Citation Nr: 21028606 Decision Date: 05/11/21 Archive Date: 05/11/21 DOCKET NO. 13-27 983 DATE: May 11, 2021 ORDER New and material evidence has been received to reopen a claim of entitlement to service connection for a skin disability, and to that extent only the claim is granted. Entitlement to service connection for tinnitus is granted. REMANDED Entitlement to service connection for hearing loss is remanded. Entitlement to service connection for a lumbar spine disability is remanded. Entitlement to service connection for a skin disability, to include acne, is remanded. FINDINGS OF FACT 1. The May 1995 rating decision that denied service connection for acne is final. 2. The evidence received since the May 1995 rating decision, by itself, or in conjunction with previously considered evidence, is new and material. 3. Resolving all reasonable doubt in favor of the Veteran, the probative, competent, and persuasive evidence of record shows that it is at least as likely as not that the Veteran has continuously had symptoms of tinnitus since service. CONCLUSIONS OF LAW 1. The May 1995 rating decision that denied service connection for acne, is final. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.156, 20.200, 20.201, 20.302, 20.1103. 2. The evidence received after the May 1995 rating decision is new and material, and the claim for service connection for a skin disability is reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156 3. The criteria for service connection for tinnitus have been met. 38 U.S.C. §§ 1101, 1112, 1113, 1110, 1137, 5107; 38 C.F.R. § § 3.102, 3.303, 3.307, 3.30. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1955 to September 1957. This matter comes to the Board of Veterans' Appeals (Board) on appeal from an August 2012 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. In March 2021, the Veteran appeared at a hearing before the undersigned Veterans Law Judge. A copy of the transcript is of record. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c); 38 U.S.C. § 7107(a)(2). 1. Whether new and material evidence has been received to reopen a claim for service connection for a skin condition, to include acne. Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. VA rating decisions that are not timely appealed are final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. A finally disallowed claim may be reopened when new and material evidence is presented or secured with respect to that claim. 38 U.S.C. § 5108. New evidence is defined as evidence not previously submitted to agency decision-makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). An adjudicator must follow a two-step process in evaluating a previously denied claim. First, the adjudicator must determine whether the evidence added to the record since the last final decision is new and material. If new and material evidence is presented or secured with respect to a claim that has been finally denied, the claim will be reopened and decided on the merits. Once it has been determined that a claimant has produced new and material evidence, the adjudicator must evaluate the merits of the claim in light of all the evidence, both new and old, after ensuring that the VA's statutory duty to assist the appellant in the development of his claim has been fulfilled. 38 U.S.C. § 5108. The claim to reopen does not require the submission of new and material evidence as to each previously unproven element of a claim for that claim to be reopened. Shade v. Shinseki, 24 Vet. App. 110 (2010). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is low. Shade v. Shinseki, 24 Vet. App. 110 (2010). Moreover, in determining whether the low threshold is met, consideration need not be limited to consideration of whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering VA's duty to assist or through consideration of an alternative theory of entitlement. The Board has thoroughly reviewed all the evidence in the claims file. The Board has an obligation to provide reasons and bases supporting a decision. However, there is no need to discuss, in detail, all the evidence submitted by or on behalf of the Veteran. The Board must review the entire record but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran should not assume that the Board has overlooked pieces of evidence that are not explicitly discussed. Timberlake v. Gober, 14 Vet. App. 122 (2000) (Board must address its reasons for rejecting evidence favorable to the Veteran). The Department of Veterans Affairs (VA) Regional Office (RO) considered and denied a claim for service connection for acne in a May 1995 rating decision. At that time, the evidence of record included the service medical records from June July 1955 to September 1957 and a November 1994 VA examination. The May 1995 rating decision denied service connection for acne because the service medical records did not demonstrate a chronic acne condition and there was no evidence showing continuing treatment for acne since separation from service. The Veteran was notified of the May 1995 rating decision and his appellate rights. The Veteran filed a timely notice of disagreement in June 1995. In September 1995, the Veteran was issued a statement of the case. The Veteran did not perfect an appeal in a timely manner subsequent to the issuance of the statement of the case. As a result, the May 1995 rating decision is final. 