Citation Nr: 21014217 Decision Date: 03/11/21 Archive Date: 03/11/21 DOCKET NO. 09-39 799 DATE: March 11, 2021 REMANDED Entitlement to service connection for a skin disorder of the face is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1969 to December 1971 and from March 2006 to September 2007. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an August 2008 rating decision of an Agency of Original Jurisdiction (AOJ) of the Department of Veterans Affairs (VA). The Veteran testified at a Decision Review Officer (DRO) hearing at the AOJ in February 2010. The Board has previously remanded this claim multiple times, most recently in November 2020. The Board sincerely regrets the significant delays caused by the remands during the appeal. However, as discussed in more detail below, an adequate medical opinion is required to resolve the claim; and the Board cannot make a decision with incomplete medical evidence. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (VA may only consider independent medical evidence to support its findings and is not permitted to base decisions on its own unsubstantiated medical conclusions). 1. Entitlement to service connection for a skin disorder of the face is remanded. The Veteran seeks service connection for a skin disorder of the face. The record shows that he has been diagnosed with mild facial xerosis (i.e., dry skin), see, e.g., February 2008 medical record; basal cell carcinoma, see, e.g., February 2011 medical record; and actinic keratosis, see, e.g., February 2011 medical record. He has served in both Vietnam (from May 1970 to December 1971) and Iraq (from August 2006 to June 2007). He claims that his skin disorder of the face manifested after his service in Iraq. See, e.g., February 2010 RO hearing testimony, p. 3. After the last remand, a medical opinion was provided in December 2020. However, the rationale provided for the medical opinion regarding whether the Veteran’s skin disorders were related to his military service was that the matter cannot be resolved without speculation, because the skin conditions were not documented in the service treatment records and mild facial xerosis and actinic dermatitis may develop even when a person is not in the service. The Board can rely on a statement that the examiner cannot provide a medical opinion without resorting to speculation but only if an adequate rationale is provided. In Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017), the United States Court of Appeals for Veterans Claims (Court) held that the Board may accept a VA examiner’s assertion that he or she cannot offer such an opinion without resort to speculation only after it determines that the examiner’s conclusion is not based on the absence of procurable information or on a particular examiner’s shortcomings or general aversion to offering an opinion on issues not directly observed. It must be clear that such an opinion is not procurable based on a lack of knowledge among the “medical community at large” and not merely on a lack of expertise, insufficient information, or unprocured testing on the part of the specific examiner. With respect to the rationale that anyone can develop these conditions, whether or not they served in the military, the requirements of service connection are not that a disease, injury, or illness is directly related to a military act of service, but that a particular injury or disease resulting in disability was incurred coincident with service. See 38 C.F.R. § 3.303 (a). Service connection also can be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. See 38 C.F.R. § 3.303 (d). Of note, the examiner found that actinic keratosis was not related to service-connected diabetes mellitus because actinic keratosis is caused by sun exposure. The Veteran has consistently maintained that his skin conditions, including his actinic keratosis, were related to his service in Iraq and the direct sun exposure. This rationale seems to contradict the previous section of the opinion that the Veteran’s actinic keratosis was not related to service because there was no record of treatment in service. Again, the Veteran is not maintaining that his actinic keratosis was treated in service but that his skin disorders diagnosed after service, are related to the sun exposure in Iraq. As a sufficient rationale is not provided, a supplemental opinion should be provided. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician (preferably a clinician who has not provided opinions in this case, if possible) regarding whether the Veteran’s skin condition (to include xerosis, actinic keratosis, and basal cell carcinoma (residual scarring)) are at least as likely as not related to sun exposure in Iraq. The examiner must review the claims file. Provide a rationale to support the opinion(s). In providing the requested opinion, consider the Veteran’s description of his in-service sun exposure in Iraq and symptoms as well as his post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran’s reported injury and symptoms in service and thereafter represented the onset of his current disability, this should be noted. Stated another way, do the Veteran’s reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran’s reports generally inconsistent with medical knowledge or implausible? If it is not possible to provide an opinion without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts) or a deficiency in the record (additional facts are required). S. L. Kennedy Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Sarah B. Richmond, 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.