Citation Nr: 21010518 Decision Date: 02/25/21 Archive Date: 02/25/21 DOCKET NO. 17-04 706A DATE: February 25, 2021 ORDER Entitlement to a rating in excess of 10 percent for coronary artery disease status post myocardial infarction, prior to January 27, 2020, is denied. Entitlement to a rating in excess of 10 percent for right knee meniscectomy and debridement is denied. Entitlement to service connection for hypertension is granted. Entitlement to service connection for a skin disorder is granted. FINDINGS OF FACT 1. Prior to January 27, 2020, the Veteran’s coronary artery disease status post myocardial infarction was productive of a workload greater than 7 metabolic equivalents (METs) but not productive of congestive heart failure, cardiac hypertrophy, or an ejection fraction of 50 percent or less. 2. Throughout the period on appeal, the Veteran’s right knee osteoarthritis disability has manifested in flexion from 0 to 110 degrees, and extension from 110 to 0 degrees, at worst; there is no objective evidence of instability but there are residuals of meniscectomy and limited motion with pain. 3. The preponderance of the evidence reflects that the Veteran has hypertension that is related to his active service. 4. The evidence is in equipoise as to whether the Veteran has a current skin disorder that is related to his active service. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 10 percent for coronary artery disease status post myocardial infarction, prior to January 27, 2020, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.10, 4.40, 4.45, 4.71a, Diagnostic Codes 7005, 7006. 2. The criteria for entitlement to a rating in excess of 10 percent for right knee meniscectomy and debridement have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5259. 3. The criteria for entitlement to service connection for hypertension have been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for entitlement to service connection for a skin disorder have been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from March 1964 to March 1968. These matters come to the Board on appeal from a July 2014 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In September 2019, the Veteran testified at a hearing before a Veterans Law Judge of the Board who is no longer active. A transcript of the hearing is associated with the record. In November 2020 correspondence, the Veteran was given the opportunity to request another hearing and was notified that if he did not provide a response in 30 days, it would be assumed that he did not want another hearing. The Veteran did not respond to the letter; therefore, the Board will proceed with adjudication of the Veteran’s claims. This case was previously before the Board in November 2019. The Veteran’s claims were remanded for additional development. The case is now again before the Board for further appellate action. Increased Rating Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the appellant working or seeking work. 38 C.F.R. § 4.2. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. The Board notes that while the regulations require review of the recorded history of a disability by the adjudicator to ensure an accurate evaluation, the regulations do not give past medical reports precedence over the current medical findings. Where an increase in the disability rating is at issue, the present level of the Veteran’s disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). It is also noted that staged ratings are appropriate for an increased rating claim whenever the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Fenderson v. West, 12 Vet. App. 119 (1999), Hart v. Mansfield, 21 Vet. App. 505 (2007). 1. Entitlement to a rating in excess of 10 percent for coronary artery disease status post myocardial infarction, prior to January 27, 2020, is denied. The Veteran contends that he is entitled to an increased rating for his coronary artery disease status post myocardial infarction, as he claims that his symptoms are worse than reflected by his current rating. The Veteran filed a claim for an increased rating for his service-connected heart disability in August 27, 2013. A July 2014 rating decision granted a rating of 100 percent for the Veteran’s coronary artery disease, effective August 27, 2013, and assigned a rating of 10 percent from November 1, 2013. The Veteran’s service-connected heart disability is rated as 100 percent disabling prior to November 1, 2013, 10 percent disabling from November 1, 2013 to January 27, 2020, and 100 percent disabling from January 27, 2020. The Veteran was rated under diagnostic code 7006 prior to January 27, 2020, and under diagnostic code 7006-7005 from January 27, 2020. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the specific basis for the evaluation assigned; the additional code is shown after a hyphen. 