Citation Nr: 21015027 Decision Date: 03/16/21 Archive Date: 03/16/21 DOCKET NO. 12-19 428 DATE: March 16, 2021 REMANDED The issue of entitlement to service connection for pulmonary fibrosis is remanded. The issue of entitlement to service connection for a skin disorder is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Marine Corps from June 1965 to October 1973. Unfortunately, the Veteran passed away in September 2016. The appellant is his surviving spouse and has been properly substituted for the claims on appeal. The Veteran appeared at a hearing before a Veterans Law Judge (VLJ) in October 2014. A transcript of that hearing is of record. The Board then remanded this appeal in December 2014 and November 2019. In September 2019 and again in January 2021, the appellant was notified that the VLJ who held the October 2014 hearing was no longer at the Board and that she could request a hearing before a new VLJ. To date, she has not responded; thus, as noted in the letter, it is assumed that she does not want another hearing. As a final introductory matter, the Board observes that the issue of entitlement to service connection for a psychiatric disorder, to include PTSD, was also remanded by the Board for issuance of a statement of the case. However, in perfecting her appeal of that issue, the appellant requested a Board videoconference hearing, which is now pending. As such, that issue will be the subject of a separate decision. Unfortunately, the Board finds that remand of the claims of entitlement to service connection for pulmonary fibrosis and a skin disorder is necessary once again in order to obtain adequate opinions. In this regard, while opinions were obtained in January 2020 and October 2020 indicating that it was less likely than not that the Veteran’s skin and pulmonary conditions were caused or aggravated by service, to include as a result of asbestos or herbicide exposure therein, the Board finds the opinions to be either unresponsive in part, or lacking sufficient rationale. For example, the examiner was specifically asked to provide whether there was clear and unmistakable evidence that any increase in disability associated with the Veteran’s scar or tinea pedis during service was due to the natural progress of the disease. In response, however, the January 2020 examiner opined that it was at least as likely as not that the exacerbations of tinea pedis in service were a natural progression of the condition. Moreover, the examiner found that exacerbations of tinea pedis in service were not evidence of a “permanent worsening” or a “permanent change” of the condition. However, as noted in the Board’s prior remand, the permanence of an increase in disability is not necessary for a finding of aggravation. As such, the examiner was advised that his or her inquiry was not limited to the definition of aggravation as a permanent worsening of the condition beyond its natural progression. Nevertheless, it appears the examiner limited his/her definition as requiring permanence. Finally, the examiner stated that the Veteran’s STRs were “silent for any rashes.” However, in 1967, the Veteran was treated for a “heat rash” in the groin area. With respect to pulmonary fibrosis, in an October 2020 addendum, the examiner stated that a medical literature search was silent for evidence that asbestos exposure later causes pulmonary fibrosis to develop. However, the Board notes that a quick internet search reveals that, according to the Mayo Clinic, “[m]any substances and conditions can lead to pulmonary fibrosis,” including lung damage from long-term exposure to toxins such as asbestos fibers. https://www.mayoclinic.org/diseases-conditions/pulmonary-fibrosis/symptoms-causes/syc-20353690 (last checked March 9, 2021). Indeed, as discussed in the Board’s December 2014 remand, VA has recognized that exposure to asbestos can produce pulmonary fibrosis. Thus, the examiner’s rationale is insufficient, and another opinion is necessary. Additionally, given the Veteran’s somewhat involved history of exposures, both pre- and post-service, the Board finds that an opinion should be requested from a health expert in occupational and/or environmental exposures. The matters are REMANDED for the following action: Arrange for an examiner who specializes in occupational, environmental, and/or military exposures to provide opinions that fully address the questions below. The claims file and a copy of this remand must be made available to the reviewing examiner, and the examiner should indicate in the report that the claims file was reviewed. Any opinions provided must include a discussion of the Veteran and appellant’s lay statements and the Veteran’s documented medical history. 1. Skin Conditions: (a.) Appendectomy Scar and Tinea Pedis: the examiner is asked to provide an opinion as to whether there is clear and unmistakable evidence that any increase in the condition of the Veteran’s scar and/or tinea pedis (noted on entrance examination) during service was due to the natural progress of the condition. The examiner should note that “clear and unmistakable evidence” means that the evidence cannot be misinterpreted and misunderstood, i.e. is undebatable. Additionally, an increase in severity does not have to be permanent to constitute aggravation. In discussing any increase/aggravation, the examiner must consider the Veteran’s lay statements that he had skin issues in service and since. The examiner also must address the documented in-service treatment for tinea pedis in June 1965, December 1965, February 1967, and August 1968. (b.) Skin rash/irritation (not of the scar or feet): the examiner is asked to provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that a skin condition (other than the appendectomy scar or tinea pedis) was incurred during, caused by, or is otherwise related to the Veteran’s active service, to include exposure to Agent Orange. In providing the foregoing opinion, please address the documented in-service treatment for a heat rash in the groin area in September 1967, and the Veteran’s lay reports of skin issues in and since service. (c.) The Board notes that the inquiry is one of direct service connection, not presumptive service connection. As such, a conclusion that the Veteran did not have a presumptive skin condition is not adequate. 2. Pulmonary Fibrosis: (a.) The examiner is asked to provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s pulmonary fibrosis was caused by, incurred during, or was otherwise related to the Veteran’s active service, to include 1) exposure to Agent Orange and 2) asbestos exposure. For purposes of the opinion, the examiner should presume that the Veteran was exposed to both herbicides and asbestos during service. With regard to asbestos, the examiner should take into consideration factors such as latency, smoking, and post-service exposure. The Board notes that the inquiry is one of direct service connection, not presumptive service connection. As such, a conclusion that the Veteran did not have a presumptive lung condition is not adequate. (b.) If the above opinion is negative, the examiner is asked to provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s pulmonary fibrosis was caused (in whole or in part) or aggravated (any incremental increase in disability or any additional impairment of earning capacity regardless of its permanence) by his service-connected heart condition. Please refer to the September 2013 DBQ completed by Dr. A.W. 3. The rationale for any opinions expressed must be set forth. If the examiner cannot provide an above opinion without resorting to speculation, he/she should explain why an opinion cannot be provided (e.g. lack of sufficient information/evidence, the limits of medical knowledge, etc.) S. C. Krembs Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Fagan 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.