Citation Nr: 21011577 Decision Date: 03/02/21 Archive Date: 03/02/21 DOCKET NO. 15-22 409 DATE: March 2, 2021 ORDER 1. Entitlement to service connection for a psychiatric disorder, to include adjustment disorder, major depressive disorder, and posttraumatic stress disorder (PTSD), is denied. REMANDED 2. Entitlement to service connection for skin cancer, to include squamous and basal cell carcinoma, is remanded. FINDINGS OF FACT 1. The preponderance of the evidence is against a finding that the Veteran has a diagnosis of PTSD under Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) or Fifth Edition (DSM-5), American Psychiatric Association. 2. A psychiatric disorder, to include adjustment disorder and major depressive disorder, did not have its onset during active service and is not otherwise related to active service. CONCLUSION OF LAW The criteria for service connection for a psychiatric disorder, to include adjustment disorder, major depressive disorder, and PTSD, have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran had active service in the United States Army from June 1979 to June 1999. The Veteran testified before the undersigned Veterans Law Judge (VLJ) at a video conference hearing in February 2019, and a transcript of the hearing has been associated with the claims file. These matters were previously denied by the Board in August 2019, after which the Veteran appealed the matters to the United States Court of Appeals for Veterans Claims (Court). In September 2020, the parties agreed to a Joint Motion for Remand (JMR) wherein they moved the Court to vacate and remand the Board’s August 2019 decision, and later that same month, the Court issued its Order granting the JMR. To the extent that the September 2020 JMR identified deficiencies regarding the August 2019 Board decision, the Board has specifically addressed these below, including the additional development discussed within the Remand section. The Board is mindful that the Veteran has submitted a December 2019 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), and opted into the modernized appeals system concerning an October 2019 rating decision that continued the assigned 50 percent disability rating for the Veteran’s obstructive sleep apnea syndrome with chronic obstructive pulmonary disorder (COPD). As such, that matter will be the subject of a future AMA Board decision. The Board notes that in a February 2020 rating decision, the agency of original jurisdiction granted a 60 percent rating for obstructive sleep apnea syndrome with COPD, effective August 27, 2019. 1. Entitlement to service connection for a psychiatric disorder, to include adjustment disorder, major depressive disorder, and PTSD. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Service connection for PTSD specifically requires the presence of three particular elements: (1) a current medical diagnosis of PTSD; (2) medical evidence of a causal nexus between current symptomatology and a claimed in-service stressor; and (3) credible supporting evidence that the claimed in-service stressor actually occurred. The Veteran asserts that a current psychiatric disorder is related to active service. At the January 2019 videoconference hearing, the Veteran testified that his in-service sleep disorder, which was later labeled as a “broken biological clock” and “circadian rhythm,” was the same condition that was later diagnosed as adjustment disorder. He believed that the military wrongfully attributed his in-service sleep troubles to his service-connected sleep apnea, rather than considering it a symptom of a separate psychiatric disorder. He further stated that he lacked accessibility to healthcare to receive proper mental health treatment and to specifically identify what was going on. Initially, the Board notes that the Veteran is separately service connected for sleep apnea and bilateral periodic limb movement disorder/restless leg syndrome, and those disabilities are not part of the current appeal before the Board. As to evidence of a current psychiatric disorder, the Board finds that post-service VA treatment records document relevant diagnoses including adjustment disorder with depressed mood, anxiety, and major depressive disorder. Thus, this first criterion is met. The Board notes here that while private treatment records from August 2017 to October 2017 document that the Veteran has been assessed with PTSD, the Board finds that the preponderance of the evidence is against a finding that the Veteran has been diagnosed with PTSD in accordance with the DSM for the period on appeal. Significantly, the 2017 assessment of PTSD by a private practitioner was made after finding that the Veteran was suffering from depression in the context of stressors at work, and the examiner made no finding that the Veteran’s symptoms were related to his lay reports of in-service stressors. Moreover, this private assessment of PTSD over several months of treatment in the fall of 2017 is not corroborated by the extensive VA treatment records within the claims file. The Board has carefully considered the Veteran’s history of positive PTSD screens