Citation Nr: 22019030 Decision Date: 03/31/22 Archive Date: 03/31/22 DOCKET NO. 17-40 679 DATE: March 31, 2022 REMANDED Entitlement to service connection for urticaria is remanded. Entitlement to service connection for xerosis cutis is remanded. Entitlement to service connection for a left shoulder condition is remanded. REASONS FOR REM AND The Veteran served on active duty from April 2008 to August 2008, February 2009 to June 2009, September 2010 to February 2011, and October 2013 to March 2014 with additional Reserve service. She timely appealed a January 2020 Board of Veterans' Appeals (Board) decision denying entitlement to service connection for urticaria, xerosis cutis, a left shoulder condition, and vaginitis, among other issues. In December 2020, pursuant to a Joint Motion for Partial Remand (JMPR), the Court vacated the Board's January 2020 decision, in part, and remanded these specific issues back to the Board. In August 2021, the Board remanded the claims for further development consistent with the January 2020 JMPR. Subsequent to this development, the AOJ granted service connection for vaginitis. See October 2021 rating decision. As this is considered a full grant of the benefits sought, that issue is no longer before the Board. Thus, the Board will only address entitlement to service connection for urticaria, xerosis cutis, and a left shoulder condition. Skin Conditions The Veteran claims her skin conditions were caused by exposure to solvents, paints, and dusty munitions storage units during seasonal training at Carswell Air Force Base (AFB), Texas from April 2008 to August 2008. See March 2017 Veteran correspondence. The Veteran's DD Form 214 confirms she served in the 301 Maintenance squad with the military occupational specialty (MOS) of munitions systems craftsman from April 2008 to August 2008 at Fort Worth Naval Air Station, which included Carswell AFB. During that timeframe, the Veteran stated she was itchy, and "about two weeks after completing...seasonal training, and during [her] drill weekend" the itching became bothersome, "sometimes so severely that [she] wanted to cry." See March 2017 Veteran correspondence. Over time, she noticed "small, red, itchy bumps" accompanied the itching and "appeared to be triggered by several things" including contact with dirt, stress, and working out. Id. The Veteran sought private treatment in September 2008 and received medication. Id. She noted after deploying to Iraq in February 2009, her condition worsened to the extent the "bumps felt swollen and [she] would break out into hives." Id. October 2008 service treatment records (STRs) note the Veteran denied ever suffering from any skin condition, including eczema and atopic dermatitis; however, April 2009 STRs reflect the Veteran stated her rashes began "around September 2008," which would be less than a month after her active-duty service at Carswell AFB. While serving in Iraq, the Veteran sought treatment for a skin condition and noted its presence was unpredictable. See April 2009 STRs. Upon examination it was noted the symptoms "seem to have worsened since her arrival here." Id. An April 2009 post deployment health assessment reflects the Veteran reported being exposed to sand, dust, and smoke from burning trash while in Iraq. Upon return from Iraq, the Veteran noted her "skin would break out from time to time" and she recollected it beginning "around September [2008]." See May 2009 STRs. In November 2009, the Veteran was diagnosed with xerosis cutis and urticaria. See November 2009 Fort Hood Medical Center records. In September 2021, a reviewing clinician stated the Veteran's skin condition less likely than not was incurred in or caused by her active duty service. As rationale, the clinician stated the urticaria and xerosis cutis were diagnosed in November 2009, when the Veteran was not on active duty. See September 2021 medical opinion. This opinion does not consider any of the Veteran's many competent statements that symptoms such as itching began during active duty at Carswell AFB from April 2008 to August 2008 and worsened to hives while serving in Iraq. See March 2017 Veteran correspondence. It also does not take into account the many STRs noting the Veteran's symptoms. As such, the opinion is inadequate. See Layno v. Brown, 6 Vet. App. 465, 469 (1994); See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The December 2020 JMPR noted the Board did not address whether the Veteran's skin conditions had a conclusive pathophysiology, an element required when discussing whether the Veteran's symptoms constituted an undiagnosed illness or a medically unexplained chronic multisymptom illness (MUCMI) under 38 C.F.R. § 3.317(b). Although March 2016 Reserve medical records note the Veteran's chronic urticaria was "likely idiopathic in nature," the August 2021 Board remand did not request a medical opinion regarding the etiology or pathophysiology of her skin conditions. As the Board cannot make independent medical determinations regarding the nature and etiology of the Veteran's skin conditions, a remand is required. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). Left Shoulder Condition The Veteran stated she first noticed left shoulder pain while serving in Afghanistan "lifting ammo-cans, [and] pushing and pulling trailers." See September 2021 VA examination report. Although the September 2021 VA examiner did not find a diagnosis for the Veteran's left shoulder, noting August 2021 x-ray imaging reflected a normal left shoulder, the Veteran stated her functional loss included lifting over 10 pounds with her left shoulder and increased pain with overhead movements. Id. The VA examiner opined the Veteran's left shoulder condition was less likely than not related to her active duty service as there was "no evidence of any left shoulder pain or injury while on active duty or within one year after release from active duty." Id. This is inaccurate as December 2014 Ireland ACH treatment records note the Veteran sought treatment for left shoulder pain and the clinician noted this was one of her "post deployment issues from Afghanistan in February 2014." This treatment for left shoulder pain occurred within one year of the Veteran's active duty service and suggests her left shoulder pain is related to her service in Afghanistan. As the September 2021 VA medical opinion was based on an inaccurate factual premise and did not address the relevant records, the opinion holds no probative value and a remand is required. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993). The matters are REMANDED for the following action: 1. Obtain any outstanding and updated relevant VA and/or private treatment records and associate the same with the claims file. 2. Thereafter, obtain an opinion from an appropriately qualified clinician, to determine the nature and etiology of the Veteran's current skin condition, to include urticaria and xerosis cutis. The evidentiary record, including a copy of this remand, must be made available to and reviewed by the reviewing clinician. The opinion should include a notation that this review took place. After a thorough review of the record the reviewing clinician should separately answer the following for each diagnosis of urticaria and xerosis cutis: Whether is it at least as likely as not that the skin condition was incurred in, or aggravated by, her time on active-duty service, to include reported exposure to solvents, paints and dusty munitions storage units during service at Carswell AFB, Texas from April 2008 to August 2008, and/or exposure to sand, dust, and burn pits while serving in Iraq from February 2009 to May 2009? AND Is the etiology OR pathophysiology of the skin condition not understood AT ALL as to this particular Veteran? The reviewing clinician is directed to the March 2017 Veteran correspondence, pages 1-3, for history of the Veteran's symptoms, contentions, and relevant service. The reviewing clinician is to consider the following: (a) October 2008 STRs noting the Veteran never had any skin condition; (b) April 2009 STRs during service in Iraq for treatment of an episodic and unpredictable rash with symptoms that "seem to have worsened since her arrival [in Iraq];" (c) April 2009 post-deployment health assessment noting the Veteran was exposed to sand, dust, and smoke from burning trash/feces while in Iraq from February 2009 to May 2009; (d) October 2009 and November 2009 Fort Hood Medical Center records noting "dry patches on skin that are irritated when touched, not responding to topical steroids" with a subsequent diagnosis of urticaria and xerosis; and (e) March 2016 Reserve medical records noting the Veteran's chronic urticaria has a "likely idiopathic nature." In rendering these opinions, the reviewing clinician should consider the Veteran competent to report her symptoms and history and the reviewing clinician is to discuss the Veteran's assertions of her skin condition. If the reviewing clinician rejects the Veteran's reports of symptomatology, a reason for doing so should also be provided. The reviewing clinician should not mistakenly rely on an absence of medical evidence in the record to support his or her conclusions. A full and complete rationale for all opinions must be provided, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 3. After the development of #1 above is complete, schedule the Veteran for an examination by an appropriately qualified clinician to determine the nature and etiology of her left shoulder condition. The evidentiary record, including a copy of this remand, must be made available to and reviewed by the examiner. A complete history should be elicited directly from the Veteran and the opinion should include a notation that this record review took place. After a thorough review of the record to include all in-service and post-service treatment records, the examiner should answer the following: Is it at least as likely as not that the Veteran's shoulder condition, to include pain and functional loss, was incurred in or is otherwise related to her time on active duty, or an injury incurred during a period of ACDUTRA or INACDUTRA? The examiner should consider December 2014 Ireland ACH treatment records noting the Veteran "has post-deployment issues from Afghanistan in February 2014" which included left shoulder pain. The examiner is further directed to May 2016 VA treatment records noting left shoulder pain, and the Veteran's statements at the September 2021 VA examination that her left shoulder pain began in "Afghanistan with lifting ammo-cans, pushing and pulling trailers" and that she cannot lift over 10 pounds or perform overhead movement with her left shoulder. In rendering this opinion, the examiner is advised that the Veteran is competent to report her symptoms and history. Such reports must be acknowledged and considered in formulating any opinion. If the examiner rejects the Veteran's reports, he or she must provide an explanation for such rejection. The examiner is not to improperly discount the Veteran's lay statements or mistakenly rely on an absence of medical evidence in the record to support his or her conclusions. The complete rationale for all opinions should be set forth, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 4. Thereafter, readjudicate the claim. If any benefit sought remains denied, provide the Veteran with a Supplemental Statement of the Case (SSOC), and return the case to the Board. DONNIE R. HACHEY Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Bona, Associate 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.