Citation Nr: 1531247 Decision Date: 07/22/15 Archive Date: 08/05/15 DOCKET NO. 14-05 006 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Louisville, Kentucky THE ISSUES 1. Whether new and material evidence has been received to reopen a claim for service connection for benign carcinoid of the colon, claimed as blood in stool, colon polyps, hemorrhoids, and gastrointestinal bleeding, to include as due to exposure to contaminated water at Camp Lejeune. 2. Entitlement to service connection for a benign carcinoid of the colon, claimed as blood in stool, colon polyps, hemorrhoids, and gastrointestinal bleeding (hereafter "colon condition"), to include as due to exposure to contaminated water at Camp Lejeune. 3. Entitlement to service connection for inflammation of the colon, including diverticulosis, diverticulitis, and ulcerative colitis, (hereafter "inflammation of the colon") to include as due to exposure to contaminated water at Camp Lejeune. 4. Entitlement to service connection for an acquired psychiatric disorder, to include adjustment disorder with anxiety and depression, to include as due to exposure to contaminated water at Camp Lejeune. REPRESENTATION Veteran represented by: Christopher Loiacono ATTORNEY FOR THE BOARD D. Martz Ames, Counsel INTRODUCTION The Veteran had active service from August 1978 to November 1982. This matter comes before the Board of Veterans' Appeals (Board) on appeal from December 2011 and February 2013 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Louisville, Kentucky. The December 2011 rating decision denied service connection for a carcinoid tumor, diverticulosis, and adjustment disorder with anxiety and depression. The February 2013 rating decision confirmed and continued the previous denials of service connection for a carcinoid tumor and diverticulosis. As a preliminary matter, with regard to the Veteran's colon condition claim, the RO denied service connection for colon polyps, hemorrhoids, blood in stool, and GI bleeding in June 2005. During the course of the appeal of that issue, the Veteran asserted that these conditions were caused by exposure to contaminated water at Camp Lejeune. He did not perfect his appeal of the June 2005 rating decision. He filed a claim for service connection for a benign carcinoid tumor of the colon in January 2011. Claims based upon distinctly diagnosed diseases or injuries cannot be considered the same for purposes of addressing the reopening of a previously denied claim. Boggs v. Peake, 520 F.3d 1330, 1337 (Fed. Cir. 2008). This is so even if the diseases or injuries involve overlapping symptomatology. Id. In the Veteran's case, although the claimed disabilities have been previously characterized broadly as blood in stool and GI bleeding and narrowly as colon polyps and hemorrhoids, the present claim for a benign carcinoid tumor is identical to the claims previously denied in June 2005. The Veteran contends that the claimed disabilities affect his colon in the same manner as he previously contended and he contends that the disabilities arise from the same injury or event during service, specifically, exposure to contaminated water at Camp Lejeune. In light of these facts, the Board finds that the Veteran is not seeking service connection for a differently diagnosed disease or injury. Therefore, new and material evidence is required to reopen this claim. See Velez v. Shinseki, 23 Vet. App. 199 (2009). Additionally, the Board notes that the AOJ has referred to the Veteran's inflammation of the colon as both diverticulitis and diverticulosis. Further, he has been diagnosed with ulcerative colitis, which is also a condition involving inflammation of the colon. In this case, the Veteran cannot be reasonably expected to understand that he has been diagnosed with three separate inflammatory conditions. Therefore, the Board has rephrased the issue as listed above. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). Similarly, the Board has also rephrased the Veteran's claim for service connection for adjustment disorder with anxiety and depression as one claim for entitlement to service connection for an acquired psychiatric disorder. Id. In January 2015, the Veteran's representative submitted additional evidence after he submitted a substantive appeal, accompanied by a waiver of Agency of Original Jurisdiction (AOJ) consideration. 38 C.F.R. §§ 20.800, 20.1304(c) (2014). Additionally, the Veteran filed his substantive appeals in January 2014 and May 2014. The Board has considered these records prior to Agency of Jurisdiction (AOJ) review. See Honoring America's Veterans and Caring for Camp Lejeune Families Act of 2012, Public Law No. 112-154, 126 Stat. 1165 (amending 38 U.S.C. § 7105 to provide for an automatic waiver of initial AOJ review of evidence submitted to the AOJ or to the Board at the time of or subsequent to the submission of a substantive appeal filed on or after February 2, 2013, unless the claimant or claimant's representative requests in writing that the AOJ initially review such evidence). The Veteran participated in an informal conference with a Decision Review Officer (DRO) in December 2013. In his substantive appeal, the Veteran requested a hearing before a member of the Board. One was scheduled in October 2014, but in September 2014, the Veteran canceled his request for a hearing. Therefore, the Board considers the hearing request cancelled, and will proceed to adjudicate the case based on the evidence of record. See 38 C.F.R. § 20.704 (2014). The issues of entitlement to service connection for inflammation of the colon and an acquired psychiatric disability are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDINGS OF FACT 1. Evidence associated with the claims file since June 2005 is new and raises a reasonable possibility of substantiating the claim of entitlement to service connection for a colon condition. 