as directed in the September 2020 JMR, including in April 2011, August 2013, and April 2014; however, the Board notes that these screening tests are essentially a mere recording of the Veteran’s subjective medical history based upon a four-question inquiry. As such, the Board finds that the positive PTSD screens of record are of less probative value as to whether the Veteran has been diagnosed with PTSD in accordance with the DSM. The Veteran’s lay reports that form the basis of the positive PTSD screens are insufficient to establish a formal diagnosis of PTSD, as the Veteran lacks the expertise to diagnose a complex psychiatric disorder such as PTSD, which diagnosis has very specific requirements. Similarly, the four-question screening test underlying the positive PTSD screens of record is inadequate to support a formal diagnosis of PTSD under the full DSM criteria as required for service connection. 38 C.F.R. §§ 3.304(f), 4.125(a). Finally, as discussed herein, the Board affords greater probative value to the December 2013 VA psychiatric examination report, which documents that the Veteran’s symptoms did not meet the diagnostic criteria for a DSM-IV or DSM-5 diagnosis of PTSD. The examiner noted that the Veteran did not attribute his current mental health complaints to service, but rather reported feeling frustrated, angry, and occasional depressed mood in response to not being recognized for his service, not being helped or assisted by the VA system or the “system” more generally. The Board finds the December 2013 medical opinion by the psychologist highly probative. The examiner had performed an in-person examination, listened to the Veteran’s history and current psychiatric complaints, reviewed the record, and provided a rationale that was based on an accurate description of the facts and medical principles. Therefore, the Board finds that the preponderance of the evidence is against a finding that the Veteran has PTSD, and service connection for PTSD is not warranted. As to evidence of an in-service disease or injury, the Board finds that the preponderance of evidence weighs against a finding that a psychiatric disorder had its onset during active service. The Veteran complained of sleeping problems in November 1987, and, although the resulting assessment was insomnia, the Veteran actually reported trouble waking for the past year and one half, rather than trouble going to sleep. Upon follow-up two weeks later, he was assessed with nicotine and caffeine overuse. A February 1988 Screening Note of Acute Medical Care documents that the Veteran requested a consultation with the mental health clinic during a follow-up visit for his insomnia. Upon periodic physical examination in August 1988, a psychiatric evaluation was normal. Additionally, although the Veteran reported frequent trouble sleeping within a concurrent report of medical history, he also specifically denied depression or excessive worry and nervous trouble of any sort. In March 1989, he continued to complain of a sleep disorder with problems waking in the morning, which resulted in him being late to formation, and his condition was assessed as anxiety and adjustment problems. On two occasions in November 1991 and one instance in December 1991, the Veteran’s service medical record is stamped with an indication that he was seen for treatment by the psychiatry department, without any further indication as to the reasons for such visits. In August 1993, he reported insomnia since 1983, with ongoing inability to wake up in the morning, and was assessed with sleep awakening problems. In September 1998, the Veteran participated in a smoking cessation class and specifically denied a history of depression. Finally, the Veteran’s November 1998 retirement examination documents a normal psychiatric evaluation without any psychiatric defects or diagnoses, although his chronic sleep disorder was noted under defects and diagnoses as insomnia and hypersomnolence. Additionally, the Veteran reported frequent trouble sleeping but denied depression or excessive worry and nervous trouble of any sort within the concurrent Report of Medical History, and the examining physician again noted the Veteran’s history of chronic insomnia with hypersomnolence. Given the above, the Board acknowledges the Veteran’s ongoing complaints regarding his sleep disorder but finds that there is no probative evidence of an in-service onset of a psychiatric disorder given the normal psychiatric evaluations and the Veteran’s repeated denials of any psychiatric symptoms other than trouble sleeping. In making this finding, the Board has considered the September 2020 JMR, wherein the parties agreed that the Board had previously failed to analyze the Veteran’s service treatment records, including a February 1988 Screening Note of Acute Medical Care, which indicated that the Veteran requested a consult with the mental health clinic, and evidence indicating treatment with the psychiatry department in November and December 1991, and well as a post-service VA medical record from February 2008, which documents that the Veteran reported insomnia and