Citation Nr: 0319923 Decision Date: 08/11/03 Archive Date: 08/25/03 DOCKET NO. 00-18 483 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUES 1. Entitlement to service connection for hypertension, including as secondary to or aggravated by service-connected post-traumatic stress disorder (PTSD). 2. Entitlement to service connection for a gastrointestinal disorder, including as secondary to or aggravated by service- connected PTSD. 3. Entitlement to service connection for a skin condition, to include skin cancer, claimed as due to exposure to herbicides. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and spouse ATTORNEY FOR THE BOARD Douglas E. Massey, Counsel INTRODUCTION The veteran served on active duty from September 1969 to July 1971. His claims initially came before the Board of Veterans' Appeals (Board) on appeal from rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in New Orleans, Louisiana. The Board remanded the case to the RO in December 2001 for additional development. The case is once again before the Board for review. The issue of entitlement to service connection for a skin condition, to include skin cancer, claimed as due to exposure to herbicides, will be discussed in the remand portion of this decision. FINDINGS OF FACT 1. The RO has notified the veteran of the evidence needed to substantiate his claims for service connection for hypertension and for a gastrointestinal disorder, and has obtained and fully developed all evidence necessary for the equitable disposition of these claims. 2. The veteran's hypertension is unrelated to service and was not caused or aggravated by his service-connected PTSD. 3. The veteran's gastrointestinal disorder is unrelated to service and was not caused or aggravated by his service- connected PTSD. CONCLUSIONS OF LAW 1. Hypertension was not incurred in or aggravated by service, and is not proximately due to or the result of a service-connected disability. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.303, 3.310 (2002). 2. A gastrointestinal disorder was not incurred in or aggravated by service, and is not proximately due to or the result of a service-connected disability. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.303, 3.310 (2002). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service connection has been established for PTSD. The veteran contends that he suffers from hypertension and a gastrointestinal condition that were either caused or aggravated by his service-connected PTSD. In the interest of clarity, the Board will initially discuss whether these issues have been properly developed for appellate purposes. The Board will then address the issues on appeal, providing relevant VA law and regulations, the relevant facts, and an analysis of the Board's decision. I. Veterans Claims Assistance Act As a preliminary matter, the Board notes that important procedural aspects of the law for veterans claiming compensation benefits have changed during the course of this appeal. On November 9, 2000, the Veterans Claims Assistance Act of 2000 ("VCAA") was enacted. Pub. L. No. 106-475, 114 Stat. 2096 (2000); see 38 U.S.C.A. §§ 5103, 5103A (West 2002). The VCAA amended 38 U.S.C.A. § 5103 to clarify VA's duty to notify claimants and their representatives of any information that is necessary to substantiate the claim for benefits. The VCAA also created 38 U.S.C.A. § 5103A. This provision of the law codifies VA's duty to assist and essentially provides that VA will make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate a claim. See 38 C.F.R. § 3.159 (2002). First, VA has a duty to notify the veteran and his representative of any information and evidence needed to substantiate and complete a claim. 38 U.S.C.A. §§ 5102 and 5103 (West 2002); 38 C.F.R. § 3.159(b) (2002). Information means non-evidentiary facts, such as the claimant's address and Social Security number or the name and address of a medical care provider who may have evidence pertinent to the claim. See 66 Fed. Reg. 45620, 45630 (August 29, 2001); 38 C.F.R. § 3.159(a)(5) (2002). The veteran in this case was notified of the information and evidence required to substantiate his claims by means of the discussions in the rating decisions of August 1998 and May 1999; the statements of the case issued in May 1999 and May 2000; the supplemental statements of the case issued in October 1999 and April 2003; as well as various letters by the RO and the Board. In a January 2002 letter, the RO notified the veteran of the development requested in the Board's December 2001 remand instructions. Letters from the RO to the veteran dated in April 2002 and June 2002 also explained the responsibility of the veteran and the VA in obtaining private treatment records. It thus appears that the veteran was notified of the evidence, if any, he was expected to obtain and the evidence, if any, that VA would obtain or request for him. See Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002);. 38 U.S.C.A. § 5103. In addition, VA must make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate a claim unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A(a); 38 C.F.R. § 3.159(c), (d). Such assistance includes making every reasonable effort to obtain relevant records (including private and service medical records and those possessed by VA and other Federal agencies) that the claimant adequately identifies to the Secretary and authorizes the Secretary to obtain. 