Citation Nr: 22064353 Decision Date: 11/17/22 Archive Date: 11/17/22 DOCKET NO. 12-27 495A DATE: November 17, 2022 ORDER Entitlement to service connection for gastroesophageal reflux disease (GERD) (also claimed as acid reflux) is denied. Entitlement to service connection for obstructive sleep apnea (OSA) is denied. Entitlement to service connection for a bilateral foot disability is denied. Entitlement to service connection for a lumbar spine disability is denied. REMANDED Entitlement to service connection for a skin rash is remanded. FINDINGS OF FACT 1. The Veteran's GERD is not related to service and was not caused or aggravated by his service-connected persistent depressive disorder (claimed as posttraumatic stress disorder (PTSD)). 2. The Veteran's OSA is not related to service and was not caused or aggravated by his service-connected persistent depressive disorder (claimed as PTSD). 3. The Veteran's bilateral foot disability is not related to service and was not caused or aggravated by his service-connected right foot fourth metatarsal fracture. 4. The Veteran's lumbar spine disability is not related to service and was not caused or aggravated by his service-connected right foot fourth metatarsal fracture, to include the position of his right foot as a result of his right foot fourth metatarsal fracture. CONCLUSIONS OF LAW 1. The criteria for service connection for GERD, to include as secondary to persistent depressive disorder, have not been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 2. The criteria for service connection for OSA, to include as secondary to PTSD have not been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 3. The criteria for service connection for a bilateral foot disability, to include as secondary to the service connected right foot fourth metatarsal fracture, have not been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 4. The criteria for service connection for a lumbar spine disability, to include as secondary to the service connected right foot fourth metatarsal fracture, have not been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1968 to August 1969. The issues of entitlement to service connection for GERD, OSA, a lumbar spine disability, and a skin rash disability come to the Board of Veterans' Appeals (Board) on appeal from an April 2016 rating decision issued by the Regional Office (RO) of the Department of Veterans Affairs (VA). The issue of entitlement to service connection for bilateral foot disabilities comes to the Board on appeal from an October 2010 rating decision issued by the RO. The issue was previously before the Board in March 2017, February 2018, and July 2019. In a July 2019 Board decision, the claim was denied. The Veteran appealed the Board's July 2019 denial to the United States Court of Appeals for Veterans Claims (Court). In May 2020 the Court granted a joint motion for remand setting aside the Board's July 2019 decision and remanding the issue for further proceedings. The case returned to the Board and was remanded for further development in October 2020, May 2021, and February 2022. Service Connection In general, service connection may be granted for a disability or injury incurred in or aggravated by active military service. See 38 U.S.C. § 1131; 38 C.F.R. § 3.303. To prevail on a direct service connection claim, there must be competent evidence of (1) a current disability, (2) an in-service incurrence or aggravation of a disease or injury, and (3) a nexus between the in-service disease or injury and the current disability. See Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Service connection may also be established by credible lay evidence and medical evidence provided by the Veteran or otherwise. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303 (2018). Service connection may also be found on a secondary basis where the following criteria is met: (1) a current disability that is not already service-connected; (2) at least one service-connected disability; and (3) evidence that the non-service-connected current disability is either proximately due to or as the result of a service-connected disability; or, aggravated by a service-connected disability. See 38 C.F.R. § 3.310 (2018); see also El-Amin v. Shinseki, 26 Vet. App. 136 (2013); Allen v. Brown, 7 Vet. App. 439 (1995). In order to establish secondary service connection, the evidence must demonstrate an etiological relationship between (1) a service-connected disability or disabilities and (2) the condition said to be proximately due to the service-connected disability or disabilities. See Buckley v. West, 12 Vet. App. 76, 84 (1998); see also Wallin v. West, 11 Vet. App. 509, 512 (1998). In addition, secondary service connection may also be found in certain instances when a service-connected disability aggravates another condition. See Allen v. Brown, 7 Vet. App. 439 (1995); 38 C.F.R. § 3.310(b). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. See Alemany v. Brown, 9 Vet. App. 518 (1996). The Board has thoroughly reviewed the record in conjunction with this case. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all the evidence of record submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record but does not have to discuss each piece of evidence). Rather, the Board's analysis below will focus specifically on what the evidence shows, or fails to show, on the claims. See Timberlake v. Gober, 14 Vet. App. 122, 129 (2000) (noting that the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive and provide the reasons for its rejection of any material evidence favorable to the claimant). The Board is charged with the duty to assess the credibility and weight given to evidence. See Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). In Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C. § 7104(a) (West 2002). Further, the United States Court of Appeals for Veterans Claims (Court) has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. See Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). Service connection for GERD The Veteran asserts that his GERD is secondary to his service-connected persistent depressive disorder. Specifically, he claims that stress from his psychological disorder can exacerbate or increase acid and references a medical article to support this connection. See February 2020 correspondence. The Veteran does not contend, and the evidence does not suggest, that his GERD is directly related to active service. Therefore, direct service connection is not warranted. The Veteran satisfies the first requirement of secondary service connection, as a March 2010 VA treatment note indicates he is diagnosed with GERD. However, the Veteran does not meet the nexus requirement of secondary service connection. Here, an August 2022 VA examiner opined that GERD is less likely than not proximately due to or aggravated by the service-connected persistent depressive disorder. In rendering the opinion, the examiner cited the article, Posttraumatic Stress Disorder and Gastrointestinal Disorders in the Danis Population, which found that, "In a cross-sectional study of patients receiving health care from the US Department of Veterans Affairs, PTSD was not associated with overall GI diagnoses," and, "A larger prospective study of disaster survivors in the Netherlands found no association between self-reported PTSD and de-novo medically documented combined GI disorders." The examiner noted the limitations of the study including that it does not differentiate between the various GI disorders making its application to GERD unclear. The examiner also cited to the article, Association Between Anxiety and Depression and Gastroesophageal Reflux Disease: Results From a Large Cross-sectional Study, which suggests GERD might be a "risk factor" for psychological conditions, such as depression. The examiner stated that while the cited article mentions anxiety/depression as risk factors for GERD, the article also mentions "older age and excessive body mass index" as risk factors for GERD. These two factors were present at the time of the Veteran's diagnosis. Additionally, eating habits, particularly eating acidic foods and large meals close to bedtime, are also listed risk factors for GERD. The examiner concluded that given the presence of more than one known non-service connected risk factor at the time of diagnosis through present, it is less likely than not GERD is proximately due to or the result of the Veteran's service-connected persistent depressive disorder. For the same reasons, the examiner opined that it is less likely than not that GERD is aggravated by the Veteran's service-connected persistent depressive disorder. The examiner acknowledged the Veteran's assertion that stress related to his depressive disorder exacerbates his GERD, however, the examiner noted that there is no documented evidence that the Veteran's GERD condition has progressed from his initial diagnosis in 2010, and any definitive progression cannot be attributed solely to his service-connected persistent depressive disorder condition. The Board also considered the Veteran's statements about his GERD condition. While the Veteran is competent to observe his various symptoms, he does not have the training or expertise to provide a competent opinion as to the cause of his condition, to include whether it was caused or aggravated by his service-connected persistent depressive disorder disability. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Board provides the August 2022 VA medical opinion substantial probative weight because it is based on consideration of the Veteran's contentions, a thorough review of the Veteran's cited medical journals, the examiner's own medical literature review, and an adequate, thorough rationale. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). As such, the objective medical findings and opinions provided by the August 2022 VA examiner weigh persuasively against the claim for service connection on a secondary basis. For the above reasons, the evidence for and against the Veteran's claim for service connection for GERD is neither evenly balanced, nor approximately so. Rather, the evidence persuasively weighs against service connection and, therefore, the benefit of the doubt doctrine is not for application as to this claim. Lynch v. McDonough, 999 F.3d 1391 (Fed. Cir. 2021). Accordingly, service connection for GERD, on a direct or secondary basis, is not warranted. Service connection for OSA The Veteran seeks service connection for OSA. He reported breathing problems at night since 1970, which is in close temporal proximity to his discharge from service. See March 2010 VA treatment records. Additionally, he asserts that his OSA may be related to his service-connected depressive disorder and cited medical articles discussing a possible relationship between sleep apnea and posttraumatic stress disorder (PTSD). Service treatment records are negative for complaints, treatment, or diagnosis for OSA. Post-service, an April 2010 VA treatment record indicates the Veteran had a sleep study done at a private facility in 2007 and was diagnosed with mild OSA. A September 2010 VA examination for posttraumatic stress disorder indicated improved sleeping with the aid of a continuous positive airway pressure (CPAP) machine. The report indicates that prior to the OSA diagnosis, the Veteran had intermittent insomnia, thrashing about in sleep, waking up, and stopping breathing. An August 2022 VA examiner opined that the Veteran's OSA was less likely than not incurred in or caused by active service. The examiner explained that there was no documented evidence demonstrating OSA was present prior to the Veteran's diagnosis in 2010. While the Veteran reported symptoms related to OSA since approximately 1970, without completion of a sleep study, a diagnosis of OSA would not have been made at that time. The examiner cited to multiple sources, which stated that (1) OSA is characterized by recurrent obstruction of the pharyngeal airway during sleep, with resultant hypoxia and sleep fragmentation and, (2) loud snoring, gasping during sleep, obesity, and enlarged neck circumference are predictive clinical features. The examiner concluded because the Veteran was reportedly not overweight during service, and there were no other reported or documented associated anatomical abnormalities to contribute to OSA, the condition is less likely than not incurred in or related to active service. Additionally, the August 2022 VA examiner opined that the Veteran's OSA is less likely than not proximately due to or aggravated by the Veteran's service connected psychiatric disability. The examiner explained that OSA is characterized by recurrent obstruction of the pharyngeal airway during sleep with resultant hypoxia and sleep fragmentation. In contrast, PTSD is related to a disruption in sleep with frequent awakenings due to psychological symptoms, such as nightmares. The examiner also reviewed the articles presented by the Veteran but found that they did not present information that enhanced the cause for a causal relationship between the Veteran's OSA and PTSD. Regarding the article titled, The PTSD-OSA Paradox: They Are Commonly Associated and They Worsen Outcomes, but Treatment Nonadherence Is Common and the Therapeutic Effect Limited. What Are Clinicians To Do, the examiner stated that the authors presented links between PTSD and sleep-disordered breathing by evaluating a study which revealed PTSD symptoms, depression, and anxiety were improved, but persistent, in the setting of appropriately treated OSA. The authors also noted treatment of both OSA, and PTSD were made more challenging when both conditions were present, but there was no clear assertion that PTSD caused or aggravated OSA beyond its natural progression. In the article titled, The Connection Between Sleep Apnea and PTSD, the authors did not definitively determine PTSD causes sleep apnea but instead, stated the more severe an individual's PTSD, the more severe their OSA. The examiner found the Veteran's OSA was stable with no documented evidence suggesting progression. The examiner cited an article title, Progression of Snoring and Obstructive Sleep Apnoea: The Role of Increasing Weight and Time and noted that increased weight is a known predictive clinical feature of OSA, and increased weight was present at the time of the Veteran's diagnosis. Regarding direct service connection, the Board finds Veteran's service treatment records fail to show any complaints, diagnosis, or treatment for OSA or other sleep disturbances. His separation examination shows no sleep complaints or unaddressed health concerns. The Veteran was not diagnosed with sleep apnea until 2007, nearly 38 years after separation and at that time, only mild OSA was observed. Additionally, the August 2022 VA examiner provided an opinion for direct service connection. Specifically, the examiner concluded that because the Veteran had no reported or documented associated