38 U.S.C. § 7105; 38 C.F.R. § § 3.156, 3.160(d), 20.200, 20.201, 20.302, 20.1103. The evidence received and submitted into the record since the May 1995 rating decision includes additional service medical records, VA records; and lay statements from the Veteran; and a May 2015 opinion letter from the Veteran's social worker. The credibility of the newly submitted evidence is presumed in determining whether the new evidence is material. Justus v. Principi, 3 Vet. App. 510 (1992). The Board notes that the Veteran has provided a May 2015 private opinion statement from a social worker. Also, additional service medical records showing in-service treatment for a skin condition have been obtained. As the medical opinions are presumed to be credible for the limited purpose of attempting to reopen a previously denied claim, and that examination addresses a relationship to service, that evidence raises a reasonable possibility of substantiating the claim. The relevant service medical record cause the claim to be adjudicated. 38 C.F.R. § 3.156(c). Accordingly, the additional evidence is material. A s new and material evidence has been received, the claim for service connection for a skin disability, to include acne, is reopened. 2. Entitlement to service connection for tinnitus The Veteran contends that currently diagnosed tinnitus is the result of noise exposure during active service. Specifically, the Veteran claims that he was exposed to acoustic noise trauma as a result of exposure to loud noises and explosions while working in the boiler room of the USS Boxer while in service. The Veteran claims that as a result of that noise exposure he began experiencing ringing in the ears during active service, which has continued to the present. The service personnel records show that the Veteran worked in the boiler room aboard the USS Boxer while in service. A review of the competent evidence of record shows the Veteran has credibly reported symptoms of tinnitus continuously since service. Therefore, the Board finds that tinnitus can be service-connected based on a credibly reported continuity of symptomatology. Therefore, the claim for service connection for tinnitus is granted. Generally, to prevail on a claim of service connection on the merits, there must be competent evidence of (1) current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence or other competent evidence of a relationship between the claimed in-service disease or injury and the present disease or injury. Hickson v. West, 12 Vet. App. 247 (1999). Service connection will be established for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110. With chronic disease shown as such in-service so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. Tinnitus, as an organic disease of the nervous system, is among the chronic diseases listed at 38 C.F.R. § 3.309 (a), the Board finds that continuity of symptomatology may establish relationship to service. 38 C.F.R. § 3.303(b). Medical evidence is required to demonstrate a relationship between a current disability and the continuity of symptomatology demonstrated if the condition is not one where a lay person's observations would be competent. Clyburn v. West, 12 Vet. App. 296 (1999). Whether lay evidence is competent and sufficient in a particular case is an issue of fact and lay evidence can be competent and sufficient to establish a diagnosis when (1) a layperson is competent to identify the medical condition (sometimes the layperson will be competent to identify the condition where the condition is simple, for example, a broken leg, and sometimes not, for example, a form of cancer, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Lay evidence presented by a Veteran concerning continuity of symptoms after service may generally be considered credible and ultimately competent, regardless of a lack of contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (2006). The Board has the authority to discount the weight and probity of evidence in light of its own inherent characteristics and its relationship to other evidence. Madden v. Gober, 125 F.3d 1477 (Fed. Cir. 1997). VA may favor one medical opinion over another, provided an adequate basis is provided. Owens v. Brown, 7 Vet. App. 429 (1995). It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case, with all reasonable doubt to be resolved in favor of the claimant. 38 C.F.R. § 3.102. In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board finds that the Veteran, as a lay person, is both credible and competent to provide evidence of the existence of the medical condition of tinnitus, as it comes to him through his senses of ringing in the ears, and he is competent to attest that it has been continuous since active service. Specifically, the Board finds that tinnitus, which manifests as ringing in the ears, is not the type of medical condition which requires specialized medical knowledge or training to assess. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). A lay person, such as the Veteran, may competently state that he perceives ringing in the ears. The Veteran may also competently state when that condition started and if it has continued to the present. The Veteran has consistently asserted that he began experience ringing in the ears during service as a result of loud noise conditions while in-service. The Board finds that the Veteran was likely consistently exposed to loud noise while working in the boiler room of a ship during active duty service, upon review ot the service personnel records. The Board finds the Veteran's lay statements regarding the continuity of tinnitus symptoms to be credible. The Board notes that the Veteran has consistently noted that the ringing in the ears began during service and that those symptoms have continued to the present. The Veteran provided those contentions in written statements to VA, and during VA examination. The Board finds the Veteran credible with regard to the assertions of continuity of tinnitus symptomatology since service. The Board acknowledges that there may be medical evidence of record contrary to the Board's findings. However, the Board assigns substantial probative weight to the Veteran's lay statements of record because the Veteran, as a layperson, may competently state that he perceives ringing in his ears and when that condition began. The Board finds that the evidence is, at worst, in equipoise as the favorable and unfavorable evidence has approximately equal evidentiary weight. Accordingly, based on the evidence and arguments presented, the Board finds that the Veteran's tinnitus was at least as likely as not present during service and has a continuity of symptomatology since service. As the Board finds that the Veteran's lay statements have competently and credibly established continuity of symptomatology, and resolving reasonable doubt in favor of the Veteran, the claim for service connection for tinnitus is granted. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 3.303(b). REASONS FOR REMAND 1. Entitlement to service connection for hearing loss is remanded. Although the Board regrets the delay, additional development is needed prior to further disposition of the claim of entitlement to service connection for bilateral hearing loss. VA's statutory duty to assist the Veteran includes the duty to conduct a thorough examination so that the evaluation of the claimed disability will be a fully informed one. Green v. Derwinski, 1 Vet. App. 121 (1991); Snuffer v. Gober, 10 Vet. App. 400 (1997). Assistance by VA includes providing a medical examination or obtaining a medical opinion when an examination or opinion is necessary to make a decision on a claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). The Veteran contends that a current bilateral hearing loss disability is the result of noise exposure in service. Specifically, the Veteran believes that exposure to acoustic trauma while working in the boiler room of the USS Boxer caused a current hearing loss disability. The Veteran also contends that noise from an airplane in-service caused the hearing disability. Noise exposure in service has been conceded by VA. At a February 2012 VA examination, the examiner diagnosed bilateral sensorineural hearing loss. However, the examiner was unable to opine as to whether the hearing loss was at least as likely as not (50 percent probability or greater) caused by or a result of an event in service without resorting to speculation. The examiner reasoned that there was no documentation of ear or frequency specific hearing levels at the time of separation. Therefore, based on the Veteran's reported history of significant noise exposure both during and after service, it was not possible to determine if the etiology of the hearing loss was related to service noise exposure without resorting to mere speculation. When VA provides an examination or obtains an opinion, the examination or opinion must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). An opinion that relies only on the absence of symptoms or treatment in-service is not adequate. A lack of medical evidence in-service treatment records does not preclude service connection. Buchanan v Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) (lack of contemporaneous medical records does not serve as an "absolute bar" to the service connection claim). As the February 2012 VA examiner relied on the absence of symptoms or treatment in-service for the negative opinion concerning the demonstrated hearing disability, the opinion is inadequate. Thus, remand is necessary for an adequate etiology opinion regarding bilateral hearing loss. VA attention has been directed to a sponsored Institute of Medicine (IOM) report on delayed onset hearing loss. While the report states that "based on the anatomical and physiological data available on the recovery process following noise exposure, it is unlikely" that the onset of hearing loss begins years after noise exposure occurs, that statement does not indicate the full extent of the report's findings pertinent to the matter. Comm. on Noise-Induced Hearing Loss and Tinnitus Assoc'd with Military Service from World War II to the Present, Inst. of Medicine, Noise and Military Serv.: Implications for Hearing Loss and Tinnitus, at 47 (Larry E. Humes, Lois M. Joellenbeck, and Jane S. Durch eds., 2005). While a portion of the IOM report found there is no evidence of delayed onset hearing loss due to noise exposure, another portion of the same IOM report found that "an individual's awareness of the effects of noise on hearing may be delayed considerably after the noise exposure." Comm. on Noise-Induced Hearing Loss and Tinnitus Assoc'd with Military Service from World War II to the Present, Inst. of Medicine, Noise and Military Serv.: Implications for Hearing Loss and Tinnitus, at 203-04 (Larry E. Humes, Lois M. Joellenbeck, and Jane S. Durch eds., 2005). Therefore, the IOM report's language may support a theory of service connection involving delayed onset of a Veteran's perception of hearing loss such that a VA examiner's citation of the report should contemplate all of the pertinent aspects of its findings. Lemmons v. McDonald, No. 15-3043, 2016 LEXIS 1646 (Vet. App. October 28, 2016) (non-precedential). 