Citation Nr: 21024245 Decision Date: 04/22/21 Archive Date: 04/22/21 DOCKET NO. 18-39 510 DATE: April 22, 2021 REMANDED Entitlement to service connection for left shoulder arthritis is remanded. Entitlement to service connection for arthritis of the back is remanded. Entitlement to service connection for right hip arthritis is remanded. Entitlement to service connection for left knee arthritis is remanded. Entitlement to service connection for right knee arthritis is remanded. Entitlement to service connection for right hand arthritis and residuals of a crush injury is remanded. Entitlement to service connection for skin cancer is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1964 to July 1968. This case comes to the Board of Veterans’ Appeals (Board) from an August 2018 decision of the Department of Veterans Affairs (VA) Regional Office. The Veteran attended a virtual Board hearing before the undersigned Veterans Law Judge in February 2021. Back, Left Shoulder, Right Hip, and Bilateral Knee Arthritis The Veteran contends that he has arthritis in his back, left shoulder, right hip, and bilateral knees that was caused by excessive strain on his joints during service. At a February 2021 virtual Board hearing, the Veteran testified that he had served as an ordinance man on an aircraft carrier, and that his duties including loading weapons by hand, including very heavy ordinances that had to be carried by just a few men. He stated that his pain started when he was in service, but he did not go to sick bay just for aches and pains, and he did not want to let down his fellow sailors during the loading. J.A., who assisted the Veteran during the hearing, testified that while the Veteran worked in construction after service, he was not a laborer, he was a surveyor, and would not have been involved in physical labor after service. The Veteran attended a VA examination in June 2018, and the examiner concluded that the Veteran’s various arthritis disorders were less likely than not related to service. He wrote that the Veteran’s joint pains did not start until 5 to 30 years after separation from service, and that they were more likely than not related to his age progression and work as a carpenter after military service. The Board finds these medical opinions to be inadequate. The examiner does not appear to have considered the Veteran’s reports of doing constant, heavy lifting in service or what impact that might have had on his joints or that his joint pain started in service. He also did not actually provide any rationale as to why the Veteran’s work as a carpenter was more likely to cause arthritis than his heavy lifting work in the military. The Board remands this issue so that new and adequate VA medical opinions can be obtained. The examiner is also asked to address the May 2016 letter from private physician M.B., who wrote that the Veteran had reported doing a lot of heavy lifting during his military service, and this may have contributed to his current arthritis and joint issues. Right Hand Residuals of Crush Injury The Veteran testified in February 2021 that he was at the Naval Air Station Oceana in Virginia and his hand was crushed during an altercation with two sailors. The Veteran’s service treatment records show that in September 1965, he was involved in an argument and he struck another person and the bulkhead with his right hand. There was slight swelling and abrasions, X-rays were negative for fracture, and he was diagnosed with a sprain. The Board also finds that a new VA medical opinion should be obtained to address the etiology of the Veteran’s right hand arthritis. While a VA medical opinion was obtained in August 2016, the examiner does not appear to have acknowledged the Veteran’s reports of having pain and tingling in his hand that continued from the time of service, and he again relied on the Veteran’s post-service work in construction, which subsequent testimony shows is not entirely accurate, and did provide an adequate rationale for why this work would more likely cause his subsequent arthritis. Skin Cancer The Veteran contends that he has skin cancer which was incurred in or caused by his active duty service. At the February 2021 virtual Board hearing, the Veteran’s attorney reported that the Veteran got a brown spot on his back from sun exposure in service. The Veteran stated that his skin cancer started 5 years ago, and that he has had two on his back and the rest of his face, hand, and arms. He said that he has had 8 patches of skin cancer removed. The Board notes that while the Regional Office has found that the Veteran had service in the in-land waterways of the Republic of Vietnam, which would allow for a presumption of exposure to herbicide agents, squamous cell carcinoma and basal cell carcinoma are not included in the list of types of cancer that are related to herbicide exposure. 38 C.F.R. §§ 3.307; 3.309(e). Nevertheless, service connection can still be awarded on a direct basis if there is medical evidence supporting such a relationship. Combee v. Brown, 34 F.3d 1039, 1043-1044 (Fed.Cir.1994). The Board acknowledges that when determining the scope of a claim, the Board must consider the Veteran’s description of the claim, the symptoms described, and the information submitted or developed in support of the claim. Clemons v. Shinseki, 23 Vet. App. 1 (2009). Here, the VA examiners have identified the Veteran’s skin lesions as sebaceous cysts and not as skin cancer. Separate claims for cysts and scars from cyst removal have already been addressed by the Regional Office. In an August 2016 rating decision, service connection for scars status post removal of sebaceous cysts was granted, and assigned an evaluation of 10 percent, effective April 18, 2016. In a January 2017 rating decision, service connection for sebaceous cysts was denied, and the 10 percent evaluation for scars from removal of sebaceous cysts was continued. The Veteran did not appeal these decisions, and they are not currently within the jurisdiction of the Board. The Veteran’s service treatment records show that he had a sebaceous cyst removed from his neck in October 1965. In November 1967, he had two small cysts removed from the left side of