treatment by a psychologist while in the military. The Board has carefully reviewed the Veteran’s service treatment records as discussed above, including those records specifically discussed in the September 2020 JMR. Notably, while the Board acknowledges that service treatment records document that the Veteran sought mental health treatment through the psychiatry department during active service, the Board finds that a review of the record weighs in favor of a finding that the Veteran’s treatment in such instances was concerning his complaints of insomnia and trouble sleeping, rather than for a psychiatric disorder. In particular, the February 1988 Screening Note of Acute Medical Care documents that the Veteran requested a consultation with the mental health clinic in conjunction with a follow-up visit for his insomnia, and his did not otherwise report any concurrent psychiatric symptoms for his request. Although the reasons for the November and December 1991 visits are not documented within service treatment records, the Board finds it probative that during a post-service VA psychiatric consultation in April 2011, the Veteran specifically denied any past psychiatric treatment, and he noted that he was seen during active service for a sleeping disorder and treated with sleep hygiene principles only, without medication. As such, the Board finds that the February 1988 record and the November and December 1991 psychiatry clinic visits do not weigh in favor of a finding that the Veteran was treated for a psychiatric disorder during active service. Rather, it is reasonable to conclude, based upon the contemporaneous in-service evidence and the Veteran’s own lay reports, that such visits concerned his request for follow-up treatment for insomnia and sleep complaints. Moreover, the Board finds that the preponderance of evidence weighs against a finding of a nexus between a current psychiatric disorder, including adjustment disorder and depression and his active service. Post-service VA treatment records from June 2002 and July 2002 document an assessment of adjustment disorder with mixed anxiety and depressed mood. In November 2002, the Veteran was assessed with adjustment disorder with depressed mood associated with his recent divorce. Later, in February 2008, the Veteran screened negative for PTSD. At that time, he reported ongoing problems with his sleeping schedule, and noted that he had problems with insomnia while in the military and that had had been seen by a psychologist regarding his sleeping schedule. He stated that he currently had no trouble going to sleep but did not feel that his sleep was restful and noted some depression and anxiety related to job hunting/employment, and child support from his ex-wife. He refused mental health treatment and stated he had gone through counseling and used exercise to help. In May 2010, the Veteran had a positive depression screen suggestive of moderate depression. In April 2011, the Veteran had a positive PTSD screen. Upon initial psychiatric consultation/evaluation later that month, the Veteran reported that he was simply following up on the positive PTSD screen. When asked about symptoms of PTSD and specific traumatic events, he denied experiencing, witnessing, or confronting any events involved in actual or threated death or serious injury. He also denied nightmares and specifically stated that he did not dream at all. He denied intrusive thoughts, recurring thoughts, or exaggerated startle response, but endorsed depression, hopelessness, and anger focused on the lack of help regarding his VA disability claim. He denied any past psychiatric treatment but reported that he was seen during active service in 1986 for a sleeping disorder, after which he was treated with sleep hygiene principles only and no medication. He reported being divorced since 2003 after 17 years of marriage, with two children, ages 21 and 23. He stated that he recently relocated to St. Louis from Milwaukee for a job after an extended period of unemployment and noted that he was currently employed in human resources at the St. Louis VAMC. He reported ongoing financial problems, including a recent foreclosure of his home in Milwaukee. The Veteran adamantly declined further treatment groups or services, including any medication, and related that he had been treated previously with Zoloft in 2001-2005 during a time he was receiving family and marital counseling (which the examiner noted he had not previously disclosed during his personal medical history). The Veteran reported that other people were his problem, as they failed to help him in his life, including VFW for not getting him VA disability benefits, contractors for not fulfilling contracts, and his ex-wife for not paying child support to him as the custodial parent. The physician diagnosed adjustment disorder with depressed mood versus a mood disorder, not otherwise specified (NOS), based upon stressors including recent relocation, financial problems, and home foreclosure. In October 2011, the Veteran submitted a statement regarding his ongoing sleep disorder, which he stated left him exhausted and