2. Entitlement to service connection for a lumbar spine disability is remanded. Although the Board regrets the delay, additional development is needed prior to further disposition of the claim of entitlement to service connection for a lumbar spine disability. VA's statutory duty to assist the Veteran includes the duty to conduct a thorough examination so that the evaluation of the claimed disability will be a fully informed one. Green v. Derwinski, 1 Vet. App. 121 (1991); Snuffer v. Gober, 10 Vet. App. 400 (1997). Assistance by VA includes providing a medical examination or obtaining a medical opinion when an examination or opinion is necessary to make a decision on a claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). The Veteran asserts that a currently diagnosed back disability began in service and continues to the present day. In the alternative, the Veteran also states that he had a growth on his back surgically removed during boot camp, which he contends caused nerve damage and tenderness to the back. The Veteran's July 1955 enlistment examination notes the Veteran as having a normal spine, lower extremity, and neurologic examination. The Veteran was noted as having pit scars on the back. The service medical records show the Veteran as complaining of a sore back one time in August 1956. There is no medical evidence of record to corroborate the assertion that the Veteran had any surgical removal of skin growths on the back during service. The August 1957 separation examination found no abnormal findings. The separation examination specifically notes the Veteran as having normal spine, lower extremity, and neurologic examination. At an October 2014 VA examination, after review of the Veteran's claim file, the examiner diagnosed degenerative arthritis of the spine, degenerative disc disease, and spondylolisthesis. The examiner opined that the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed injury, event, or illness in service. The examiner reasoned that the Veteran had only one incident of a sore back treated with diathermy while in service. Multiple physical examinations before and after indicated no back condition and the service separation examination indicated no complaint of a back condition, no physical abnormalities, and that the Veteran was approved for separation with no physical disability. The evidence of record does not show spondylolisthesis until imaging in March 2002, which suggested spondylolisthesis at the L5-S1 level which was grade 1. The evidence does not show significant degenerative back disease until imaging on MRI in September 2010. That was an age-related finding and had no medical connection to the vague low back pain noted on one occasion in service. There was no condition or abnormality at the L4-5 level. The Board finds the October 2014 VA examination to be incomplete. In essence, the October 2014 VA examiner reasoned that because the Veteran's lumbar spine disability did not begin in service, the claimed disability was not the result of service. An opinion that relies only on the absence of symptoms or treatment during service is incomplete. As the October 2014 examiner relied on the absence of chronic symptoms or treatment in service for the negative opinion concerning the demonstrated disability, the Board finds the October 2014 VA examination to be incomplete. The Board also notes that when asked if pain, weakness, fatigability, or incoordination significantly limited functional ability either during flare-ups or when the joint was used repeatedly over a period of time, the examiner stated that it was not possible to determine without resorting to mere speculation, because there is no conceptual or empirical basis for making such a determination without directly observing function under these conditions. The Board finds the October 2014 back examination to be incomplete as the examiner did not provide an opinion as to functional loss of range of motion during flare-ups or after repeated use over time because the Veteran was not examined during a flare-up or after repeated use. The Board notes that an opinion is speculative when it is based on the absence of procurable information or an examiner's shortcomings or general aversion to offering an opinion on issues not directly observed. Direct observation of functional impairment during a flare-up is not a prerequisite to offering an opinion. Case law and VA guidelines anticipate that examiners will offer flare up opinions based on estimates derived from information procured from relevant sources, including the lay statements of Veterans. Sharp v. Shulkin, 29 Vet. App. 26 (2017). Accordingly, the Board again finds the October 2014 VA back examination report to be incomplete for rating purposes. Because the Veteran may have a disability that is related to service, the Board finds that the Veteran should be provided a VA examination to determine the nature and etiology of the Veteran's clamed lumbar spine disability. Therefore, on remand an examination must be scheduled and an opinion as to the etiology of the Veteran's lumbar spine disability should be requested. McLendon v. Nicholson, 20 Vet. App. 79 (2006); 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). 