2. The preponderance of the evidence reflects that the Veteran does not have a colon condition due to any incident of his active duty service, including his in-service exposure to contaminated water at Camp Lejeune. CONCLUSIONS OF LAW 1. Evidence received since the June 2005 rating decision that denied service connection for a colon condition, which was the last final denial with respect to this issue, is new and material; the claim is reopened. 38 U.S.C.A. §§ 5108, 7105 (West 2014); 38 C.F.R. §§ 3.104, 3.156, 3.160(d), 20.200, 20.302, 20.1103 (2014). 2. The Veteran's colon condition (claimed as blood in stool, colon polyps, hemorrhoids, and gastrointestinal bleeding) was not incurred or aggravated in service. 38 U.S.C.A. §§ 1101, 1110, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist VA has met all statutory and regulatory notice and duty to assist provisions set forth in the Veterans Claims Assistance Act of 2000 (VCAA). 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); Honoring America's Veterans and Caring for Camp Lejeune Families Act of 2012, Pub. L. No. 112-154, §§ 504, 505, 126 Stat. 1165, 1191-93; 38 C.F.R. §§ 3.102, 3.159, 3.326(a) (2014). Prior to initial adjudication, a letter dated in August 2011 satisfied the duty to notify provisions with regard to the Veteran's service connection claim. With regard to the duty to assist, the Veteran's service treatment records, VA medical treatment records, service personnel records, and a private medical opinion have been obtained. A VA examination adequate for adjudication purposes was provided to the Veteran in connection with his claim in November 2011. See McLendon v. Nicholson, 20 Vet. App. 79 (2006); Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The examiner provided a rationale for the opinion. Id. at 312; see also Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Shinseki v. Sanders, 556 U. S. 396, 129 S. Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination). Further, the purpose behind the notice requirement has been satisfied because the Veteran has been afforded a meaningful opportunity to participate effectively in the processing of his claims, to include the opportunity to present pertinent evidence. II. Petition to Reopen a Previously Denied Claim In June 2005, the RO denied the Veteran's claim for service connection for a colon condition on the basis that there was no nexus between the claimed condition and service. He filed a timely Notice of Disagreement (NOD) in July 2005. In October 2005, the RO denied his claim in a Statement of the Case (SOC). In November 2005, he submitted a VA Form 21-4138 (Statement in Support of Claim) stating that he disagreed with the October 2005 SOC. He asserted that the water at Camp Lejeune was contaminated and requested a "...complete examination of the public records from this Marine base before denying benefits...." He subsequently submitted additional evidence. In May 2006, the RO issued a Supplemental Statement of the Case (SSOC) denying his claim. In the notice letter accompanying the SSOC, the Veteran was informed that it was "...in further reference to the appeal you have filed from our decision on your claim for benefits. It is not a decision on the appeal you have initiated. It is a [SSOC] which contains changes or additions to the original [SOC] sent to you on October 3, 2005." The Veteran was informed that he need to submit a substantive appeal on a VA Form 9 or its equivalent to perfect his appeal to the Board within 60 days of the SSOC or request an extension of the 60 day time limit. If the Veteran did not respond within the 60 days with either a substantive appeal or a request for an extension, the RO informed him, "...we will assume you do not wish to complete your appeal and we will close our records." The RO did not issue any further communications to the Veteran with regard to this issue for multiple years. The RO did not treat his claim as if it were in appellate status. The next communication from the Veteran was in 2011. Therefore, he did not perfect his appeal to the Board. Accordingly, the June 2005 rating decision became final. 38 U.S.C.A. § 7105 (West 2014); 38 C.F.R. §§ 3.104, 3.160(d), 20.200, 20.302, 20.1103 (2014). The Board has no jurisdiction to consider a claim based on the same factual basis as a previously disallowed claim. 38 U.S.C.A. § 7104(b) (West 2014); King v. Shinseki, 23 Vet. App. 464 (2010); see DiCarlo v. Nicholson, 20 Vet. App. 52, 55 (2006) (holding that res judicata generally applies to VA decisions). However, the finality of a previously disallowed claim can be overcome by the submission of new and material evidence. See 38 U.S.C.A. § 5108 (West 2014). New evidence means existing evidence not previously submitted to agency decisionmakers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a) (2014). In determining whether evidence is new and material for purposes of deciding whether a claim should be reopened, "the credibility of the evidence is to be presumed." Savage v. Gober, 10 Vet. App. 488(1997); Justus v. Principi, 3 Vet. App. 510, 513 (1992). Only in cases in which the newly submitted evidence is "inherently false or untrue" does the presumption of credibility not apply. Duran v. Brown, 7 Vet. App. 216, 220 (1994). After the June 2005 final denial, the Veteran asserted the theory that exposure to contaminated water at Camp Lejeune caused his colon condition. In Boggs v. Peake, it was determined that although "a new theory of causation for the same disease or injury that was the subject of a previously denied claim cannot be the basis of a new claim under [38 U.S.C.A. § 7104(b) (West 2002)]," any evidence supporting the veteran's new theory of causation constitutes new and material evidence, and the claim must then be reopened under 38 U.S.C.A. § 5108. 