Citation Nr: 21013150 Decision Date: 03/08/21 Archive Date: 03/08/21 DOCKET NO. 17-20 622 DATE: March 8, 2021 REMANDED Entitlement to service connection for a right knee disability is remanded. Entitlement to service connection for a left knee disability is remanded. Entitlement to service connection for a skin disability is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1985 to July 1989. This appeal comes before the Board of Veterans' Appeals (Board) from March 2015 and November 2015 rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO). In December 2020, the Veteran testified before the undersigned Veterans Law Judge (VLJ). A hearing transcript is associated with the record. The VLJ held the record open for 90 days for the submission of supporting medical evidence. Evidence was subsequently received from the Veteran’s representative in January 2020, along with a waiver of agency of original jurisdiction (AOJ) review of that evidence. The Board has recharacterized the Veteran’s claims more broadly based on the Veteran’s contentions and the medical evidence of record to ensure complete consideration of the claims’ scope. See Clemons v. Shinseki, 23 Vet. App. 1 (2009); see also Brokowski v. Shinseki, 23 Vet. App. 79 (2009) (The scope of a claim includes any disability that may reasonably be encompassed by the claimant’s description of the claim, reported symptoms, and other information of record). In remanding these matters, the Board makes no finding, implicit or otherwise, as to the credibility of the Veteran’s assertions. Neither the Veteran’s credibility nor any lack thereof should be presumed in this remand. 1. Entitlement to service connection for a right knee disability. 2. Entitlement to service connection for a left knee disability. Issues 1-2. The Veteran contends that his current right and left knee disabilities stem from the rigors and wear-and-tear of physical training during service. He testified that his symptoms had their onset during service and were caused by his participation in field operations as an infantryman as well as long marches and runs on uneven terrain, carrying heavy loads on his back, and often while wearing boots. The Veteran further asserts that, following service, his bilateral knee symptoms progressively worsened and he consequently underwent numerous arthroscopic surgeries and, ultimately, bilateral knee replacements. See Hearing Transcript at 4-6 (December 2019); Veteran’s statement (VA Form 21-4138) (December 2014); Notice of Disagreement (NOD) (April 2015). In support of his claim, the Veteran submitted copies of letters he had written during service to his girlfriend regarding the physical demands and effects of his training. In one undated letter, the Veteran wrote that he had to “sit in weird positions to shoot” and that one position really hurt his knee because of “that Osgood Schlatter’s disease I had.” In another letter that is partially illegible, the Veteran appears to describe cold weather training in which he had to carry a big sled that was strapped to him. See NOD (April 2015). For reasons explained below, the Board finds that remand is required prior to deciding the appeal. The Veteran’s DD Form 214 shows his military occupational specialty was rifleman. His service treatment records (STRs) reflect that he was treated on one occasion after he hurt his right knee in June 1988 (a description of the injury was not provided). During his visit, the Veteran denied any prior injuries but indicated he had suffered 3 stress fractures in the past, including in his right leg, great toe and left hand. He was observed to bear weight without difficulty and a physical examination of the right knee showed no edema or erythema. The examiner noted the right patella was stable and the Veteran was assessed with a normal right knee examination. Another notation recorded in a Problem Summary List shows treatment in June 1988 for either a right or bilateral (illegible) knee (illegible) injury. A June 1989 Report of Examination at the Veteran’s service separation reflects normal clinical evaluation of the lower extremities. His Report of Medical History, dated in June 1989, reflects that the Veteran denied the he ever had or having now swollen or painful joints, arthritis, and “trick” or locked knee. Following service, the Veteran underwent arthroscopic surgery related to his meniscus in the right and left knees in March 1995 and July 1995 and again, in May 2002. See NOD (April 2015) with attached evidence including Patient financial history by date of service (Florida Joint and Spine Institute). A private surgical report indicates the Veteran underwent partial bilateral knee replacements in June 2005 related to diagnoses of advanced degenerative