3. Entitlement to service connection for a skin condition, to include acne is remanded. Although the Board regrets the delay, additional development is needed prior to further disposition of the claim for entitlement to service connection for a skin condition, to include acne. VA's statutory duty to assist the Veteran includes the duty to conduct a thorough examination so that the evaluation of the claimed disability will be a fully informed one. Green v. Derwinski, 1 Vet. App. 121 (1991); Snuffer v. Gober, 10 Vet. App. 400 (1997). Assistance by VA includes providing a medical examination or obtaining a medical opinion when an examination or opinion is necessary to make a decision on a claim. 38 U.S.C. § 5103A (d); 38 C.F.R. § 3.159 (c)(4). The Veteran contends that a currently diagnosed skin disability began during active duty service and continues to the present. The Veteran's July 1955 enlistment examination notes the Veteran as having several scars along the back, ear, thigh, and legs. The service medical records indicate the Veteran was treated for several skin conditions while in-service. The August 1957 separation examination found no abnormalities, specifically noting normal skin and lymphatics. The record shows that the Veteran was most recently provided VA skin examination in May and November 1994, over 27 years ago. During VA examination in November 1994, the examiner diagnosed inactive facial acne with few residual scars on the left jaw. The Board recognizes that, generally, the mere passage of time is not a sufficient basis for a new examination. Palczewski v. Nicholson, 21 Vet. App. 174 (2007). The Board finds that not only is the most recent examination remote, but the examinations appear to no longer indicate the current level of disability and do not contain any etiology opinions. In support of the claim, the Veteran has also provided a May 2015 private medical opinion from a social worker. In that opinion, the examiner expresses support for the claim and suggests a relationship between the Veteran's skin disability and service. The Board finds the May 2015 private opinion to be incomplete, as the examiner did not provide an adequate rationale to support the opinion, or provide any supporting documentation to show that individual had training to provide etiological opinions for skin disabilities. A mere conclusion without an underlying rationale is of no probative value. Miller v. West, 11 Vet. App. 345 (1998). The Board finds that rationale to be inadequate as the examiner did not properly explain what led to the opinion and cited no supporting evidence. It is also unclear that the examiner reviewed the medical evidence of record for the claimed disability or if the examiner, as a social worker, is competent to provide a medical etiology opinion. The examiner did not explain how the evidence related to the medical opinion that the claimed disability was related to service. As the May 2015 private examiner did not provide an adequate rationale, the opinion is incomplete. The Veteran has not been provided a VA examination which addresses any relationship between any currently diagnosed skin disability and service. Therefore, the Board finds that a VA opinion to determine any relationship between any currently diagnosed skin disability and active service should be scheduled. The Veteran is notified that it is his responsibility to report for any scheduled examination and to cooperate in the development of these claims. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. § 3.655. The matters are REMANDED for the following action: 1. Request the Veteran identify the names, addresses, and approximate dates of treatment for all VA and non-VA health care providers who provided treatment for all claimed disabilities. After securing the necessary releases, attempt to obtain all copies of pertinent treatment records identified by the Veteran that are not currently of record. 