38 U.S.C.A. § 5103A(b) and (c); 38 C.F.R. § 3.159(c)(1-3). Assistance also includes providing a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). The Board finds that VA has complied with the duty-to-assist requirement of the VCAA. Pursuant to the Board's remand, the veteran underwent several VA examinations to determine whether his hypertension and gastrointestinal condition were either caused by or aggravated by PTSD. In addition, there do not appear to be any outstanding medical records that are relevant to this appeal. The RO obtained the veteran's service medical records as well as all outstanding VA outpatient treatment records. The RO also requested medical records from each private source identified by the veteran; unfortunately, the Board notes that some of these records are not available. A report from A.C., Jr., dated April 2002, notes that he had no office records pertaining to the veteran. The RO also sent letters to J.A., M.D., in April and June of 2002 requesting any medical records pertaining to the veteran; to date, no reply has been received. See VCAA at 2097-98 (stating that the efforts to obtain outstanding relevant records shall continue until the records are obtained unless it is reasonably certain that such records do not exist or that further efforts to obtain those records would be futile.) The Board thus finds that all reasonable efforts to secure and develop the evidence that is necessary for an equitable disposition of the issues on appeal have been made by the agency of original jurisdiction. For the reasons discussed, the Board concludes that the veteran has been notified of the evidence and information necessary to substantiate his claims and has been notified of VA's efforts to assist him. See Quartuccio, supra. As a result of the development that has been attempted and completed, there is no reasonable possibility that further assistance will aid in substantiating the claims. As such, further development is not necessary to meet the requirements of 38 U.S.C.A. §§ 5103 and 5103A. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on the VA with no benefit flowing to the veteran are to be avoided). Disposition of the veteran's claims for hypertension and a gastrointestinal disorder at the present time is appropriate. II. Service Connection for Hypertension The veteran contends that he has hypertension that was either caused or aggravated by his service-connected PTSD. For the reasons set forth below, the Board finds that the preponderance of the evidence is against the veteran's claim. To establish service connection for a particular disability, the evidence must show that the disability resulted from disease or injury that was incurred in or aggravated by service. 38 U.S.C.A. §§ 1110 ; 38 C.F.R. § 3.303. Service connection also may be granted for a chronic disease, such as hypertension and peptic ulcers, if the disease if manifested to a compensable degree (10 percent) within one year following service. This presumption can be rebutted by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2002). Service connection may also be established when the evidence, regardless of its date, shows that a veteran had a chronic condition in service, or during an applicable presumption period, and still has such a condition. Such evidence must be medical unless it relates to a condition as to which lay observation is competent. For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303(a). If the chronicity provision is not applicable, a claim may still be established if the condition observed during service or any applicable presumption period still exists, continuity of symptomatology is demonstrated thereafter, and competent evidence relates the present condition to that symptomatology. 38 C.F.R. § 3.303(b); Savage v. Gober, 10 Vet. App. 488, 495-98 (1997). Further, a disability, which is proximately due to or results from another disease or injury for which service connection has been granted shall be considered a part of the original condition. See 38 C.F.R. § 3.310(a). When aggravation of a veteran's nonservice-connected condition is proximately due to or the result of a service-connected condition, such veteran shall be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Id.; see also Allen v. Brown, 7 Vet. App. 439, 448 (1995). In this case, none of the veteran's service medical records shows that he had high blood pressure in service. A May 1969 pre-induction examination report lists a blood pressure reading of 130/80 while sitting. At his separation examination in July 1971, his blood pressure was noted to be 120/80 in the sitting and recumbent positions. There is also no indication that the veteran was on high blood pressure medication at any time during service. Furthermore, no evidence shows high blood pressure readings within one year of the veteran's separation from service. Several private health care providers first identified high blood pressure readings in the 1980's. In July 1983, R.C., M.D., reported the veteran's blood pressure to be 140/90. In 1986, L.C., M.D., listed blood pressure readings of 170/100 and 144/104. The assessment was high blood pressure. The veteran's hypertension is also well documented in VA outpatient treatment records dated from 1994 to 2001. None of these reports, however, includes a medical opinion linking the veteran's hypertension to service or to his service- connected PTSD. In a January 1999 letter, J.F., M.D., stated that he had been treating the veteran who suffered from PTSD and