Citation Nr: 22057782 Decision Date: 10/14/22 Archive Date: 10/14/22 DOCKET NO. 17-40 093A DATE: October 14, 2022 REMANDED Service connection for multiple cysts or residuals of multiple cysts of the right eyebrow, also claimed as secondary to herbicide exposure, is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1967 to July 1970 and from June 1972 to December 1990. This issue was previously before the Board in December 2019. Most recently, in October 2021, the Board remanded the issue to obtain a VA medical opinion to determine whether any cysts or residuals of cysts, including on the back right shoulder, front left shoulder, and below the eyebrow where etiologically related to the Veteran's active service, to include herbicide exposure. While on remand, a November 2021 rating decision granted service connection for coronary artery disease status post-myocardial infarction associated with herbicide exposure. As a result, the issue is no longer on appeal before the Board. Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). The Board notes an August 2020 rating decision granted entitlement to service connection for a left shoulder scar as a residual of a nevus excision on the basis of Agent Orange exposure. Thus, that decision is considered a partial grant of the issue on appeal. The Board further notes while the rating decision mostly addresses the grant of service connection for the Veteran's left anterior shoulder scar, the rating decision also notes, "We have assigned a 0 percent evaluation for your multiple cysts to include residuals of cyst above right eye below eyebrow." However, the Board observes the Veteran's most recent codesheet from September 2022 does not reflect he has been service connected for multiple cysts or residuals of multiple cysts of the right eyebrow. He has only been service connected for a residual scar of the right mid back and as noted above, the left anterior shoulder. Accordingly, the remaining issue is whether his scar of the right eyebrow area is related to his active service, including herbicide exposure, and the issue has been recharacterized to reflect the partial grants. Service connection for multiple cysts or residuals of multiple cysts of the right eyebrow, also claimed as secondary to herbicide exposure, is remanded. The Veteran contends growths or cysts he had removed are due to exposure to Agent Orange during his military service in Thailand. See June 2012 Statement in Support of the Claim. As to a current diagnosis, the Board notes a January 2020 Scars/Disfigurement Disability Benefits Questionnaire reflects a diagnosis of three scars of the right eyebrow area, the right mid-back area, and the left anterior shoulder. Thus, the first Shedden element is satisfied. As to an in-service event, in its October 2021 decision, the Board found it is at least as likely as not the Veteran was exposed to herbicides during his service in Thailand. As such, the second Shedden element is met. Furthermore, according to a January 2020 examination report, the Veteran recalls he developed a lump on his skin during active duty, and during a break in service, he sought evaluation and it was excised. He does not recall the diagnosis. He noticed a similar cyst around 1974, and it was removed or excised from the back of his shoulder. He reports a third lesion was also excised from a location he does not recall in the mid-1980s. After he retired, he had one removed from an area of his eyelid. More recently, he had some precancerous lesions "burned off." Turning to the nexus requirement, the AOJ obtained an opinion in May 2022. The examiner notes lipomas and blue nevi do not represent manifestations of an underlying condition that would be deemed chronic or recurrent in nature, and there is no relationship anatomically or pathophysiologically between the multiple cysts, excisions, or residuals of multiple cysts, to include on the right shoulder, the front left shoulder, and below the right eyebrow to the Veteran's service-connected lipoma and blue nevus and respective excisions. The examiner goes on to state the Veteran's blue nevus was likely familial, though it had been noted as acquired, and they state even if it was acquired, it is unrelated to any other condition, nor would it cause inclusion cysts. They note lipomas are fatty tumors and are pathophysiologically and anatomically unrelated to inclusion cysts, and neither blue nevi nor lipomas and inclusion cysts are related to Agent Orange exposure. They further note any skin condition arising due to exposure to Agent Orange would likely represent a contact dermatitis or an allergic dermatitis; though, chloracne is an exception but does not apply as the Veteran has never been diagnosed with that condition. The examiner summarizes by noting the Veteran's lipoma and blue nevus, status post-excisions, do not represent manifestations of a chronic underlying condition, and inclusion cysts are anatomically and pathophysiologically unrelated to blue nevi and lipomas. Therefore, the examiner concludes, the Veteran's inclusion cysts are unrelated to his service-connected blue nevus and lipoma arising from service, and they state a negative opinion. The Board does not find the May 2022 opinion adequate for several reasons. First, a written, the VA examiner's opinion is conclusory in nature and lacks adequate rationale. See Miller v. West, 11 Vet. App. 18, 22 (2007) (bare conclusions, even those reached by healthcare professionals, are not probative without a factual predicate in the record). For example, the examiner states, the Veteran's blue nevus was likely familial. They then essentially conclude the opposite by stating even if it was acquired, it is unrelated to any other condition, nor would it cause inclusion cysts. Furthermore, the examiner's finding that the Veteran's blue nevus would not cause inclusion cysts is inconsistent with the fact the Veteran has scars from his excisions due to the removal of cysts. Finally, the examiner's wording of their finding that the Veteran's condition was not caused by Agent Orange seems to suggest it is because it is not one of the presumptive skin conditions associated with herbicide exposure; however, the Veteran can still seek service connection for his condition on a direct basis. Accordingly, the Board finds a remand is required to obtain an adequate opinion with sufficient rationale for the conclusions reached. The matters are REMANDED for the following action: 1. Obtain VA treatment records since April 2022 and associate them with the claims file. 2. The AOJ should ask the Veteran to identify the providers of treatment for the claimed excisions involving his right eyebrow as they may be necessary for an examiner to provide an accurate opinion. 3. Forward the Veteran's claims file to an appropriate examiner for an opinion addressing the nature and etiology of his scar, status-post skin lesion excision of the right eyebrow. It is left to the discretion of the examiner as to whether another examination is needed; if the examiner determines that such is required to provide the above opinion, this additional examination should be scheduled. After a review of the case file, including this Remand, the Board asks the examiner to opine as to the following: Please state the likelihood that the Veteran's skin lesion excisions of the right eyebrow were caused by service or is otherwise etiologically related to active-duty service, to include exposure to herbicides. The examiner should note that the Veteran is presumed to have been exposed to herbicides during service. The examiner is specifically requested to discuss whether any of the excisions of the right eyebrow were due to underlying conditions causing the service-connected blue nevus and lipoma excisions and discuss whether such underlying condition would be deemed chronic or recurrent in nature. If the examiner cannot provide an opinion without resorting to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit the requested opinion to be made. The examiner must provide a complete rationale for all opinions expressed. N. RIPPEL Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Buck Denton 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.