often unable to concentrate at work or on personal/life tasks. In September 2012, he submitted a similar statement regarding his ongoing sleep disorder (broken biological clock) and newly-diagnosed adjustment disorder. He stated that he did not sleep for 48-72 hours once every two to three months, which was diagnosed by military mental health as a broken biological clock. Additionally, he noted that discussions with VA mental health resulted in a diagnosis of adjustment disorder based on his perception of veteran services and benefits. VA treatment records from August 2013 document the Veteran’s known mood disorder, which was not followed by psychiatric treatment providers. Upon VA examination in December 2013, a VA examiner noted that the Veteran had previously been diagnosed with DSM-IV adjustment disorder or mood disorder but concluded that the Veteran did not currently have a diagnosed mental disorder under DSM-5 criteria. The examiner stated that overall, the Veteran reported appropriate frustration and anger over his difficulty working with VA and employers that do not recognize his service experience; however, the examiner noted that such complaints of frustration, anger, and occasional depressed mood do not constitute a DSM-IV or DSM-5 mental disorder. Notably, the Veteran denied significant distress or impairment in his functioning due to his frustration, anger, and occasional depressed mood, and he did not attribute his mental health complaints to active service. Rather, he reported feeling frustrated, angry, and depressed in response to not being recognized for his service, and not being helped or assisted by the VA system or the “system” more generally. Despite these complaints, the Veteran reported that he did well at his job and enjoyed his relationship with his girlfriend and their new daughter. As such, the examiner stated that although the Veteran had previously been diagnosed with DSM-IV adjustment disorder or mood disorder, he did not have a current DSM-5 or DSM-IV mental disorder. In April 2014, the Veteran screened positive for PTSD and depression, though he denied feeling hopeless about the present or future, did not report thoughts about taking his own life or suicide attempts, and he declined referral for further intervention. In January 2015 the Veteran was noted to not have any psychiatric disorders, and in November 2015, he appeared with normal affect and conversation upon psychiatric behavioral evaluation. Private treatment records from August 2016 document a positive psychiatric history for anxiety and depression, but a current psychiatric review was normal. In August 2017, private treatment records from Maury Regional Health document that the Veteran was referred for problems with depression and anxiety. He reported treatment by VA since his retirement from military in 1999 and previous diagnoses including PTSD, depression, anxiety, substance abuse, and adjustment disorder but stated he had never seen a psychiatrist. His reported symptoms included anger outbursts, crying spells, frustration, negativity to VA, and morbid thoughts. He reported being in Europe and Honduras during active service, with threats of bombs and sniper fire, but no formal combat. He denied nightmares or flashbacks and reported some startle reflex and sleep impairment, but also denied suicidal or homicidal ideation, and audiovisual hallucinations. He was assessed with major depressive disorder, rule out PTSD. Notably, the physician explained that the Veteran was currently suffering from depression in the context of stressors at work. Upon follow-up in September 2017, the Veteran had been started on Prozac the prior month but had not noticed any changes in symptoms. He continued to be very negative in regard to VA, with ongoing anger, irritability, crying spells, and low frustration tolerance. He was assessed with PTSD with depressed mood. Finally, in October 2017, the Veteran noted improvement with an increased Prozac dose, resulting in a better mood. He still suffered from anxiety and frustration in regard to situations with the VA and reported ongoing trouble getting up in the morning. His assessed condition remained PTSD and major depressive disorder, with some improvement with increased Prozac. Private treatment records from July 2018 document a past medical history including anxiety and depression, but a psychiatric review of systems was negative. Similarly, in November 2018, the Veteran denied persistent symptoms of depression or anxiety, prolonged insomnia, unusual nightmares, or suicidal/homicidal ideation. In February 2019, the Veteran’s wife submitted a letter wherein she reported that the Veteran gets distraught and physically ill when a letter from VA arrives. She stated that she would withhold the letters, but the frustration greatly affected their personal and family well-being. She stated that his requests for assistance had gone unacknowledged as physicians placed the cause on things other than VA and noted that without acknowledging the connection to being a veteran and service connection of the behavior, they were unable to obtain or afford the