arthritis of the medial compartments of both knee joints. See operative report (Dr. Ashok Sonni/Florida Hospital Heartland) (June 2005). A medical statement dated in January 2020 from the Veteran’s private family practice physician, Dr. Marvin Maxwell, indicates he also underwent total knee replacements in both knees during the appeal period. A medical clearance appointment confirms the Veteran underwent total right knee arthroplasty revision in April 2015. (Maxwell Medical) (February 2015). A March 2015 VA examination report reflects a diagnosis of degenerative joint disease of the right knee, status post partial knee replacement. The examination report, however, does not show a diagnose of any left knee disability despite the Veteran report of bilateral knee symptoms that he believed were due to active service. The Board also notes the VA examination report contains an incomplete history pertaining to the Veteran’s assertions of rigorous in-service physical training and the onset of his bilateral knee symptoms. In this regard, the Veteran reported that his knees hurt in service and he self-treated with wraps, Icy Hot, and Tylenol, and was told to wear a knee brace. However, the examination report does not detail the Veteran’s reports of onset, detailing the circumstances/events, or progression of symptoms both in and since his active duty. The associated March 2015 VA medical opinion addressed only the right knee, and concluded that it was less likely than not incurred in or caused by service because: (1) the one right knee pain complaint in 1988 was acute, had not resulted in a contemporaneous diagnosis; (2) it had resolved without any reference to right knee problems noted on the separation examination; and (3) there was no evidence of chronic right knee symptoms shown during service or in the years immediately following service separation. Notwithstanding the absence of a diagnosis and etiological opinion regarding the left knee, the Board finds the March 2015 VA knee examination and medical opinion are inadequate. First, the record reflects the Veteran has undergone total knee replacements in both knees since the March 2015 VA knee examination was conducted. As such, an updated VA examination is required to address the change in right and left knee diagnoses during the appeal period. In addition, the VA examiner did not elicit from the Veteran a full history regarding the nature and onset of his bilateral knee symptoms in service nor was the continuity of those symptoms after service separation contemplated in formulating the medical opinion. See McKinney v. McDonald, 28 Vet. App. 15, 30-31 (2016) ("the VA examiner's failure to consider [a veteran's] testimony when formulating her opinion renders that opinion inadequate."). Also, a medical opinion "must support its conclusions with an analysis that the Board can consider and weigh against contrary opinions." Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The Board recognizes the Veteran submitted several favorable nexus opinions from his private doctors. The Board, however, finds that the opinions do not provide a sufficient basis upon which to grant the appeal. A medical statement dated May 2015 from Dr. Hugh Morris simply describes the current status of the Veteran’s bilateral knee disabilities, indicating the Veteran was recovering from recent right knee revision replacement and needed replacement of the left knee joint in the near future. The Board notes that Dr. Morris provided no positive nexus opinion linking the Veteran’s bilateral knee disabilities to his service. Rather, he merely stated the Veteran was quite young to have these types of problems and provided no further explanation to support that assertion. Consequently, this statement is inadequate for adjudicative purposes. It is also noted that a medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record. See Stefl v. Nicholson, 21Vet. App.102, 124-25. A “medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two.” Nieves-Rodriguez v. Peake, 22Vet. App.295, 301 (2008). Next, a medical opinion from Dr. Sonni dated in June 2015 indicates that, in 1995, he performed arthroscopic surgeries for meniscus injuries to both the Veteran’s knee joints. Dr. Sonni stated the Veteran had informed him the meniscus injuries were service-related. Furthermore, Dr. Sonni reported he had no independent recollection of the exact history that was provided by the Veteran in 1995 prior to the surgeries as the records from that time have been destroyed. The statement is inadequate for adjudicative purposes as it appears to be predicted on an inaccurate medical history that that the Veteran had meniscal injury in service, which is not borne out by the STRs. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (an opinion based on an inaccurate factual premise has no probative value). Lastly, in medical opinions issued by Dr. Maxwell, dated in June 2015, June 2017, and December 2019, are inadequate for adjudicative purposes. The physician indicated he has treated the Veteran for several years; and he opined that the Veteran’s severe arthritis problems and current knee disabilities were more likely than not related to his service based on the rapid degeneration of the knees without any outside forces playing a major factor. In his December 2019 medical opinion, Dr. Maxwell indicated he had reviewed the Veteran’s STRs and his treatment record since his separation form service, and he concluded that severe wear-and-tear to the knees during service caused the current bilateral knee disabilities. His rationale was that the Veteran had “severe and premature degeneration of both knees” and this was due to “chronic traumatic activity while in the Marine Corp.” In a January 2020 supplemental opinion, Dr. Maxwell stated that “It is not normal to have issues with meniscus destruction and cartilage destruction at a young age.” Then he stated that “forced marches with heavy loads, backpacks and walking on irregular and hard surfaces, including carrying logs and equipment, have contributed to the destruction of his joints—most specifically his knees.” He referenced the Veteran’s medical treatment from a young age to reduce swelling, as well as treatment with cortisone injections, endoscopic procedures, and partial and total knee replacements in both knees. The Board finds Dr. Maxwell’s opinions, individually and collectively, are inadequate for adjudicative purposes as their present form. Although the opinion reflects that “It is not normal to have issues with meniscus destruction and cartilage destruction at a young age,” it does not provide any discussion of the Veteran’s medical documented history to include onset and progression of symptoms, or when meniscal damage is first documented. The opinions reflect that the physician did not treat the Veteran in the years soon after his service discharge and again appear to be predicated on an inaccurate factual premise that the Veteran had meniscal injury in service. See Reonal, supra. Although the physician reports a review of the relevant records to include the Veteran’s STRs, which reflect normal clinical evaluation of the lower extremities at his 1989 service separation examination, there is no meaningful discussion of those records. As such, the Board finds that the favorable private nexus opinions in this case, provide an insufficient basis upon which to grant the appeal. An adequate medical examination report or opinion must “sufficiently inform the Board of a medical expert's judgment on a medical question and the essential rationale for that opinion.” Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012). Although an examiner need not discuss all potentially favorable or unfavorable evidence in order to render an adequate opinion, see Monzingo, 26 Vet. App. at 105, it must be clear that the examiner was “informed of sufficient facts upon which to base an opinion relevant to the problem at hand.” Nieves-Rodriguez, 22 Vet. App. at 303. Given the above discussion, the Board concludes that an additional VA examination and medical opinion are warranted to determine the etiology of the Veteran’s current right and left knee disabilities based on a full review of the lay and medical evidence of record, as well as an interview and physical examination of the Veteran. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). 3. Entitlement to service connection for a skin disability is remanded. The Veteran contends that his current skin disabilities are related to a severe sunburn he experienced during service. He has argued that the severity of the sunburn made him more susceptible to the development of skin cancers following service. See Hearing Transcript at 17, 19 (December 2019). Alternatively, he asserts that his skin disabilities may be related to exposure to contaminated water at Camp Lejeune and/or chemical contaminants while serving aboard ship in Puerto Rico. See Hearing Transcript at 3, 15-18 (December 2019). For reasons explained below, the Board finds that remand is required prior to deciding the appeal. The Veteran’s STRs document that, in April 1988, he was treated onboard ship for a sunburn and blisters to his shoulders after spending approximately 6 hours at the beach. The Veteran reported he had applied sunscreen shortly before departing the ship for the beach. Upon physical examination, the Veteran was alert and oriented and his entire body surface was found to be reddened with blisters on his face and shoulders. The doctor