hypertension. Dr. J.F. indicated that the veteran had been suffering from PTSD since three weeks after his discharge from active duty in 1971. Dr. J.F. then stated: "It is my feeling that [the veteran] has a nervous disorder consistent with post traumatic stress disorder with resultant medical conditions known to be aggravated by stress, including hypertension[.]" Pursuant to the Board's December 2001 remand and the various VA examinations in connection with his claim, the veteran was examined in February 2002 for coronary artery disease. At that time, he reported that he developed hypertension in 1990 and was subsequently diagnosed with PTSD in 1992. He reported that he smoked one to three packs of cigarettes per day and drank a six-pack of beer per day several times a week. Following a physical examination, the examiner diagnosed the veteran as having (1) systemic hypertension, (2) normal systolic left ventricular function by echo with a suggestion of abnormal diastolic relaxation, (3) multiple risk factors for coronary artery disease, and (4) left carotid bruits. The examiner noted that the veteran's cardiovascular risk factors included hypertension, smoking, age, general family history, and an elevated LDL. PTSD was not mentioned. The veteran was also afforded a psychiatric examination in February 2002, at which time the diagnoses included PTSD, depressive episode (not otherwise specified), peptic ulcer disease, and hypertension. The examiner explained that there appeared to be a temporal relationship between the veteran's development of PTSD symptoms and exacerbations of his medical conditions; however, the examiner never clarified which medical conditions (i.e., hypertension or gastrointestinal conditions). He then explained that, although a temporal relationship existed, there were also confounding factors, such as the veteran's use of alcohol and steroidal anti- inflammatory drugs, both of which can exacerbate his gastrointestinal condition. The examiner then stated that there was simply not enough medical evidence to substantiate a definitive physiologic mechanism by which the veteran's PTSD had equivocally resulted in his physical symptoms. In December 2002, the examiner who performed the February 2002 cardiovascular examination submitted an addendum report in which he ruled out the possibility of a relationship between the veteran's hypertension and his service-connected PTSD. The examiner explained that the diagnosis of hypertension was made prior to the diagnosis of PTSD and that the veteran's hypertension was well controlled on medication. To illustrate, the examiner noted that fourteen blood pressure values had been taken since 1998, only two of which showed a systolic blood pressure at or above 150 and no diastolic pressures above 90. The examiner observed that the veteran's blood pressure was well controlled despite the veteran's history of PTSD, which might predispose him to anxiety and a hyperadrenergic state. The examiner thus concluded that the etiology of the veteran's hypertension was not likely to be PTSD, and that the veteran's risk factors for hypertension included a family history of heart disease and a long history of heavy cigarette smoking which extended over three decades. The examiner stated that, "The [veteran's] systemic hypertension preexisted his diagnosis of PTSD and currently is well controlled and also does not seem to be exacerbated by the [veteran's] PTSD." After reviewing the record, the Board finds that the preponderance of the evidence is against the veteran's claim for service connection for hypertension. First, hypertension was not shown in service or during the one-year presumptive period after service. Moreover, no medical evidence relates this condition to service. Thus, service connection for hypertension cannot be established under a direct theory of service connection. Second, the Board concludes that the preponderance of the evidence is against a finding that the veteran's hypertension was secondary to or aggravated by his service-connected PTSD. The only medical evidence in support of the veteran's claim is Dr. J.F.'s January 1999 letter in which he stated that "[the veteran] has a nervous disorder consistent with post traumatic stress disorder with resultant medical conditions known to be aggravated by stress, including hypertension[.]" The difficulty with this opinion is that there is no evidence that Dr. J.F. reviewed the veteran's claims file or considered the veteran's risk factors for hypertension, thereby diminishing the probative value of the opinion. See Swann v. Brown, 5 Vet. App. 177, 180 (1993) (without a review of the claims file, an opinion as to etiology of an underlying condition can be no better than the facts alleged by the veteran); see Black v. Brown, 5 Vet. App. 177, 180 (1993); see also Elkins v. Brown, 5 Vet. App. 474, 478 (1993) (rejecting a medical opinion as "immaterial" where there was no indication that the physician reviewed the claimant's service medical records or any other relevant documents which would have enabled him to form an opinion on service connection on an independent basis). In contrast, VA examiners in February 2002 and December 2002 reviewed the veteran's claims file and determined that the his hypertension was neither caused nor aggravated by his PTSD. The February 2002 psychiatric examination report includes a medical opinion that that there was simply not enough medical evidence to substantiate a definitive physiologic mechanism by which