Citation Nr: 21029159 Decision Date: 05/12/21 Archive Date: 05/12/21 DOCKET NO. 17-56 622 DATE: May 12, 2021 REMANDED Entitlement to service connection for psoriasis, to include as related to service in the Southwest Asia Theater of Operations during the Persian Gulf War, is remanded. Entitlement to service connection for a left hip disability, to include degenerative arthritis, is remanded. REASONS FOR REMAND Having reviewed the record, the Board finds remand is warranted for additional development. First, the record indicates that the Veteran receives co-managed care with a private clinician, Dr. A.M. During the July 2020 hearing, the Veteran testified that Dr. A.M. indicated in treatment notes that his left hip disability is associated with service. However, treatment records from Dr. A.M. have not yet been associated with the claims file. Of note, VA treatment records from May 2014 through August 2017 indicate that private treatment records from Dr. A.M. have been scanned into Vista Imaging. However, these scanned documents do not appear to have been added to the claims file. Accordingly, remand is warranted to obtain treatment records from Dr. A.M. and B. Hill Orthopedic Surgery Center. On remand, any documents scanned into Vista Imaging should be added to the claims file. Additionally, with proper authorization from the Veteran, an attempt should be made to obtain any additional, outstanding treatment records from Dr. A.M. and B. Hill Orthopedic Surgery Center. Additionally, the Veteran asserts that his current skin disability is related to exposure to environmental hazards during the Persian Gulf War. Military personnel records show that the Veteran has qualifying service during the Persian Gulf War as he served in Saudi Arabia from September 1990 to May 1991. Accordingly, remand is warranted for an examination to determine whether his skin condition is related to service in the Southwest Asia Theater of Operations. Further, September 1988, March 1989, and April 1989 service treatment records note the presence of a hemangioma during service. In light of this, remand is warranted for an examination to determine whether the Veteran's current skin condition is at least as likely as not related to service, to include the in-service diagnosis of a hemangioma and service in the Southwest Asia Theater of Operations. With respect to the left hip disability, the Veteran has not asserted that it is related to service due to exposure to environmental hazards in the Persian Gulf War. However, remand is warranted for an addendum opinion after outstanding private treatment records are added to the claims file, to includes any records already scanned into Vista Imaging. On remand, the examiner should state whether a left hip disability clearly and unmistakably both preexisted the Veteran's entry into active service, and was not aggravated beyond the normal progress of the disability during or as a result of active service. If the examiner finds that the current left hip disability did not clearly and unmistakably pre-exist service, then he/she should opine whether it at least as likely as not had an onset during service, or is otherwise related to service. The examiner's attention is invited to the May 1988 enlistment examination, which did not note a hip disability at the time of entrance. Additionally, VA treatment records indicate that the Veteran has a diagnosis of psoriatic arthritis. If service connection is granted for psoriasis, the examiner should opine whether it is at least as likely as not that a left hip disability was proximately due to or aggravated by service-connected psoriasis. Finally, any outstanding VA treatment records from August 2017 to present should be obtained and associated with the claims file. The matters are REMANDED for the following actions: 1. Ask the Veteran to complete a VA Form 21-4142 for Dr. A.M. and B. Hill Orthopedic Surgery Center. Make two requests for the authorized records, unless it is clear after the first request that a second request would be futile. 2. Obtain the Veteran's (a) VA treatment records for the period from August 2017 to present and (b) co-managed treatment records from Dr. A.M. that have been scanned into Vista Imaging. Attention is invited to the VA treatment records from May 2014 through August 2017 noting that treatment records from Dr. A.M. have been scanned into Vista Imaging. 3. After any outstanding private treatment records are associated with the claims file (to include records from Dr. A.M. that have already been scanned into Vista Imaging), schedule the Veteran for an appropriate examination to determine the nature and etiology of his skin condition. The examiner is asked to provide responses to the following: A) Identify the Veteran's objective indications of a disability. "Objective indications" of a qualifying chronic disability include both objective evidence perceptible to an examining physician and other non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). Non-medical indicators include evidence such as time lost from work, the Veteran having sought treatment for his symptoms, and change in the Veteran's appearance, physical abilities, and mental or emotional attitude. 60 Fed. Reg. 6661, 6663 (Feb. 3, 1995). B) By history, physical examination, or laboratory testing, can the Veteran's objective indications of a disability be attributed to a known clinical diagnosis? If the signs and symptoms are not characteristic of a known clinical diagnosis, the examiner should so indicate. There is no requirement that the examiner provide a diagnosis of undiagnosed illness. Attention is invited to the Veteran's current diagnoses of psoriasis and psoriatic arthritis. C) If the Veteran's objective indications cannot be attributed to a known clinical diagnosis, is there affirmative evidence that the undiagnosed illness is not incurred during active service during the Persian Gulf War or that it was caused by a supervening condition or event that occurred since the Veteran's departure from service during the Persian Gulf War? The examiner should note that a positive response to this question requires affirmative evidence. The mere absence of evidence is not sufficient. D) If the Veteran's objective indications can be attributed to a known clinical diagnosis, is the pathophysiology of the Veteran's condition (1) inconclusive, (2) partially understood, or (3) fully understood? This determination as to each must be based on the Veteran's specific case and cannot be based on the pathophysiology of the disease or disability population as a whole. E) If both the etiology and pathophysiology are partially understood or fully understood, then is it at least as likely as not that the Veteran's diagnosed condition was incurred in, or is otherwise related to active service, to include (1) an in-service hemangioma as noted in September 1988, March 1989, and April 1989 service treatment records or (2) exposure to environmental hazards in the Gulf War on a direct basis pursuant to Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). 4. After any outstanding private treatment records are associated with the claims file (to include records from Dr. A.M. that have already been scanned into Vista Imaging), obtain an addendum opinion from an appropriate clinician regarding the Veteran's left hip disability. The examiner (or an appropriate substitute) should provide the following opinions: A) Whether a left hip disability clearly and unmistakably both (i) preexisted the Veteran's entry into active service, and (ii) was not aggravated beyond the normal progress of the disability during or as a result of active service (i.e., that it clearly and unmistakably did not increase or that any increase was clearly and unmistakably due to the natural progress of the disease). B) If the examiner finds that the current left hip disability did not clearly and unmistakably pre-exist service, then he/she should opine whether it at least as likely as not had an onset during service, or is otherwise related to service. The examiner's attention is invited to the May 1988 enlistment examination, which did not note a hip disability at the time of entrance. C) The examiner should also opine whether it is at least as likely as not that a left hip disability was proximately due to or aggravated by psoriasis/psoriatic arthritis. Any opinions offered should be accompanied by the underlying reasons for the conclusion. TANYA SMITH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Vang, Stephanie 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.