anatomical abnormalities to contribute to OSA during active service, the condition is less likely than not incurred in or related to active service. The examiner also discussed the Veteran's reported symptoms since approximately 1970 however, determined that without completion of a sleep study, a diagnosis of OSA would not have been made at that time. As such, the probative evidence does not indicate that sleep apnea began during service or was otherwise related to service. Regarding secondary service connection, the August 2022 VA examiner found that the Veteran's OSA was not caused or aggravated by the Veteran's PTSD. The examiner discussed the etiological difference between OSA and PTSD and noted the Veteran's increased weight and its association with OSA. The Board affords the August 2022 VA medical opinion substantial probative weight because it is based on consideration of the Veteran's contentions, a thorough review of the Veteran's cited medical journals, the examiner's own medical literature review, and an adequate and thorough rationale. For the above reasons, the Board finds the evidence for and against the Veteran's claim for service connection for OSA is neither evenly balanced, nor approximately so. Rather, probative evidence weighs persuasively against a finding that the Veteran's OSA began during service, is due to service, or was caused or aggravated by his service-connected persistent depressive disorder. Therefore, the benefit of the doubt doctrine is not for application and the claim is denied. Lynch v. McDonough, 999 F.3d 1391 (Fed. Cir. 2021). Service connection for bilateral foot disability The Veteran asserts that his bilateral foot disability, diagnosed as plantar fasciitis is related to active service. The Veteran reported that he fractured all of his toes during basic training and that his boots were modified such that his feet were not allowed to move. The Veteran's mother stated that she visited him one weekend during service, and he could hardly walk. See February 2012 statement. The Veteran claimed that he did not report his foot pain upon discharge or seek treatment immediately after service because he was raised to "tough it out." See February 2021 correspondence. Service treatment records document the Veteran's complaints of swelling and pain in his right foot. A February 1968 x-ray revealed a healing stress fracture of the 4th metatarsal. Post service, a March 2010 VA treatment report indicates complaints of occasional burning in his feet. An October 2016 private treatment report indicated intermittent plantar fasciitis (which, at that time, was asymptomatic) and pronation of mid foot upon stance. Upon examination, the Veteran reported that his chiropractor was concerned about the Veteran's foot position when he walked and stood, and alluded to the fact that the condition may contribute to back pain. The examiner prescribed customized prefabricated shoe inserts and more supportive shoes however, the examiner also stated that the shoes and inserts may not improve the Veteran's back pain since the Veteran's back pain may have been due to lifting and moving washers and dryers at his work. The Veteran was afforded VA examinations with corresponding medical opinions in June 2017, March 2019, January 2021, and August 2021. However, prior Board decisions determined that the medical opinions were inadequate for adjudication. Consequently, the Veteran was afforded another VA examination in August 2022. The examiner opined that it was less likely than not that the Veteran's plantar fasciitis was related to service. The examiner was unable to establish a direct connection between the lay evidence (i.e., Veteran's statements and Veteran's mother's statements) and the Veteran's current foot pain because the Veteran reported pain with increased ambulation during the day that radiates from his toes. The examiner noted no clear diagnosis upon examination; however, the examiner did not refute the October 2016 bilateral plantar fasciitis diagnosis. On examination, the plantar surface of the Veteran's feet was soft and did not indicate underlying thickened plantar fascia, which the examiner explained that underlying thickened plantar fascia would be expected in the setting of a chronic-ongoing significantly disabling plantar fasciitis condition present for over 50 years due to chronic inflammation of the involved plantar fascia. The examiner stated that he could not state with certainty that the Veteran's condition was never present during service, however "confidently stated" the plantar fasciitis condition was less likely than not present to a significantly disabling degree during service and/or after service. The examiner further stated that it would be difficult, without resorting to speculation, to state that a chronically-disabling bilateral foot condition was present when the Veteran's 50 year work history and available records provide evidence to the contrary. The August 2022 examiner opined that the Veteran's