing. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary or medically appropriate in this case, he or she should clearly explain so in the report and identify the basis for that determination. The examiner should also indicate whether there is any form of ankylosis. In addition, the examiner should state whether there is malunion of the left femur with slight knee or hip disability, moderate knee or hip disability, or marked knee or hip disability; whether there is a fracture of the neck of the left femur with a false joint; and whether there is nonunion from a fracture of the shaft or anatomical neck of the left femur with or without loose motion. He or she should also indicate whether the Veteran has a flail joint. The presence of objective evidence of pain, excess fatigability, incoordination, and weakness should also be noted, as should any additional disability (including additional limitation of motion) due to these factors. Further, the VA examiner should comment as to whether range of motion measurements for active motion, passive motion, weight-bearing, and/or nonweight-bearing can be estimated for the other VA examinations conducted during the appeal period. See, e.g. July 2006, June 2007, January 2011, and August 2019 VA examination reports. If the examiner is unable to provide a retrospective opinion as to these specific range of motion findings, he or she should clearly explain so in the report. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important “that each disability be viewed in relation to its history[,]” 38 C.F.R. § 4.1, copies of all pertinent records in the appellant’s claims file, or in the alternative, the claims file, must be made available to the examiner for review. 5. After completing the foregoing development, the Veteran should be afforded a VA examination to ascertain the current severity and manifestations of his service-connected skin disability. The examiner is requested to review all pertinent records associated with the claims file. It should be noted that the Veteran is competent to attest to factual matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should state this with a fully reasoned explanation. The examiner should report all signs and symptoms necessary for rating the disability. In particular, he or she should specify the location and extent of the disability in terms of percentage of the body affected; percentage of exposed areas affected; and the frequency that systemic therapy such as corticosteroids or immunosuppressive drugs has been required during the past 12 months. Any medications used to treat the disorder should be identified. The examiner should state whether the Veteran’s reported symptoms near or/on his groin during the appeal period were manifestations or complications of his service-connected disability. In so doing, the examiner should address the Veteran’s lay statement that his service-connected skin disorder spread from his feet to his groin. He or she should also address the VA medical records that document that the Veteran was prescribed medication for symptoms of skin disorder of the groin and that he was instructed to put his socks on before his underwear to prevent recurrence of his condition. See, e.g., July 2019 VA dermatology record. To the extent possible, the examiner should distinguish the symptoms associated with the service-connected skin disorder and any symptoms associated with a nonservice-connected disorder. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important “that each disability be viewed in relation to its history[,]” 38 C.F.R. § 4.1, copies of all pertinent records in the appellant’s claims file, or in the alternative, the claims file, must be made available to the examiner for review. J.W. ZISSIMOS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Wulff, 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.