38 C.F.R. § 4.27. Diagnostic Code 7005 rates coronary artery disease and Diagnostic Code 7006 rates myocardial infarction with residuals. Diagnostic Code 7005 provides ratings for arteriosclerotic heart disease (coronary artery disease) and requires documented coronary artery disease. Arteriosclerotic heart disease resulting in a workload of greater than 5 METs but not greater than 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilation on electrocardiogram, echocardiogram, or x-ray, is rated as 30 percent disabling. Arteriosclerotic heart disease resulting in more than one episode of acute congestive heart failure in the past year, or; workload of greater than 3 METs but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent, is rated as 60 percent disabling. Arteriosclerotic heart disease resulting in chronic congestive heart failure, or; workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent, is rated as 100 percent disabling. 38 C.F.R. § 4.104. Diagnostic Code 7006 provides the same rating criteria as Diagnostic Code 7005, except that it recognizes a history of documented myocardial infarction and provides for a 100 percent disability rating during and for three months following a myocardial infarction, documented by laboratory tests. 38 C.F.R. § 4.104, Diagnostic Code 7006. Turning to the evidence, a September 2013 VA cardiology note reported that, since his discharge after his heart attack in July 2013, the Veteran was doing well. He was physically active and lost 10 pounds after changing his diet. An October 2013 VA primary care note reported that the Veteran denied any chest pain or shortness of breath. The Veteran reported that he follows a low-fat low-sodium diet and exercises frequently. The Veteran submitted a December 2013 Ischemic Heart Disease Disability Benefits Questionnaire that was completed by a doctor. The Veteran was diagnosed with coronary artery disease, hypertension, and “hypercholesterol.” The doctor reported that the Veteran experienced “chest pain not clearly angina at rest.” It was reported that the Veteran’s METs level has been found to be consistent with 1-3 METs. The doctor opined that the Veteran’s heart condition probably does not impact the Veteran’s ability to work. He reported that he was able to exercise on a treadmill. However, he noted that the Veteran was being evaluated for ongoing chest pain “so this is still uncertain.” The Veteran was afforded a VA heart conditions examination in December 2013. The examiner diagnosed the Veteran with coronary artery disease - acute myocardial infarction and noted the Veteran had a heart attack five months ago. A diagnostic exercise test was not conducted; however, the examiner reported the Veteran denied experiencing symptoms with any level of physical activity. At a December 2013 VA knee examination, the Veteran reported that he walked one to two miles on a treadmill daily at level 3 and gradually increased the incline. A January 2014 VA cardiology clinic note documented the Veteran’s report that he had continued to exercise by walking 1-5 miles at a time with no functional limitations. He reported he could outwalk his wife and did not get symptoms of shortness of breath or chest pain. He reported occasional chest pain at rest, lasting anywhere from 15 minutes to a few hours. A November 2014 VA cardiology note reported the Veteran continued to do well with a good diet and exercise. A January 2016 VA cardiology report indicated that the Veteran completed 9 minutes and 35 seconds of exercise on a treadmill, achieving 11 METS of exercise. Exercise was limited by fatigue, but no symptoms of chest discomfort occurred during exercise. An April 2016 VA cardiology note reported the Veteran continued to be very active and walks 2 to 3 miles daily without chest pains or difficulty. He has occasional positional orthostasis but denied lightheadedness or syncopal events. An October 2016 VA cardiology note reported the Veteran continued to have 1 to 2 episodes per week of atypical chest pain, which usually occur at rest and were described as short lasting. Therefore, it was determined that an objective reassessment with an exercise tolerance test was warranted. An October 2016 VA cardiology report indicated that the Veteran completed 9 minutes and 25 seconds of exercise on a treadmill, achieving 11 METS of exercise. Exercise was limited by knee pain, but no symptoms of chest discomfort occurred during exercise. A November 2016 VA cardiology report included an arrythmia summary that indicated an unremarkable 30-day event recorder. It was reported that the Veteran’s symptoms do not appear to correlate with heart rate or rhythm. A January 2017 VA physical therapy consult reported that the Veteran had been walking 10,000 steps per day. However, due to thyroid issues and fatigue, he reported currently walking 1,000 steps per day. The Veteran was provided another VA heart conditions examination in February 2017. The Veteran was diagnosed with coronary artery disease, supraventricular arrhythmia, and “acute, subacute, or old myocardial infarction.” The examiner reported that the results of an exercise stress test in October 2016 were a normal maximal exercise stress test, without diagnostic echocardiogram changes of cardiac ischemia and without symptoms of cardiac ischemia. The Veteran performed a METs level of 11. After an interview based METs test, the examiner reported that the “Veteran denies experiencing symptoms attributable to a cardiac condition with any level of physical activity. The preponderance of the evidence does not support the criteria for a rating in excess of 10 percent for the Veteran’s heart disability prior to January 27, 2020. Based upon review of the evidence of record, the Board finds that the Veteran’s coronary artery disease is best contemplated by the 10 percent criteria. The Veteran’s coronary artery disease is not indicative of a workload of less than 7 METs that results in dyspnea, fatigue, angina, dizziness, or syncope. Further, there is no evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. Thus, the Board finds that the Veteran’s coronary artery disease status post myocardial infarction is best contemplated by the 10 percent criteria. Accordingly, the Board concludes that the Veteran’s coronary artery disease status post myocardial infarction does not warrant a rating in excess of 10 percent for the period on appeal. As the preponderance of the evidence is against an increase, the benefit of the doubt rule is not applicable. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). 2. Entitlement to a rating in excess of 10 percent for right knee meniscectomy and debridement is denied. The Veteran contends that he is entitled to a higher rating due to the severity of his right knee symptoms, including increased inflammation and pain. The Veteran filed a claim for a compensable rating for his service-connected right knee disability in August 27, 2013. A July 2014 rating decision denied the claim and continued a noncompensable rating under Diagnostic Code 5257. A January 2017 rating decision granted an increased rating to 10 percent for right knee meniscectomy and debridement, under Diagnostic Code 5259, previously rated as right knee contusion and strain residuals, effective August 27, 2013. The RO issued an August 2020 Supplemental Statement of the Case continuing the 10 percent rating for symptomatic residuals of semilunar cartilage removal and painful motion of the knee. When evaluating musculoskeletal disabilities, VA must consider granting a higher rating in cases in which the Veteran experiences functional loss due to limited or excess movement, pain, weakness, excess fatigability, or incoordination (to include during flare-ups or with repeated use), where those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). The provisions of 38 C.F.R. §§ 4.40 and 4.45 are to be considered in conjunction with the DCs predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). Testing of range of motion of joints that have painful motion should include both active and passive motion, motion in weight bearing and non-weight bearing, and, if possible, the range of motion of the opposite undamaged joint. Correia v. McDonald, 28 Vet. App. 158 (2016). Painful motion with joint or periarticular pathology and unstable joints due to healed injury are recognized as productive of disability entitled to at least a minimal compensable rating for the joint. 38 C.F.R. § 4.59. The general rating schedules for limitation of motion of the knee are DCs 5260 and 5261. 38 C.F.R. § 4.71a. Normal range of motion of the knee is to 0 degrees extension and to 140 degrees flexion. 38 C.F.R. § 4.71a, Plate II. Under DC 5260, limitation of flexion of the knee is rated 10 percent disabling for flexion limited to 45 degrees. A 20 percent rating is assigned for flexion limited to 30 degrees. A 30 percent rating is assigned for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, DC 5260. Under DC 5261, limitation of extension of the knee is rated 10 percent disabling for extension limited to 10 degrees. A 20 percent rating is assigned for extension limited to 15 degrees. A 30 percent rating is assigned for extension limited to 20 degrees. A 40 percent rating is assigned for extension limited to 30 degrees. A 50 percent rating is assigned for extension limited to 45 degrees. 38 C.F.R. § 4.71a, DC 5261. In addition, there are special provisions for rating degenerative arthritis (to include osteoarthritis) under Diagnostic Code 5003. When there is painful motion of a major joint caused by degenerative arthritis (rated under Diagnostic Code 5003) that is detected on x-ray, such painful motion will be considered limited motion pursuant to 38 C.F.R. § 4.59. Painful motion is entitled to a minimum 10 percent rating, per joint, combined under Diagnostic Code 5003, even if there is no actual limitation of motion. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); Lichtenfels v. Derwinski, 1 Vet. App. 484 (1991). The Veteran was afforded a VA knee examination in December 2013. The Veteran reported his right knee pain had decreased since his right knee surgery five years ago, though he still has pain when he exercises too much. He reported that he walked 1-2 miles on a treadmill daily. The examiner report full range of motion with flexion and extension with no objective evidence of painful motion. The examiner reported that the Veteran had frequent episodes of joint pain related to his meniscus condition. The Board finds that this examination was inadequate because the examination did not include range of motion testing for the Veteran’s knees in both passive motion and non-weight-bearing circumstances. See Correia v. McDonald, 28 Vet. App. 158 (2016). A January 2014 VA cardiology clinic note documented the Veteran’s report that he had continued to exercise by walking 1-5 miles at a time with no functional limitations. A May 2015 VA radiology report showed that the Veteran had mild right degenerative changes worst at the medial compartment with medial joint space narrowing. An April 2016 VA cardiology note reported the Veteran continued to be very active and walks 2 to 3 miles daily. An October 2016 VA cardiology report indicated that the Veteran completed 9 minutes and 25 seconds of exercise on a treadmill, but exercise was limited by knee pain. A January 2017 VA physical therapy consult reported that the Veteran had been walking 10,000 steps per day. However, due to thyroid issues and fatigue, he reported currently walking 1,000 steps per day. In January 2018, the Veteran submitted a VA Form 21-4138, Statement in Support of Claim, in which he expressed that he experienced an increase in right knee pain and inflammation. The Veteran was provided another VA knee examination in January 2020. The Veteran was diagnosed with bilateral chondromalacia patella and status post meniscectomy for repeat of right knee meniscal tear. The Veteran reported his right knee disorder impacted his ability to climb ladders, squat, kneel, or navigate inclines and declines. He reported that walking more than a mile causes increased pain in his knees. The Veteran demonstrated right knee flexion from 0 to 110 degrees and extension from 110 to 0 degrees. The examiner noted that pain with flexion and extension that did not cause functional loss. The examination was not conducted immediately after repetitive use. The examiner stated that the examination was medically consistent with the Veteran’s statements describing functional loss with repetitive use over time. According to the examiner, pain, weakness, fatigability or incoordination do not significantly limit functional ability with repeated use over a period of time. The Veteran did not report experiencing flare ups. Joint stability testing was performed and found no instability. No ankylosis was reported. The examiner noted that the Veteran had a right knee meniscal tear but did not report any symptoms associated with the meniscal tear, such as joint locking, pain, or effusion. After consideration of the entire record and relevant law, the Board finds that a rating in excess of 10 percent for the Veteran’s service-connected for right knee meniscectomy and debridement is not warranted. During his January 2020 VA examination, the Veteran demonstrated right knee flexion from 0 to 110 degrees and extension from 110 to 0 degrees, with pain on flexion and extension that did not cause functional loss. He reported that walking more than a mile caused increased pain in his knees. The examiner noted that the Veteran had a right knee meniscal tear but did not report any associated symptoms. After a thorough review of the current evidence of record, the Board finds that it does not support assignment of a higher rating under DC 5259 as the Veteran’s 10 percent rating is the highest rating available pursuant to that diagnostic code. A higher or separate compensable rating will therefore be warranted only if such a rating is warranted under another diagnostic code that does not result in pyramiding, specifically, under DC 5260, 5261 or 5257. However, at his January 2020 VA examination, the Veteran demonstrated right knee flexion from 0 to 110 degrees and extension from 110 to 0 degrees, with pain on flexion and extension that did not cause functional loss. The examiner noted that the Veteran exhibited no joint instability and had a right knee meniscal tear but did not report any associated symptoms. Although the January 2020 VA examiner noted that the Veteran exhibited joint pain and the Veteran has complained of right knee pain, he is already being compensated for painful motion of the right knee joint. Accordingly, as the preponderance of the evidence is against the claim for a higher initial rating, the Board finds that the claim of entitlement to a rating in excess of 10 percent for right knee meniscectomy and debridement must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 3. Entitlement to service connection for hypertension is granted. The Veteran contends that he has hypertension that is related to an in-service injury, event, or disease. The Veteran’s DD Form 214 reported that he served in the Air Force from March 1964 to March 1968, including a tour in Vietnam. The Veteran’s awards included the Vietnam Service Medal and Republic of Vietnam Campaign Medal. The Veteran’s service treatment records show treatment in Vietnam between January 1967 and June 1967. Applicable regulations provide that a veteran who served on active duty in Vietnam during the Vietnam era is presumed to have been exposed to herbicide agents. 