bilateral foot disability is less likely than not proximately due to, the result of, or aggravated by the Veteran's service-connected right foot fourth metatarsal fracture. In rendering the opinion, the examiner stated that the Veteran's toes did not reveal any abnormal findings to suggest a history of prior significant fracture. Additionally, the 2017 bilateral foot x-rays did not reveal any significant abnormalities at either foot, which suggests healing of the previous fourth metatarsal fracture without any new fractures. The examiner concluded that there is no nexus to suggest the previous fourth metatarsal fracture contributed to the development of the Veteran's plantar fascitis. The Board assigns the August 2022 opinions significant probative value because it is based on consideration of the Veteran's contentions, a thorough review of the Veteran's record, and an adequate and thorough rationale. While the examiner could not state with certainty that the Veteran's bilateral foot condition was never present during service, the examiner did state that if plantar fasciitis was present during service, the condition was less likely than not present to a significantly disabling degree. Indeed, the examiner need not show a relationship to a degree of medical certainty; rather, it must only be at least as likely as not (e.g., a state of relative equipoise). See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The examiner's opinion is substantially probative evidence weighing against direct service connection. Therefore, the claim is denied on a direct basis. Likewise, the examiner opined that the Veteran's bilateral foot condition is not proximately due to, the result of, or was aggravated by the Veteran's service-connected right foot fourth metatarsal fracture. The examiner based the opinion on the medical evidence, to include associated x-rays, the Veteran's lay statements, and physical examination. As such, the Board finds the persuasive, substantially probative evidence does not warrant service connection on a secondary basis. For the above reasons, the Board find the evidence for and against the Veteran's claim for service connection for bilateral foot conditions is neither evenly balanced, nor approximately so. Rather, the probative evidence weighs persuasively against a finding that the Veteran's bilateral foot conditions began during service, are due to service, or were caused or aggravated by his service-connected right foot fourth metatarsal fracture. Thus, the benefit of the doubt doctrine is not for application and the claim is denied. Lynch v. McDonough, 999 F.3d 1391 (Fed. Cir. 2021). Service connection for a lumbar spine disability The Veteran maintains that his chiropractor told him that his foot position may be causing his back pain. See October 2016 private treatment records. Additionally, the Veteran's representative claims that the Veteran has repeatedly contended that his back condition began in service. The Veteran satisfies the first requirement of direct service connection and secondary service connection, as a February 2016 private treatment report shows a diagnosis of lumbar segmental dysfunction with associated lumbalgia and myospasm complicated by a right pelvic tilt. Service treatment records are negative for complaints, treatment, or a diagnosis of a lumbar spine disability. Post-service, the record shows that the Veteran complained of back pain on several occasions, as early as March 2010. The Veteran underwent VA examination in August 2022. He reported hurting his back during active service in Vietnam and that back pain has since continued. The examiner opined that it is less likely than not that the Veteran's back condition is related to active service. The examiner acknowledged the Veteran's lay statements but explained that if a significantly disabling condition were present, it would be likely that the Veteran would have sought care in some form. The examiner reviewed the 2016 imaging study from a private chiropractor, noting that according to the chiropractor, it appeared that no significant degenerative changes were identified at the lumbar spine. The examiner stated that a lack of imaging over time suggests the claimed back condition has not been significantly progressive to a degree warranting repeat imagining. Additionally, the examiner noted that the podiatrist who evaluated the Veteran in 2016 asserted that the Veteran's low back condition was likely due to his strenuous work history over the years. The examiner could not deny with certainty that some degree of low back pain might have been present during and/or immediately after service; however, the examiner explained that if low back pain was present, it did not prevent the Veteran from maintaining consistent reemployment for 50 years after service. The examiner maintained that it would be very difficult, without resorting to speculation, to state that a chronically-disabling condition was present when the Veteran's reported work history and