described the blisters as diffuse, small opacities with clear, non-draining fluid. The Veteran reported moderate pain and discomfort. In addition, there was mild tenderness to palpation of his shoulders. The doctor assessed primary sunburn to 20 percent of the Veteran’s body surface area (BSA), secondary sunburn to 30 percent of his BSA and secondary sunburn to 60 percent of his face. The Veteran was prescribed topical corticosteroids, Prednisone and Benadryl, assigned to light duty for 4 days, and advised to apply Eucerin or Lubriderm creams. The Board notes STRs contain treatment for additional skin-related complaints. For instance, records dated in October 1986 and October 1988 note multiple verruca on the left hand, right forearm, and left knee. In addition, a May 1989 note shows an assessment of fibrosis dermatoma on the left axillary region and a mole on the right side of the lower back. In June 1989, the dermatology clinic assessed the Veteran with warts and nevus (6-8 small filiform warts with flat, verrucous lesions in the left armpit area) that were excised with liquid nitrogen and a sample from a shave biopsy was then sent to pathology. During the visit, the Veteran was also noted to have 6-10 similar polypoid flesh-colored and brown growths on his back. Post-service medical records reflect numerous skin diagnoses, most notably related to basal cell carcinoma and squamous cell carcinoma. His private medical records reveal the first diagnosis of basal cell carcinoma almost four years following service separation. See tissue pathology (Metpath, Inc.) (September 1993); Veteran’s statement (VA Form 21-4138) (August 2015). A dermatopathology report dated May 2006 shows a low back specimen revealed seborrheic keratosis, a specimen from the left post jawline showed dermal elastosis and specimens from the left conchal bowl (external ear) and right lower post check showed actinic keratosis. A June 2007 private treatment record notes a few raised tan/beige/brown papules on the anterior and posterior trunk and a red, round, raised patch measuring 1.2 cm on the right shoulder. During the visit, the Veteran was assessed with seborrheic keratosis and possible basal cell carcinoma. In August 2007, the Veteran was noted to have an 8-9 mm raised beige papule on his right neck and a healed pink keloid on his right upper back; a right neck shave biopsy showed a diagnosis of actinic keratosis superimposed on irritated seborrheic keratosis. A record dated in June 2008, the Veteran was seen for complaints of new spots on his left anterior shoulder and neck. In 2012, the Veteran underwent several excisions stemming from squamous cell carcinoma, including in the left preauricular area. In November 2012, the Veteran underwent surgery on his right shoulder related to a diagnosis of basal cell carcinoma. A surgical report from Water’s Edge Dermatology dated in May 2015 shows the Veteran had a tumor removed from his left lateral scalp that was caused by basal cell carcinoma. A final pathology note dated in March 2017 reflects excision of basal cell carcinoma on the left posterior shoulder and mid upper back and squamous cell carcinoma on the right scaphoid fossa. During an October 2015 VA skin examination, the Veteran was diagnosed with basal cell carcinoma and squamous cell carcinoma in addition to actinic keratosis. The VA examiner opined that the Veteran’s current skin disabilities are less likely than not due to sun exposure during service. In so finding, the examiner explained that squamous cell carcinoma and basal cell carcinoma are common types of cancers with risk factors that include aging, skin type, ethnicity and geographic residence. The examiner further explained that the most important environmental risk factor for squamous cell carcinoma was cumulative sun exposure (UV radiation) over one’s lifetime with exposure at an early age being more significant. However, the most important risk factor for basal cell carcinoma is intermittent, intense sun exposure during childhood. While the examiner acknowledged the Veteran suffered a second-degree sunburn during service, he indicated it could not be characterized as severe because the Veteran did not have severe pain or systemic symptoms at the time. The examiner also noted it resolved without complication. The Board finds the October 2015 VA medical opinion is inadequate as it failed to address the documented in-service treatment for the Veteran’s other skin complaints, noted above, that were unrelated to sun exposure. Thus, the examiner did not comment on whether any of those findings represented the first manifestations of actinic keratosis and/or skin cancers diagnosed after the Veteran’s separation from service. In addition, the examiner listed a number of risk factors for the development of skin cancer but did not discuss whether the Veteran’s current skin disabilities could be attributed to any of those risk factors or any alternative causes other than UV exposure. In determining the adequacy of a medical examination or opinion, an examination or opinion is considered adequate, "where it is based upon consideration of the veteran's prior medical history and examinations and also describes the disability, if any, in sufficient detail so that the Board's '"evaluation of the claimed disability will be a fully informed one.'" Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). In October 2015, the Veteran submitted a favorable nexus opinion from his dermatologist, Dr. Mark Leach, who opined that the Veteran’s severe in-service sunburns and chronic sun exposure have contributed to his significant skin cancer history. The doctor stated that the one severe burn the Veteran received while in Puerto Rico had caused significant actinic elastosis and skin degradation. The doctor noted that the Veteran has had more than 20 skin cancer surgeries to remove multiple squamous cell and basal cell carcinomas. The Veteran has also had multiple modalities to destroy actinic keratosis including topical chemotherapy. In a statement received in April 2017, Dr. Leach stated that UV sun exposure has an additive effect and cannot be erased. He restated that the Veteran’s sun exposure in Puerto Rico contributed to the development of multiple skin malignancies through the last 25 years. Lastly, Dr. Leach reported the Centers for Disease Control (CDC) and AAD (American Academy of Dermatology) have related the majority of skin cancers to previous early sun exposure, most commonly before the age of 30. In a nexus statement submitted in January 2020, the Dr. Leach indicated he reviewed the Veteran’s claims file, including STRs, and opined that his multiple cutaneous malignancies were mostly likely caused by or a result of UV exposure while in the military; however, in his rationale, he incongruously reiterated his earlier comments that the Veteran’s severe burns and UV sun exposure in Puerto Rico “contributed” to his multiple skin malignancies. The Board finds that Dr. Leach’s medical opinions are inadequate. First, the Veteran’s STRs show treatment for one sunburn during service but Dr. Leach incorrectly stated the Veteran had multiple sunburns in service. See Reonal v. Brown, 5 Vet. App. 460, 461 (1993) (an opinion based on an inaccurate factual premise has no probative value). Second, he determined the in-service sunburn(s) caused actinic elastosis and skin degradation without explaining which clinical findings in the STRs led him to that conclusion. Similarly, he determined the Veteran’s sunburn(s) were severe but did not cite to any relevant in-service findings to support that characterization. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008) (noting that “a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two”). Next, the Board finds Dr. Leach’s rationale. in which he cites to the CDC and AAD, is not supported by a reasoned explanation linking their determinations concerning sun exposure prior to the age of 30, to the Veteran's particular medical history prior to, during and following service. See Polovick v. Shinseki, 23 Vet. App. 48, 54 (2009) (although general medical research may be considered, it cannot be the sole basis for examiner's conclusion). Finally, Dr. Leach opined that the Veteran’s in-service sunburns and UV exposure contributed to his later diagnosed skin cancers, but he did not indicate which of the Veteran’s other risk factors may also have contributed to his skin cancer. In sum, the private dermatologist’s medical opinions are inadequate for adjudicative purposes because they are not definitive and supported by detailed rationale when weighed against the other evidence of record. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). During his hearing, the Veteran raised alternative theories of entitlement to service connection for his skin disabilities. Specifically, he asserted that his skin disabilities may have been caused by the contaminated water at Camp Lejeune. See Hearing Transcript at 3, 22. To the extent the Veteran also argued his skin disabilities may be related to exposure to chemicals while he was stationed on board a ship in Puerto Rico, the Board notes that during his hearing, the Veteran provided no additional details or description of his alleged chemical exposure. Effective March 14, 2017, VA amended 38 C.F.R. §§ 3.307 and 3.309 providing a presumption of service connection for certain diseases based on exposure to contaminants present in the water supply at Camp Lejeune. In order to qualify