the veteran's PTSD had equivocally resulted in his physical symptoms. In the December 2002 addendum, the examiner clarified that the veteran's hypertension was not caused or exacerbated by PTSD. In support of the opinion, the examiner reasoned that the veteran's hypertension preexisted the diagnosis of PTSD, and that hypertension was well controlled despite the veteran's PTSD symptoms. In other words, exacerbations of hypertension did not correlate with exacerbations of PTSD symptoms. The Board places greater probative value on the opinions provided by VA health care professionals because they were based on a review of the claims file and supported by sound rationale. See Owens v. Brown, 7 Vet. App. 429, 433 (1995) (holding that VA may favor the opinion of one competent medical expert over that of another when decision makers give an adequate statement of reasons and bases); See Owens v. Brown, 7 Vet. App. 429, 433 (1995) (holding that VA may favor the opinion of one competent medical expert over that of another when decision makers give an adequate statement of reasons and bases); Guerrieri v. Brown, v. Brown, 4 Vet. App. 467, 473 (1993) ("the probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches.... As is true with any piece of evidence, the credibility and weight to be attached to these opinions [are] within the province of the [Board as] adjudicators. . ."). The Board has also considered the veteran's own lay statements, including testimony presented at a hearing held before the undersigned Member of the Board in October 2000. The veteran testified that his hypertension was first diagnosed in 1986 or 1987 and was related to his service- connected PTSD. The Board emphasizes, however, that as a layperson the veteran is not competent to testify as to the cause etiology or worsening of his hypertension. See Grottveit v. Brown, 5 Vet. App. 91, 93 (1993); Espiritu v. Derwinski, 2 Vet. App. 492 494-95 (1991) (laypersons are not competent to render medical opinions); see also 66 Fed. Reg. 45,620, 45, 630 (Aug. 29, 2001) (to be codified at 38 C.F.R. § 3.159(a)(2) (competency is an adjudicative determination). Therefore, the veteran's lay statements are of limited probative value. In conclusion, the Board finds that the preponderance of the evidence is against the veteran's claim for service connection for hypertension. Hence, there is not an approximate balance of positive and negative evidence to which the benefit-of-the-doubt standard applies. VCAA, Pub. L. No. 106-475, 114 Stat. 2096, 2098-2099 (2000); see also Dela Cruz v. Principi, 15 Vet. App. 143, 148-49 (2001) (holding that the VCAA did not alter the benefit-of-the doubt doctrine). Accordingly, the appeal for compensation for hypertension must be denied. III. Service Connection for a Gastrointestinal Disorder The veteran claims that a gastrointestinal disorder that was caused by or aggravated by his service-connected PTSD. For the following reasons, the Board finds that the preponderance of the evidence is against the veteran's claim as to this issue. None of the veteran's service medical records, including the July 1971 separation examination report, makes any reference to stomach-related problems. There is also no evidence of any stomach problems within one year of the veteran's separation from active duty. When the veteran was evaluated by Payne and Keller of LA, Inc. in December 1978, he denied any stomach trouble, including ulcers and abdominal pain. When evaluated by Dr. R.C. in 1986, the veteran reported abdominal cramping and a history of a nervous stomach and gastritis. However, an ultrasound performed in November 1987 revealed a normal stomach. A December 1993 VA outpatient treatment report noted the veteran's history of chronic nervousness and gastritis since his service in Vietnam. The diagnostic impression was PTSD, alcohol abuse and rule out psychological condition affecting a physical condition versus alcohol gastritis. At a VA examination in February 1994, the veteran reported epigastric pain when nervous. The diagnosis was nervous dyspepsia secondary to nervous tension and anxiety. In April 1997, the veteran was admitted to Riverview Medical Center for acute stomach cramps and vomiting after eating crawfish fettuccini the night before. The diagnoses were acute gastroenteritis, ileus and diverticulitis. VA outpatient treatment reports dated from 1994 to 2001 also show diagnoses of PTSD, gastritis and gastroesophageal reflux disease (GERD). None of these reports includes any medical opinion relating any of the veteran's gastrointestinal disorders to service or to his service-connected PTSD. In his January 1999 letter, Dr. J.F. stated that the veteran continued to suffer from PTSD as well as bouts of peptic ulcer disease and gastroesophageal reflux disorder. Dr. J.F. expressed his belief that "[the veteran] has a nervous disorder consistent with post traumatic stress disorder with resultant medical conditions known to be aggravated by stress, including [] dyspepsia secondary to peptic ulcer disease." On a VA gastrointestinal examination in February 2002, the veteran gave a history of abdominal pain since his service in Vietnam. He also admitted that he drank two six-packs of beer every other day and smoked two packs of cigarettes a day for the past thirty-five years. Based on a review of the claims file and findings from a physical examination, the examiner concluded that the veteran's present problems could be due to reflux esophagitis and/or