2. Then, schedule the Veteran for a VA audiology examination, with an examiner who has not previously examined the Veteran, to diagnose and obtain an opinion regarding the etiology of any right or left ear hearing loss disability. The examiner must review the claims file, to include this Remand in its entirety; the Veteran's lay statements, including hearing testimony, concerning in-service noise exposure and hearing loss symptoms during and since service; the previous VA examination; and the IOM report concerning an individual's delayed awareness on the effects on hearing from noise, and the onset of current symptomatology, and should indicate review of the file in the examination report. The Board notes that exposure to noise during service has been conceded by VA. The examiner must opine as to whether it is at least as likely as not (50 percent probability or greater) that any portion of the Veteran's hearing loss is etiologically related to active service or any event, disease, or injury during service, to include noise exposure, including whether any right or left ear hearing disability (1) began during active service, (2) was noted during service with continuity of the same symptomatology since service, (3) was caused by any service-connected disability or treatment for any service-connected disability, or (4) has been aggravated (increased in severity beyond the natural progress of the disorder) by any service-connected disability or treatment for any service-connected disability. The examiner is advised that the Veteran is competent to report his symptoms during and since service and that those reports must be acknowledged and considered in formulating any opinion. If the Veteran's reports are discounted, the examiner should provide a reason for doing so. The examiner must consider and discuss those lay statements and should reconcile the opinion with any previous opinions of record. A clearly stated rationale for any opinion offered should be provided and must not be based solely on the lack of any in-service record. 3. Schedule the Veteran for a VA spine examination, with a medical doctor who has not previously examined the Veteran, to diagnose and determine the nature and etiology of any low back disability. The examiner must review the claims file, including this Remand and the Veteran's lay statements, including hearing testimony, and should indicate review of the file in the report. The examiner should diagnose all low back disabilities found or shown in the record during the pendency of the claim. The examiner should reconcile the diagnosis with the previous evidence of record. For each back disability diagnosed, to include pain resulting in functional loss, the examiner must opine whether it is at least as likely as not (50 percent or greater probability) that each back disability is etiologically related to active service or any event, disease, or injury during service, including whether any back disability (1) began during active service, (2) manifested as back arthritis within one year after separation from service, or (3) was noted during service with continuity of the same symptomatology since service . Please cite to any evidence to support a finding of back arthritis within one year following separation from service. The examiner should address the Veteran's lay statements regarding the claimed disabilities and their etiology and symptoms during and since service. The examiner should address the significance, if any, of the Veteran's in-service back complaint as it pertains to the current diagnosis. The examiner must consider and discuss the lay statements and should reconcile the opinion with any previous opinions of record. A clearly stated rationale for each opinion offered must be provided and cannot be based on the lack of an in-service record of the claimed disability. In writing the report, the examiner should refer to any service medical records, indicating in-service treatment for any of the claimed disabilities. 4. Then, schedule the Veteran for a VA skin examination, with a medical doctor who has not previously examined the Veteran, to determine the nature and etiology of a claimed skin disability, to include acne. The examiner must review the claims file, including this Remand and the Veteran's lay statements, including hearing testimony, and should indicate review of the file in the report. The examiner is advised that the Veteran is competent to report symptoms and history and that those reports must be acknowledged and considered in formulating any opinion. If the Veteran's reports are discounted, the examiner should provide a reason for doing so. The examiner should provide the following opinions, based on the record: (a) Is it clear and unmistakable(medically undebatable) that any skin disability preexisted the Veteran's entrance to active service? The examiner should state what evidence supports that opinion. (b) If a skin disability is found to have clearly and unmistakably preexisted service, the examiner should opine whether it is clear and unmistakable that a preexisting skin condition was not aggravated (worsened beyond the natural progress of the disease) during service. (c) For any skin disability that is found to not have clearly and unmistakably preexisted entrance to active service, the examiner should opine whether it is at least as likely as not (50 percent or greater probability) that the skin disability is etiologically related to active service or any event, disease, or injury during service, including whether any skin disability (1) began during active service, or (2) was noted during service with continuity of the same symptomatology since service. The examiner must discuss any significance of the Veteran's rashes during service, as it pertains to the current skin diagnosis. A clearly stated rationale for each opinion offered must be provided and must not be based on the lack of an in-service record of the claimed disability. Harvey P. Roberts Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Mondesir, Eric 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.