for presumptive service connection under these provisions, there must be evidence of: (1) a diagnosis of one of the enumerated diseases under 38 C.F.R. § 3.309(f), (i.e., adult leukemia, aplastic anemia and other myelodysplastic syndromes, bladder cancer, kidney cancer, liver cancer, multiple myeloma, non-Hodgkin's lymphoma, and Parkinson's disease), if manifest to a degree of 10 percent or more at any time after service; and (2) service of at least 30 days (consecutive or nonconsecutive) at Camp Lejeune during the period beginning on August 1, 1953, and ending on December 31, 1987. Although skin cancer and actinic keratosis are not enumerated diseases determined to be associated with exposure to contaminated water at Camp Lejeune, the exclusion of a disability from the list of disabilities for which presumptive service may be assigned does not preclude service connection on a direct basis. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). In this case, the Veteran’s military personnel records have been associated with the claims file but are mostly illegible. Although the records confirm the Veteran was stationed at Camp Pendleton in the late 1980’s, the dates of his assignment are unclear. Therefore, as a threshold issue, on remand, the agency of original jurisdiction (AOJ) should attempt to verify the Veteran’s dates of service at Camp Pendleton and then determine whether those dates meet the service requirements outlined in 38 C.F.R. § 3.307. Based on the foregoing and in light of the record, the Veteran's testimony and the additional theories of service connection advanced by the Veteran and his representative during the hearing, the Board finds that a new VA examination and medical opinion is required. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for all non-VA medical providers seen for his knee and skin symptoms or diagnoses since service discharge. Make two requests for the authorized records from all identified sources, unless it is clear after the first request that a second request would be futile. 2. Verify the dates of the Veteran’s service at Camp Lejeune and then determine whether those dates meet the qualifying service date provisions under 38 C.F.R. § 3.307. Also attempt to verify the Veteran’s reported exposure to “contaminants” while aboard ship in Puerto Rico. Document all attempts to verify exposures. If additional information is needed, contact the Veteran. 3. Schedule the Veteran for a VA examination by an appropriate clinician, such as an orthopedic specialist, to determine the nature and etiology of all bilateral knee disabilities. The entire claims file, to include a copy of this REMAND, should be made available to and reviewed by the clinician. Detail the Veteran’s right and left knee symptoms in service and thereafter, including the nature, onset, progression and severity of his reported symptoms. If there is any medical reason to accept or reject the proposition that his reported symptoms in service and since represent the onset of either knee disability in service, this should be noted. The medical opinion should identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). If another etiology is the more likely cause of the Veteran’s gastrointestinal symptoms during and following service, the examiner must provide a complete explanation of his or her reasoning. NOTE (1): An adequate medical opinion may not be predicated solely on the absence of an in-service diagnosis or documented complaints/findings. NOTE (2): The examiner is not required to accept the Veteran’s theory that his right and left knee symptoms first manifested during service and persisted following separation, if there is a reason (e.g. incongruous with clinical history; his symptoms do not align with how the currently diagnosed disability is known to develop; the Veteran’s reports are generally inconsistent with medical knowledge or implausible) and it is fully explained. The examiner is required to fully explain why he or she disagrees with the Veteran’s theory of onset/causation. The clinician should address the following: (a) Identify all current right and left knee disabilities. Clarify for the record whether the Veteran had (i) Osgood-Schlatter’s disease in his active service; and/or (ii) abnormal meniscal pathology during his active service. (b) Opine on whether any right and/or left knee disability at least as likely as not (i) had its onset during active service, or (ii) is related to an in-service injury, event, or disease, to include performing field maneuvers and physical training on uneven terrain carrying heavy loads and while wearing boots. (c) Opine on whether any right and/or left knee arthritis (i) began during active service, or (ii) manifested within one year