gastritis. The examiner did not mention the veteran's PTSD in the report. An EGD (esophagogastroduodenoscopy) was subsequently performed, revealing a mildly distorted distal esophagus. As previously discussed, a February 2002 psychiatric examination report listed diagnoses of PTSD, depressive episode (not otherwise specified), peptic ulcer disease, and gastroesophageal reflux disease. The examiner indicated that there appeared to be a temporal relationship between the veteran's development of PTSD symptoms and exacerbations of his medical conditions. He then explained that, although a temporal relationship existed, confounding factors also exited, such as the veteran's use of alcohol and steroidal anti-inflammatory drugs, both of which could have exacerbated his gastrointestinal condition. The examiner concluded that there was simply not enough medical evidence to substantiate a definitive physiologic mechanism by which the veteran's PTSD had equivocally resulted in his physical symptoms. The veteran was afforded another VA gastrointestinal examination in December 2002 by the same examiner who conducted the February 2002 examination. The examiner stated that the EGD performed in March 2002 was essentially within normal limits. The examiner made no reference to the likelihood of a relationship between the veteran's stomach problems and his service-connected PTSD. As a result, another VA examiner reviewed the claims file in February 2003 and offered the following opinion: "[I]t is unlikely that non-ulcer dyspepsia and nonerosive gastroesophageal reflux disease is due to or aggravated by the service connected PTSD." The examiner then added that "personal habits such as diet and smoking behavior are the most likely contributors to the disorders in question." In light of the reported findings, the Board concludes that the preponderance of the evidence is against the veteran's claim for service connection for a gastrointestinal disorder. There is no evidence that the veteran's gastrointestinal disorder had its onset in service or during the one-year presumptive period after service. Furthermore, the preponderance of the evidence is against a finding that his gastrointestinal disorder was caused or aggravated by his service-connected PTSD. The only medical evidence of a nexus between the veteran's gastrointestinal disorder and PTSD is Dr. J.F.'s January 1999 letter, wherein he states that the veteran has a nervous disorder consistent with post-traumatic stress disorder with resultant medical conditions known to be aggravated by stress, including dyspepsia secondary to peptic ulcer disease. As previously discussed, however, this opinion is of limited probative value due to the fact that there is no evidence that Dr. J.F. reviewed the veteran's claims file prior to rendering his opinion. See Swann, Black and Elkins, all supra. The Board places greater probative value on the VA examination reports of February 2002 and February 2003, which included a review of the veteran's claims file before determining that there was no relationship between the veteran's gastrointestinal disorders and PTSD. See Owens and Guerrieri, both supra. In particular, the February 2002 psychiatric examination report includes a medical opinion that there was simply not enough medical evidence to substantiate a definitive physiologic mechanism by which the veteran's PTSD had equivocally resulted in his physical symptoms. The examiner reasoned that, although a temporal relationship existed between the veteran's gastrointestinal disorders and PTSD, there were confounding factors, such as the veteran's use of alcohol and steroidal anti-inflammatory drugs that could have exacerbated his gastrointestinal condition. Still another VA examiner who reviewed the claims file in February 2003 determined that it was unlikely that the veteran's non-ulcer dyspepsia and nonerosive gastroesophageal reflux disease were due to or aggravated by PTSD. Instead, the veteran's diet and smoking habits were cited as the most likely factors. The Board also observes that several medical records mention the veteran's self-reported history in which he stated that his gastrointestinal disorder was either caused or aggravated by PTSD. However, no medical professional offered an independent medical opinion confirming the veteran's self- reported history. See Leshore v. Brown, 8 Vet. App. 406, 409 (1995) (holding that evidence which is simply unenhanced information recorded by a medical examiner does not constitute competent medical evidence). In conclusion, the Board finds that the preponderance of the evidence is against the veteran's claim for service connection for a gastrointestinal disorder. Hence, there is not an approximate balance of positive and negative evidence to which the benefit-of-the-doubt standard applies. Despite lay statements by the veteran and several family members that his gastrointestinal disorder is related to either service or his service-connected PTSD, as laypersons without medical expertise or training, their statements alone are insufficient to prove the nexus element. See Grottveit and Espiritu, both supra. Accordingly, the appeal is denied. ORDER Service connection for hypertension is denied. Service connection for a gastrointestinal disorder is denied. REMAND The veteran also contends that he has a skin condition, including skin cancer, as a result of having been exposed to herbicides in service. The record shows that the veteran has been diagnosed with actinic