available records provide evidence to the contrary. The examiner opined that it was less likely than not that the Veteran's back condition was caused or aggravated by the Veteran's service-connected right foot fourth metatarsal fracture. The examiner noted a previous VA examiner's report that "unless the injury resulted in a major muscle or nerve damage causing partial or complete paralysis or shortening of the injured limb resulting in length discrepancy of more than 5 cm so that the individuals gait pattern has been altered to the extent that clinically there is an obvious Trendelenburg gait." The examiner noted that upon examination, the Veteran exhibited no leg length discrepancy of more than 5 cm. The examiner also noted the 2017 bilateral foot x-ray depicted no significant abnormalities in either foot and opined that there was no nexus to suggest the previous fourth metatarsal fracture contributed to the development of the Veteran's lumbar spine disability. Lastly, the examiner opined that it was less likely than not that the Veteran's back condition was caused or aggravated by the Veteran's right foot position. The examiner explained that the examination did not reveal any significant positional abnormalities with the right foot position compared to the left foot position. Additionally, the lumbar spine disability is a separate and distinct condition from the diagnosed pathology at the right foot in this case and, as such, there is no established nexus to suggest a causal relationship. The Board affords the August 2022 opinions substantial probative weight as they are based on consideration of the Veteran's contentions, a thorough review of the Veteran's record, and an adequate and thorough rationale. Given the competent evidence, the examiner did not find a relationship between the Veteran's back disability and active service, or the Veteran's service-connected right foot fourth metatarsal fracture and resulting right foot position. The Board finds the evidence for and against the Veteran's claim for service connection for back condition is neither evenly balanced, nor approximately so. Rather, the probative evidence weighs persuasively against a finding that the Veteran's back condition began during service, is due to service, or was caused or aggravated by his service-connected right foot fourth metatarsal fracture. For the above reasons, the benefit of the doubt doctrine is not for application and the claim is denied. Lynch v. McDonough, 999 F.3d 1391 (Fed. Cir. 2021). REASONS FOR REMAND Service connection for a skin rash Further development is necessary before this claim can be adjudicated. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. The AOJ has not complied with the Board's previous remand directives. As such, another remand is required. Stegall v. West, 11 Vet. App. 268, 271 (1998). In February 2022, the Board remanded this issue to obtain a VA medical addendum opinion to determine the etiology of the Veteran's skin rash, as one had not been previously provided. A June 2022 VA examiner opined that the Veteran's skin rash was less likely than not incurred in or caused by active service. As rationale, the examiner indicated there were no diagnoses, treatment, or evaluations for dermatitis or any skin condition during active service. The examiner also noted that the medical literature indicating an association between dermatitis and Agent Orange exposure are inconclusive. The Board finds the June 2022 VA opinion to be inadequate. Specifically, the examiner appeared to rely on the absence of a diagnosis in service and/or the lack of presumptive service connection eligibility in reaching the conclusion. Moreover, the Board notes treatise evidence must "not simply provide speculative generic statements not relevant to the veteran's claim." See Wallin v. West, 11 Vet. App. 509, 514 (1998); see also 38 C.F.R. § 3.159 (a)(1) (competent medical evidence may include statements contained in authoritative writings such as medical and scientific articles and research reports and analyses). Indeed, the examiner did not provide an opinion as to whether, in this Veteran's case, a nexus existed. Accordingly, the Board finds that another addendum opinion is required. The matter is REMANDED for the following action: Obtain an addendum opinion from an appropriate VA examiner to determine the etiology of the Veteran's skin rash. The examiner must review the claims file and provide a response to the following: Is the Veteran's skin rash at least as likely as not related to active service (likelihood is at least approximately balanced or nearly equal, if not higher), to include in-service exposure to herbicide agents? The examiner is advised that a negative opinion cannot be based solely on the fact that the rash is not on the list of diseases that are presumptively associated with exposure to herbicide agents. SHAUN S. SPERANZA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. R. Bobb, 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.