appropriate mental health services for the Veteran. The Board finds that a review of the evidence reviewed above does not weigh in favor of a finding of a nexus between a current psychiatric disorder, including adjustment disorder, and the Veteran’s active service. Notably, upon VA examination in December 2013, a VA examiner concluded that the Veteran’s reported psychiatric symptoms did not meet current criteria for a psychiatric disorder. Additionally, the examiner noted that the Veteran did not attribute his symptoms at that time to active service, but rather, to other ongoing life stressors. Additionally, there is no competent evidence that a mental health professional has attributed a psychiatric disorder to the Veteran’s active service. As discussed above, the Board has found that the most probative evidence of record does not support a finding that the Veteran has been diagnosed with PTSD in accordance with the DSM for the period on appeal. At the February 2019 Board hearing, the Veteran and his representative asserted that the Veteran’s claimed psychiatric disorder was actually present during active service. He testified that he was seen throughout active service for sleep impairment, which was listed as insomnia but was really an inability to sleep until he was completely exhausted. He reported depression that “had always been there,” but stated that he was not evaluated for it during active service, though he later stated he was diagnosed off and on with adjustment disorder and mood disorders throughout his military career. He noted, based on personal research, that these things were all associated with adjustment disorder, which was not diagnosed until close to his retirement. The Veteran summarized that his claimed condition began in 1983 as a sleep disorder, which he complained of throughout his military career, and which was later labeled as a broken biological clock. Then later it was assessed as a circadian rhythm problem, and as time progressed, it was assessed as adjustment disorder. The Veteran stated that he believed VA had wrongfully attributed his sleep complaints to his service-connected sleep apnea rather than as a symptom of his claimed psychiatric disorder. To the extent that the Veteran’s lay statements, including as discussed above, assert that a current psychiatric disorder is related to his active service, such statements lack probative value as the Veteran has not been shown to possess medical or psychiatric expertise to render a nexus opinion regarding a complex and internal disease process. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran’s own opinion is nonprobative evidence Additionally, when the Veteran sought psychiatric treatment after service for psychiatric symptoms, he consistently attributed his symptoms to various life stressors, including marital problems and eventual divorce, job stressors and relocation, and financial problems including home foreclosure. He did not attribute these symptoms to active service at the time of treatment, and even reported in February 2008 that his in-service treatment was limited to sleep hygiene principles, with no medication and no further mention of a psychiatric disorder. Given the above, the Board finds that preponderance of the evidence weighs against the Veteran’s claim for service connection for a psychiatric disorder, to include adjustment disorder and major depressive disorder due to a lack of competent and credible evidence of a nexus between the post-service psychiatric disorder and service. As such, there is no reasonable doubt to be resolved, and the claim for service connection for a psychiatric disorder is denied. REASONS FOR REMAND 2. Entitlement to service connection for skin cancer, to include squamous and basal cell carcinoma, is remanded. As noted above, the parties agreed to a September 2020 JMR, which has been ordered by the Court. Therein, the parties agreed that the Board’s August 2019 decision failed to explain whether the duty to assist was fulfilled and, specifically, whether the Veteran was provided with an adequate examination in support of his claim for service connection for skin cancer. The parties noted that the Veteran has consistently asserted that his skin cancer is due to long-term, unprotected sun exposure as a result of his duties as a truck driver during active duty from 1979 to 1999; however, in its August 2019 denial, the Board relied on a June 2013 VA negative nexus opinion that is unclear as to whether the VA examiner properly considered the Veteran’s lay statements of prolonged sun exposure as a cause of his skin cancer or his descriptions of in-service exposure. VA’s duty to assist includes obtaining a medical opinion when such an examination or opinion is necessary to make a decision on the claim. Furthermore, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Given the above, the Board finds that it is unclear whether the June 2013 VA examination properly addressed the Veteran’s lay statements of long-term exposure to the sun in service and whether this caused his skin cancer. As such, the Board finds that an addendum opinion is warranted