Citation Nr: 22041005 Decision Date: 07/18/22 Archive Date: 07/18/22 DOCKET NO. 11-27 799 DATE: July 18, 2022 REMANDED Entitlement to service connection for a skin disorder other than cold urticaria, to include as secondary to service-connected idiopathic cold agglutinin autoimmune disorder, is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1998 to June 2004. He also had additional service in the Wisconsin Army National Guard. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2009 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). In December 2016, the Board remanded the case to afford the Veteran a hearing. The Veteran testified at a hearing before the undersigned Veterans Law Judge in June 2017. A transcript is of record. In November 2017, April 2020, August 2021, and April 2022, the Board remanded the case for further development. The case has since been returned to the Board for appellate review. During the pendency of the appeal, in a January 2021 rating decision, the agency of original jurisdiction (AOJ) granted service connection for cold urticaria and assigned a 10 percent evaluation effective from July 23, 2010. The grant of service connection for this issue constitutes a full award of the benefits sought on appeal. See Grantham v. Brown, 114 F.3d 1156, 1158 (Fed. Cir. 1997) (holding that a separate notice of disagreement must be filed to initiate appellate review of "downstream" elements such as the disability rating or the effective date assigned). Therefore, this matter is no longer on appeal, and no further consideration is necessary at this time. Nevertheless, the AOJ issued a supplemental statement of the case (SSOC) in January 2021, addressing the issue of entitlement to service connection for a skin disorder (also claimed as hives) as directly due to the Veteran's active duty service. Although the Veteran is already service-connected for cold urticaria, the Board has previously remanded a broader claim for a skin disorder and noted that there was some evidence showing that the Veteran may also have rosacea. In light of the particular procedural history of the case, the evidence of record, and the Veteran's contentions, the Board finds that the claim for a skin disorder other than cold urticaria remains on appeal. See Locklear v. Shinseki, 24 Vet. App. 311 (2011); Tyrues v. Shinseki, 23 Vet. App. 166, 178-79 (2009), aff'd, 631 F.3d 1380 (Fed. Cir. 2011) (VA is free to dismember a claim and adjudicate it in separate pieces). Upon review, the Board finds that additional development is needed prior to adjudication of the issue remaining on appeal. Following the most recent remand, an April 2022 VA examiner, a general medicine physician, indicated that the Veteran's skin disorder is not related to his active duty service on a direct or secondary basis. However, he also stated that an opinion could not be provided because the Veteran has a long list of active and inactive skin disorders or lesions. Instead, the examiner highly recommended that the Veteran be evaluated for an in-clinic examination by a qualified provider (preferably a dermatologist) to determine the current severity of the skin conditions. The examiner further stated that a detailed clinical history and thorough physical examination should be performed to assess the current status of the skin disorders. Later that same month, another VA examiner, an occupational medicine physician, opined that a skin disorder was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. He noted that there is no evidence in the service treatment records documenting episodes of chronic cold-induced urticaria or rosacea, but that the Veteran was treated for cellulitis and contact dermatitis while on active duty. However, he stated there is no evidence that either of these conditions evolved into a chronic or frequently recurrent disorder. The examiner also observed that the Veteran was diagnosed with cold agglutinin induced urticaria (hives) and rosacea years after discharge from military service. He commented that these conditions are separate and distinct clinical entities, are not otherwise interrelated, and are both conditions of unknown etiology. The examiner further noted that many other skin disorders are now resolved. In addition, the second April 2022 VA examiner opined that the claimed condition is less likely than not proximately due to or the result of the Veteran's service-connected disability. He also concluded that, regardless of an established baseline, the claimed condition is less likely than proximately due to or the result of the Veteran's service-connected disability. He reiterated the same rationale for both of these opinions as he did for direct service connection. Nevertheless, the Board finds that the April 2022 VA medical opinions are inadequate. The first April 2022 VA examiner recommended an examination by a qualified provider (preferably a dermatologist). Such a statement raises a question as to the competency or qualifications of the VA examiner. See Wise v. Shinseki, 26 Vet. App. 517 (2014). However, the second opinion was provided by an occupational medicine physician, and there is no explanation as to why an opinion was not requested or needed from a dermatologist. Moreover, the April 2022 VA examiners did not address a September 2002 master workplace exposure data summary and the Veteran's June 2017 hearing testimony regarding the onset of his symptoms and in-service exposure to chemicals, as directed in the prior remand. See Stegall v. West, 11 Vet. App. 268 (1998) (holding that a remand confers on the claimant, as a matter of law, the right to compliance with the remand order). In addition, as noted above, the second April 2022 VA examiner provided the same rationale for both the causation and aggravation elements of secondary service connection. Specifically, the examiner opined that urticaria and rosacea are separate and distinct clinical entities of unknown etiology and are not otherwise interrelated. The Court has held that causation and aggravation are independent concepts and should have separate findings and rationales. See Atencio v. O'Rourke, 30 Vet. App. 74 (2018); El Amin v. Shinseki, 26 Vet. App. 136, 140 (2013). For these reasons, the Board finds that an additional VA medical opinion is needed. The matters are REMANDED for the following action: 1. The Veteran should be afforded a VA examination by a suitably qualified examiner (preferably a dermatologist) to determine the nature and etiology of any current skin disorder other than cold urticaria, that may be present. If a dermatologist is not available, an explanation should be documented in the claims file. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and assertions. It should be noted that the Veteran is competent to attest to factual matters of which he has first-hand knowledge. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should state this with a fully reasoned explanation. The Veteran is already service-connected for cold urticaria. Thus, an opinion is not needed for the etiology of that disorder. The examiner should identify any skin disorders other than cold urticaria that have been present during the pendency of the appeal, to specifically include hives and rosacea. If any previously diagnosed skin disorders are not found, the examiner should address whether they were misdiagnosed or have resolved. For any skin disorder other than cold urticaria identified, the examiner should provide an opinion as to whether it is at least as likely as not that the disorder manifested in or is otherwise causally or etiologically related to the Veteran's military service, to include any symptomatology or military environmental exposures therein. In rendering this opinion, the examiner should address the service treatment records documenting complaints pertaining to the Veteran's skin. See e.g., service treatment records dated March 2000 (Veteran reported having a breakout of hives on his face and extremities) and October 2000 (noting an assessment of hand cellulitis). He or she should also address a September 2002 master workplace exposure data summary and the Veteran's June 2017 hearing testimony regarding the onset of his symptoms and in-service exposure to chemicals. The examiner should also provide an opinion as to whether it is at least as likely as not that the disorder was either caused by or aggravated by the Veteran's service-connected primary idiopathic cold agglutinin autoimmune hemolytic anemia disorder. The examiner should address both the causation and aggravation questions in his or her rationale. In other words, even if the Veteran's service-connected primary idiopathic cold agglutinin autoimmune hemolytic anemia disorder did not cause his skin disorder, the examiner should still address whether the service-connected condition could have worsened his skin disorder. (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a conclusion as it is to find against it.) ("Aggravation" is defined as worsening beyond the natural progression of the disease.) A clear 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. 2. After completing these actions, the AOJ should ensure compliance with the remand directives and take any corrective action needed. 3. The AOJ should conduct any other development as may be indicated. J.W. ZISSIMOS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. DeVerter, 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.