keratosis. The Board requested in the December 2001 remand that the veteran's claims folder be submitted to a VA examiner for a nexus opinion as to whether it is at least as likely as not (50 percent likelihood or greater) that actinic keratosis or any other currently diagnosed skin condition may be medically related to possible herbicide exposure during the veteran's Vietnam service. It does not appear, however, that this was accomplished. A VA examiner reviewed the claims folder in February 2002 and concluded that the veteran had a diagnosis of actinic damage with a history of actinic keratosis. However, no opinion was provided concerning the likelihood that this condition was related to possible herbicide exposure during the veteran's Vietnam service. A VA examiner reviewed the claims folder again in December 2002, at which time she concluded that "actinic keratoses are found in patients who have never been exposed to Agent Orange (actinic keratoses are generally thought to be due to sun exposure). Therefore it is just as unlikely as not that the [veteran's] actinic keratoses are due to anything service related." Thus, the question posed in the Board's December 2001 remand remains unanswered. In Stegall v. West, 11 Vet. App. 268, 271 (1998), the Court held that "where . . . the remand orders of the Board . . . are not complied with, the Board itself errs in failing to insure compliance." Therefore, the veteran's claims folder should be reviewed again by a VA examiner who should comment on whether it is at least as likely as not (50 percent likelihood or greater) that the veteran's skin condition may be medically related to possible herbicide exposure during his Vietnam service. If a favorable opinion is provided, the RO should attempt to verify whether the veteran was exposed to Agent Orange during his service in Vietnam. Accordingly, the case is hereby remanded to the RO for the following actions: 1. The veteran's claims folder should be reviewed by the same examining physician who conducted the VA skin examination in December 2002, if available. If that physician is unavailable, the case should be referred to another suitably qualified physician. The examiner should provide an opinion as to whether it is at least as likely as not (50 percent likelihood or greater) that actinic keratosis or any other currently diagnosed skin disorder is medically related to possible herbicide exposure during the veteran's Vietnam service. Arrangements should be made to physically examine the veteran if deemed necessary by the reviewing doctor. In such case, all necessary tests and studies should be accomplished. To the extent possible, the examiner should explain the medical reasoning for the nexus opinion, whether on the basis of a file review or with benefit of physical examination. 2. If a favorable nexus opinion is received linking the veteran's actinic keratoses or any other diagnosed skin disorder to herbicide exposure in 1970 or 1971, the RO should prepare a summary of the inclusive dates the veteran was in Vietnam and the assigned unit(s). This summary and all supporting unit documentation regarding the veteran's service in Vietnam should be sent to USASCRUR at 7798 Cissna Road, Springfield, Virginia 22150. The USASCRUR should be requested to verify to the extent possible whether the veteran was exposed to Agent Orange during his service in Vietnam. 3. The RO should then review the examination report to ensure that it is in complete compliance with this remand. Any further action to comply with the notice and duty to assist provisions of the Veterans Claims Assistance Act of 2000, Pub. L. No. 106-475, 114 Stat. 2096 (2000) (the VCAA) [codified as amended at 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002)], which is deemed necessary should be accomplished. 4. If the benefit sought on appeal is not granted, the veteran and his representative should be furnished a supplemental statement of the case, and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The Board does not intimate any opinion as to the merits of the case, either favorable or unfavorable, at this time. The veteran is free to submit any additional evidence he desires to have considered in connection with his current appeal. No action is required of the appellant unless or until he is notified. This claim must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. ____________________________________________ CHARLES E. HOGEBOOM Veterans Law Judge, Board of Veterans' Appeals IMPORTANT NOTICE: We have attached a VA Form 4597 that tells you what steps you can take if you disagree with our decision. We are in the process of updating the form to reflect changes in the law effective on December 27, 2001. See the Veterans Education and Benefits Expansion Act of 2001, Pub. L. No. 107-103, 115 Stat. 976 (2001). In the meanwhile, please note these important corrections to the advice in the form: ? These changes apply to the section entitled "Appeal to the United States Court of Appeals for Veterans Claims." (1) A "Notice of Disagreement filed on or after November 18, 1988" is no longer required to appeal to the Court. (2) You are no longer required to file a copy of your Notice of Appeal with VA's General Counsel. ? In the section entitled "Representation before VA," filing a "Notice of Disagreement with respect to the claim on or after November 18, 1988" is no longer a condition for an attorney-at-law or a VA accredited agent to charge you a fee for representing you.