upon remand which properly considers all the relevant evidence of record, including the Veteran’s lay statements. The matter is REMANDED for the following action: Refer the Veteran’s claims file an appropriate examiner for an opinion regarding the Veteran’s claim of entitlement to service connection for skin cancer, to include squamous and basal cell carcinoma. If the examiner finds that an in-person examination is warranted, then schedule the Veteran for a VA skin examination. To assist in a review of the claims file, the examiner is informed of the following facts with citations in the record, when applicable: • The Veteran had active duty from June 1979 to June 1999. • The Veteran is claiming that he developed skin cancer from unprotected sun exposure during his 20 years of active duty. • The Veteran is already separately service-connected for dyshidrosis and eczema, and those disabilities are not part of the current claim. • At a February 2012 VA respiratory examination, the Veteran reported he smoked 2 packs of cigarettes a day from 1980 to 1998, which is a 38-pack-year history. See VBMS entry with document type, “VA Examination,” receipt date 02/03/2012, p. 16. • Post-service private treatment records document the Veteran’s diagnosis of skin cancer in August 2012. Specifically, a curettage biopsy of the right temple showed squamous cell carcinoma. The punch biopsy of the left nasolabial fold showed fibrosis and inflammation secondary to prior procedure without evidence of epithelial neoplasm. See VBMS entry with document type “Medical Treatment Record - Non-Government Facility,” receipt date 04/12/2013, pp. 8-9. • Service treatment records including an August 1988 periodic examination that documents a normal clinical evaluation of the Veteran’s skin, without any notation of skin cancer as a current defect or diagnosis. Additionally, within a concurrent report of medical history, the Veteran’ denied any tumor, growth, cyst, cancer, or other skin diseases. The Veteran’s November 1998 retirement physical examination likewise documents a normal clinical evaluation of the Veteran’s skin, and though the physician noted a history of hand and foot dyshydrostic eczema, there is no documentation of skin cancer, specifically. Within a concurrent report of medical history at retirement, the Veteran reported a tumor, growth, cyst, or cancer, but denied current skin diseases, and the physician again noted his history of hand and foot dyshydrostic eczema. See VBMS entry with document type, “Medical Treatment Record - Government Facility,” receipt date 06/09/2014, pp. 1 & 3; see also VBMS entry with document type, “STR – Medical,” receipt date 12/18/2009, pp. 43 & 47. • Post-service treatment records from October 1999 document the Veteran’s subjective complaints of a hand and foot skin disorder. A concurrent dermatology report documents blisters on his hands and feet with itchy and peeling skin since 1983, which was diagnosed as dyshidrosis. See VBMS entry with document type, “VA Examination,” receipt date 10/07/1999, pp. 1 & 13. • In July 2006, the Veteran reported some current skin lesions and a history of actinic keratoses in the past, and he was assessed with multiple actinic keratoses. Upon dermatology follow-up in September 2006, he had several scaly patches on his right temple and right medial canthus. He reported similar lesions treated in the past with liquid nitrogen about two years before and stated that he thought he was told that these were skin cancers; however, he never had them biopsied and they did not require surgery. He was assessed with actinic keratosis of the face and treated with cryotherapy and liquid nitrogen. See VBMS entry with document type, “Medical Treatment Record - Non-Government Facility,” receipt date 11/15/2013, pp. 2 & 4. • In February 2008, the Veteran reported eczema with a rash in his groin and dry, flaky skin on his arms and legs. In May 2008, his eczema was responding well to treatment with topical cream. See VBMS entry with document type, “Medical Treatment Record - Government Facility,” receipt date 07/08/2008, pp. 4 & 19. • In December 2011, the Veteran reported several flat, scaly patches on his arms and face which were assessed as possible keratosis. In January 2012, he was referred to a dermatology clinic for evaluation of the skin lesions and reported that the lesions on his face and left arm began about five years ago and had slowly increased in size. He further reported a history of significant sun exposure with sunburns when working as a truck driver, although he was very conscious of sun exposure and currently worked in human resourced, which limited his exposure. He was assessed with actinic keratosis of the bilateral temporal region and left forearm, which was treated with liquid nitrogen. See VBMS entry with document type, “CAPRI,” receipt date 01/24/2012, with “#2” in the subject field, pp. 1-3. • A February 2012 VA skin examination shows the VA examiner documented a current skin diagnosis of dyshidrosis eczema beginning in 2000-2001; however, the examiner specifically noted that the Veteran did not have benign or