after separation from service, or (iii) was noted during service with continuity of the same symptomatology since service. The opinion should reflect consideration of: (1) STRs documenting complaints of right knee pain in June 1988 following an injury and a notation on the Problem List indicating treatment in June 1988 for either the right or bilateral knees (difficult to read) related to an injury; (2) The favorable medical opinions from Dr. Marvin Maxwell and other non-VA medical providers attributing the Veteran’s current bilateral knee disabilities to the rigors of his physical training during service; (3) the Veteran’s letter to his girlfriend written during service wherein he describes shooting exercises requiring him to sit in awkward positions that aggravated his Osgood-Schlatter’s disease; (4) The gap in time between service discharge in July 1989 and the Veteran’s initial consultation with his orthopedic doctor in November 1993; and (5) whether the documented in-service findings and/or the Veteran's reports of his in-service physical training activities and symptoms align with how the currently diagnosed bilateral knee disabilities are known to present and develop. 4. Schedule the Veteran for a VA examination by an appropriate clinician, such as a dermatologist, to determine the nature and etiology of all skin disabilities. The entire claims file, to include a copy of this REMAND, should be made available to and reviewed by the clinician. If the Veteran has been found to have qualifying service at Camp Lejeune, the clinician should be provided the dates of the Veteran’s service there. Detail the Veteran’s symptoms in service and thereafter, including the nature, onset, progression and severity of his reported symptoms. The examiner should elicit a complete history of the Veteran’s sun exposure and sunburns prior to, during and following discharge from service as well as any exposure to chemicals during his service onboard a ship in Puerto Rico. The medical opinion should identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). If another etiology and/or risk factor is the more likely cause of the Veteran’s skin complaints, findings and diagnoses during and following service, the examiner must provide a complete explanation of his or her reasoning. NOTE (1): An adequate medical opinion may not be predicated solely on the absence of an in-service diagnosis or documented complaints/findings. NOTE (2): The examiner is not required to accept the Veteran’s various theories of causation, including that his current skin disabilities, including basal cell carcinoma, squamous cell carcinoma and actinic keratosis, are proximately due to or caused by: (1) a severe sunburn during service; or (2) sun and chemical exposure during his service aboard a ship in Puerto Rico; or (3) exposure to contaminated water at Camp Lejeune. However, the examiner is required to fully explain why he or she disagrees with the Veteran’s theory of onset/causation. The clinician should address the following: (a) Opinion on whether any skin disability, to include basal cell carcinoma and squamous cell carcinoma, at least as likely as not (i) began during active service, or (ii) manifested within one year after separation from service, or (iii) was noted during service with continuity of the same symptomatology since service, or (iv) is related to an in-service injury, event, or disease, to include a first and second degree sunburn (with blistering on the face and shoulders in April 1988 after spending 6 hours at the beach). (b) ONLY IF SERVICE IS VERFIED AT CAMP LEJEUNE, opine on whether any skin disability is at least as likely as not related to exposure to contaminated water at Camp Lejeune. (c) ONLY IF THE VETERAN’S EXPOSURE TO SPECIFIC CONTAMINANT ABOARD SHIP WHILE HE WAS IN PUERTO RICO IS VERIFIED AND IDENTIFIED BY THE VA REGIONAL OFFICE, opine on whether any skin disability is at least as likely as not related to that exposure. The opinion should specifically address: (1) STRs documenting the symptoms, findings, assessment and treatment for a sunburn in April 1988; (2) STRs documenting treatment for lesions, moles, warts, nevus, and fibrosis dermatoma on various parts of the Veteran’s body throughout service; and (3) the favorable medical opinions from Dr. Leach attributing the Veteran’s current skin disabilities to UV sun exposure and sunburn(s) during service. 5. Ensure that the VA medical opinions obtained include a complete rationale for the conclusions reached. The medical opinions must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. (Continued on next page) 6. Readjudicate. C.A. SKOW Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Krunic, 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.