38 C.F.R. § 3.307(a)(1)(6)(iii). An herbicide agent means a chemical in an herbicide used in support of the United States and allied military operations in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 6, 1975, specifically: 2,4-D; 2,4,5-T and its contaminant TCDD; cacodylic acid; and picloram. 38 C.F.R. § 3.307(a)(6)(i). An April 1968 VA form reported that the Veteran’s separation medical examination was not on file. In December 2013, the Veteran submitted a VA Form 21-4138, Statement in Support of Claim, in which he expressed that he worked on a flight line in Vietnam from August 1966 to August 1967. He reported that, while working on the flight line, he was sprayed with Agent Orange by a C-123 aircraft testing its spray bars prior to take-off. He believes the substance was Agent Orange based on its color. A study by the National Academy of Sciences, Engineering, and Medicine (NAS) released in November 2018, concluded that epidemiologic evidence was sufficient to conclude that there is a positive association between exposure to herbicides used during the Vietnam War and hypertension. See National Academies of Sciences, Engineering, and Medicine: Veterans and Agent Orange: Update 11 (2018). https://www.nap.edu/catalog/25137/veterans-and-agent-orange-update-11-2018 (last visited Feb. 3, 2021). The Veteran was afforded a VA hypertension examination in January 2020. The examiner reported a diagnosis of hypertension with a date of diagnosis as October 2011. The examiner opined that the Veteran’s hypertension was less likely than not (less than 50 percent or greater probability) proximately due to or the result of the Veteran’s service-connected heart disability. As rationale, the examiner explained that there is a vast amount of evidence of hypertension contributing to and being a major causative factor for heart disease and myocardial infarction. However, the converse is not well documented in the medical literature. The treatment for the majority of patients who have cardiac abnormalities is often classes of antihypertensives. This does not mean, however, that these individuals have hypertension; rather, merely that they are treated with antihypertensives to prevent later recurrence of myocardial infarction. Moreover, the examiner noted a diagnosis of hypertension in the claimant’s medical record in October 2011. The examiner opined that the Veteran’s hypertension was at least as likely as not (50 percent or greater probability) incurred or caused by an in-service injury, event, or illness. As rationale, the examiner provided the following: We note the claimant is presumed to have been exposed to chemical herbicide during his service. We also note that the National Academies of Science recent research has indicated that hypertension, as a diagnosis, has been “moved to the category of ‘sufficient’ evidence of an association from its previous classification in the ‘limited or suggestive’ category” of a link between hypertension and exposure to Agent Orange (tactical herbicide). There is enough epidemiological evidence to conclude that there is a positive association” (NAS). The Board affords great probative weight to the January 2020 VA examination and medical opinion, as the examiner opined that it was at least as likely as not that the Veteran’s hypertension was caused by his presumed exposure to herbicide agents, as he found sufficient epidemiological evidence to conclude a positive association with his current diagnosis of hypertension. Accordingly, the Board finds that the preponderance of the evidence warrants service connection for the Veteran’s hypertension. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 4. Entitlement to service connection for a skin disorder is granted. The Veteran contends that he has a skin disorder that is related to an in-service injury, event, or disease. The Veteran’s DD Form 214 reported that he served in the Air Force from March 1964 to March 1968, including a tour in Vietnam. The Veteran’s awards included the Vietnam Service Medal and Republic of Vietnam Campaign Medal. An April 1964 service treatment record reported the Veteran had a rash on his upper and lower trunk. The impression was possible measles. The Veteran’s service treatment records show treatment in Vietnam between January 1967 and May 1968. A March 1967 service treatment record reported that the Veteran had a pustular rash in his pubic area. The impression was folliculitis. An October 6, 1967 service treatment record reported the Veteran had small papules beneath his skin. The impression was herpes. An October 11, 1967 service treatment record reported the Veteran had a venereal wart on his penis. An April 1968 VA form reported that the Veteran’s separation medical examination was not on file. A February 1994 private medical record reported that the Veteran had a scaling rash on his hands. He was diagnosed with eczema. A December 2007 private treatment record noted diagnoses of seborrheic dermatitis of the face and psoriasis of elbows and fingers. A September 2011 VA medical record reported a diagnosis of dermatitis, “most likely psoriasis flare.” A VA medical opinion was provided on January 17, 2020. The examiner opined that the Veteran’s psoriasis is less likely than not incurred in or caused by service, to include herbicide exposure. As rationale, the examiner explained that the skin conditions for which the Veteran was seen in service are unrelated to and are not precursors for psoriasis. She also explained that psoriasis is caused by genetic factors in combination with environmental triggers. The Veteran was provided a VA skin examination on January 27, 2020. The examiner diagnosed the Veteran with eczema and psoriasis. The examiner opined that the Veteran’s skin disorder was at least as likely as not (greater than 50 percent probability) incurred in or caused by the Veteran’s military service. As rationale, the examiner explained that the Veteran’s service medical records show multiple instances of the Veteran seeking treatment for skin rashes and lesions, as well as pustular eruptions of the face. The claimant continued to have outbreaks despite multiple topical and systemic medications and was diagnosed with psoriasis and eczema. The Veteran relayed a credible history of being doused with chemical herbicide during his time of service and shortly following these exposures he states he began to develop these skin eruptions for which he sought medical treatment and advice. Another VA medical opinion was obtained in August 2020 from the examiner who provided the opinion on January 27, 2020, as it conflicted with the prior opinion provided on January 17, 2020. The examiner noted that he disagreed with the prior examiner’s conclusions related to a 2016 journal article, which found that, although there is some evidence, it is far from conclusive in skin diseases such as eczema and even less support for psoriasis. The examiner stated that this finding presents the possibility that support for the connection may present itself at some future date, which he claim is provided by a June 2020 journal article published in the Journal of the Korean Society of Clinical Toxicology and the Department of Emergency Medicine at the Veterans’ Health Service Medical Center in Seoul. The examiner explained that the article shows clinical and research evidence linking exposure to organochlorines, namely Agent Orange, and the development of psoriasis. The examiner explained that the prior examiner’s own cited evidence acknowledging the “unknown” nature of the connection between organochlorine compounds and exposure with development of psoriasis lends itself to at least consideration of a degree of likelihood. He explained that this, coupled with the June 2020 article in which a connection between Agent Orange (organochlorine compounds) and development of psoriasis is considered to be “recognized as suspected complications of defoliant exposure,” along with the claimant’s credible history, documented evidence of skin rashes and complaints of skin conditions during service, clinical examination of the claimant, and the claimant’s later development of psoriasis, leads this examiner to stand by his original medical opinion in opposition to that of the January 17, 2020 examiner. Therefore, the examiner opined that the Veteran’s psoriasis was at least as likely as not (50 percent or greater probability) incurred in or caused by the Veteran’s military service, including exposure to herbicide. The Board affords great probative weight to the August 2020 VA medical opinion, as the examiner opined that it was at least as likely as not that the Veteran’s psoriasis was incurred in or caused by the Veteran’s military service, including exposure to herbicide, as he found sufficient epidemiological evidence to conclude a positive association with his current diagnosis of psoriasis. Accordingly, the Board finds that the preponderance of the evidence warrants service connection for the Veteran’s skin disorder. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. KELLI A. KORDICH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Moore, 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.