malignant neoplasms or metastases related to any skin diagnoses. See VBMS entry with document type, “VA Examination,” receipt date 02/03/2012, pp. 30-40. • In July 2012, the Veteran underwent shave biopsy for unusual basaloid neoplasm and epidermal hyperplasia with atypical keratinocytes. In September 2012, this was diagnosed as squamous cell carcinoma of the right temple, which had been present for several months and was treated in the past with cryotherapy. See VBMS entry with document type, “Medical Treatment Record - Non-Government Facility,” receipt date 04/12/2013, pp. 6 & 19. • A February 2013 skin examination report shows the VA examiner noted the Veteran had a current diagnosis of squamous cell and basal cell cancer. The examiner noted that beginning in 2004, the Veteran was diagnosed with actinic keratoses cells on observation on the bilateral temples. In 2008 and 2010, he had the bilateral temple lesions frozen with liquid nitrogen. In 2012, he developed more bleeding and swelling of the lesion on right temple and had additional lesions on bilateral cheeks and bilateral forearms. He had the left temple and right cheek actinic keratoses cells frozen with liquid nitrogen in January 2012. A lesion on the left edge of his mustache and right temple lesion were biopsied and found to be basal cell carcinoma and squamous cell carcinoma, respectively. The right temple lesion was treated surgically in October 2012. Additionally, a left forearm lesion was not biopsied, but was also thought to be basal cell carcinoma. The examiner also noted other bilateral forearm lesions and a new growth on the mid-line neck which had not been evaluated. The examiner summarized that the Veteran had a basal cell carcinoma of the left-upper mustache region of the face and squamous cell carcinoma of the right temple, with actinic keratoses in various areas, which had all been resolved by either liquid nitrogen cryosurgery, biopsies, or Mohs surgery, and that he was currently asymptomatic. See VBMS entry with document type, “VA Examination,” receipt date 02/12/2013, pp. 1-12. • In June 2013, another VA examiner opined that the Veteran’s claimed skin cancer was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner reasoned that service records indicated that Veteran was treated in service for multiple inflammatory skin conditions, including eczema, acne, and various rashes all over his body; however, the examiner stated that the Veteran’s current basal cell carcinoma, squamous cell carcinoma, and actinic keratoses were neoplastic skin lesions or pre-malignant skin lesions related to long term sun exposure, and were not caused by eczema, acne, or rash. The examiner stated that the Veteran’s in-service skin conditions were inflammatory conditions, not neoplastic conditions, and that they do not lead to the development of skin cancer. See VBMS entry with document type, “VA Examination,” receipt date 06/17/2013, pp. 18-20. • Private treatment records from April 2016 document that the Veteran’s skin was normal. In July 2018, his past history of basal cell skin cancer was noted, but his skin was again normal upon physical examination. See VBMS entry with document type, “Medical Treatment Record - Non-Government Facility,” receipt date 10/29/2018, pp. 4 & 22. • During a June 2019 VA skin examination for his service-connected dyshidrotic eczema, the Veteran reported a history of skin cancer beginning at the age of 40; however, the examiner stated that his skin cancer was not related to his dyshidrotic eczema. See VBMS entry with document type, “C&P Exam,” receipt date 06/13/2019. • The examiner’s review of the record is NOT restricted to the evidence listed above. This list is provided in an effort to assist the examiner in locating potentially relevant evidence. Following a review of the claims file, including the relevant evidence discussed above, the VA examiner is asked to render an opinion as to whether it is as likely as not (a 50 percent probability or greater) that the Veteran’s skin cancer, to include squamous and basal cell carcinoma, is related to service, which was from June 1979 to June 1999, to include sun exposure during that period of time. Upon what facts and medical principles do you base the opinion? In rendering the requested opinion, the examiner is asked to consider and discuss the relevant evidence of record, including the Veteran’s lay statements that his skin cancer is due to long term, unprotected sun exposure as a result of his duties as a truck driver during active duty from 1979 to 1999. A full rationale must be provided for all medical opinions given. If the examiner is unable to provide an opinion without resorting to mere speculation, he or she should explain why this is so. The examiner shall then explain whether the inability to provide a more definitive opinion is the result of a need for more information and indicate what additional evidence is necessary, or whether he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). A. P. SIMPSON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Chad Johnson, 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.