his chin. Private treatment records show that in April 2012, he was found to have diffuse actinic damage with scaly papules. He was diagnosed with basal cell carcinoma on his ear and face. After an April 2014 biopsy, the Veteran was diagnosed with squamous cell carcinoma. The Veteran was found to have additional squamous cell carcinomas in 2014. In 2015, he attended a follow-up for neoplasm of uncertain behavior. The Veteran attended a VA examination in August 2016, and his skin lesions were diagnosed as sebaceous cysts. The examiner did not find that the Veteran had any benign or malignant skin neoplasms. The Veteran also attended a VA examination in November 2016, where he was again diagnosed with sebaceous cysts, and the examiner found that he did not have any benign or malignant skin neoplasms. There have been no medical opinions obtained addressing the Veteran’s claims of having skin cancer, and no examiner seems to have been aware that the Veteran had been treated on multiple occasions for squamous cell carcinoma and basal cell carcinoma. Because the evidence does indicate that the Veteran had cysts that manifested in service, he has credibly reported getting brown spots on his skin after severe sun exposure in service, and he has been found to have service in Vietnam allowing for a presumption of exposure to herbicide agents, the Veteran should have been afforded a VA examination to specifically consider whether his skin cancer is related to service. While he did attend examinations for the skin, these examinations are not adequate for this issue, because they addressed only his sebaceous cysts, and the examiners were not aware of his past treatment for squamous cell carcinoma and basal cell carcinoma. This issue is therefore remanded so that a new examination and opinion can be obtained. The Veteran also reported to his nurse practitioner that he had cancer in 1987, and he should be asked to provide the medical records related to this treatment, or any other earlier treatment for skin cancer. He should also provide any other additional treatment records showing continued treatment for skin cancer since he filed his claim in 2016. The matters are REMANDED for the following action: 1. Obtain all VA treatment records since March 2020. 2. Send to the Veteran and his representative a letter requesting that the appellant provide sufficient information and a signed and dated authorization, via a VA Form 21-4142 (Authorization and Consent to Release Information) to enable VA to obtain any additional, relevant private medical records relating to his arthritis and skin cancer, including any treatment for skin cancer since the Veteran submitted his claim in June 2016, and in or around 1987. If the Veteran provides new completed release forms authorizing VA to obtain these treatment records, then attempt to obtain them with at least one follow-up request if no reply is received. 3. Obtain an addendum medical opinion addressing the nature and etiology of the Veteran’s arthritis in the back, left shoulder, right hip, right hand, and bilateral knees. If the examiner finds that a new VA examination must be held prior to providing an opinion, schedule such an examination. If feasible, the examination may be held via telehealth during social distancing restrictions and an opinion can be provided based on other medical evidence of record. The examiner must be provided access to the Veteran’s entire claims file and must specify in the report that the claims file has been reviewed.  The examiner should then address: a) What are the Veteran’s current diagnoses relating to arthritis or other joint disorders of the back, right and left knees, right hip, right hand, and left shoulder? b) For all disorders found, is it as likely as not that the disorder had its onset during service or is related to any injury or incident in service, including the Veteran’s reports of having back and joint strain from regularly loading extremely heavy equipment onto the ship as part of his regular duties? The examiner should address the May 2016 letter from physician M.B., who wrote that the Veteran heavy lifting during his military service, and that this may have contributed to his current arthritis and joint issues. For the Veteran’s right hand disorder, please discuss the Veteran’s treatment in September 1965 for swelling, abrasions, and sprain in the right hand, and his assertions that since that incident, he has had tingling and pain in that hand. A complete and fully explanatory rationale must be provided for any opinion offered.  If any opinion cannot be rendered without resorting to speculation, the examiner must explain why 4. Schedule the Veteran for an examination to address the nature and etiology of any current skin cancer disorder. If feasible, the examination may be held via telehealth during social distancing restrictions and an opinion can be provided based on other medical evidence of record.    The examiner must be provided access to the Veteran’s entire claims file and must specify in the report that the claims file has been reviewed.  The examiner should then address: a) Has the Veteran had any recurrences of squamous cell carcinoma, basal cell carcinoma, or any other type of skin cancer since 2016? Does he have any residuals, such as scars, from his prior skin cancer treatment? The examiner must review all private records, including the 2012-2015 treatment records from Apex Dermatology. b) For all types of skin cancer found, is it as likely as not that the disorder had its onset during service or is related to any injury or incident in service, including the Veteran’s exposure to bright sun while working on an aircraft carrier and his presumed exposure to herbicide agents in Vietnam? Please discuss the Veteran’s reports of getting brown spots in service after sun exposure and the service treatment records showing removal of cysts. A complete and fully explanatory rationale must be provided for any opinion offered.  If any opinion cannot be rendered without resorting to speculation, the examiner must explain why. DELYVONNE M. WHITEHEAD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Mary E. Rude, 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.