520 F.3d 1330, 1336-37 (Fed. Cir. 2008). The Veteran submitted treatise evidence in support of his theory. Reopening of the Veteran's claim for service connection for a colon condition based on the receipt of new and material evidence is therefore warranted. Shade v. Shinseki, 24 Vet. App. 110, 121 (2011)(holding that the phrase "raises a reasonable possibility of substantiating the claim" in applicable regulation as "enabling rather than precluding reopening"). In December 2011, the RO denied the Veteran's claim for service connection for a colon condition on its merits, as opposed to adjudicating it as a petition to reopen a previously denied claim. Therefore, the Board may proceed to address the claim on its merits. See Bernard v. Brown, 4 Vet. App. 384, 393 (1993). III. Service Connection for a Colon Condition Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. § 1110 (West 2014); 38 C.F.R. § 3.303 (2014). If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity for certain diseases. 38 C.F.R. §§ 3.303(a),(b), 3.309(a) (2014); see also Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2014). In order to establish service connection for the claimed disorder, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical, or in certain circumstances, lay evidence of a nexus between the claimed in-service disease or injury and the current disability. See 38 C.F.R. § 3.303 (2014); see also Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); Hickson v. West, 12 Vet. App. 247, 253 (1999); Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). The requirement of a current disability is "satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim." See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). The standard is whether a disability exists at the time the claim was filed. See Romanowsky v. Shinseki, 26 Vet. App. 289, 293 (2013). The Veteran was diagnosed with a carcinoid tumor in 2010. The first element of a service connection claim is satisfied. Shedden, 381 F.3d at 1166-67. VA has acknowledged that persons residing or working at the U.S. Marine Corps Base Camp Lejeune from August 1953 through December 1987 were potentially exposed to drinking water contaminated with volatile organic compounds (VOCs). See Veterans Benefits Administration (VBA) Fast Letter 11-03 (January 11, 2011). The Veteran served at Camp Lejeune during 1981 and 1982. Therefore, the Board finds that he was exposed to contaminated water at Camp Lejeune. The second element of a service connection claim is satisfied. Shedden, 381 F.3d at 1166-67. For background purposes, in the early 1980s, it was discovered that two on-base water-supply systems were contaminated with the VOCs trichloroethylene (TCE), a metal degreaser, and perchloroethylene (PCE), a dry cleaning agent. Benzene, vinyl chloride, and other VOCs were also found to be contaminating the water-supply systems. These water systems served housing, administrative, and recreational facilities, as well as the base hospital. The Agency for Toxic Substances and Disease Registry (ATSDR), a branch of the Federal Department of Health and Human Services, conducted a Public Health Assessment of Camp Lejeune in 1997, which did not determine whether base personnel experienced any long-term health care effects from consumption of the contaminated water. However, the assessment indicated that the drinking water contaminants created a past public health hazard. Additional studies have been conducted involving the National Academy of Sciences' National Research Council (NRC) and the ATSDR. Based on a congressional mandate, the Navy requested that the NRC undertake a study to assess the potential long-term health effects for individuals who served at Camp Lejeune during the period of water contamination. In the resulting report, Contaminated Water Supplies at Camp Lejeune, Assessing Potential Health Effects (June 2009), the NRC reviewed previous work done by the ATSDR, including computerized water flow modeling, and concluded that additional studies may not produce definitive results because of the difficulties inherent in attempting to reconstruct past events and determine the amount of exposure experienced by any given individual. To address potential long-term health effects, the NRC focused on diseases associated with TCE, PCE, and other VOCs. Based on analyses of scientific studies involving these chemicals, the NRC provided an assessment of the potential association between certain diseases and exposure to the chemical contaminants. The NRC analysis used categories of potential disease "health outcomes." The categories included: (1) sufficient evidence of a causal relationship; (2) sufficient evidence of an association; (3) limited/suggestive evidence of an association; (4) inadequate/insufficient evidence to determine whether an association exists; and (5) limited suggestive evidence of no association. The analysis found that no diseases fell into the categories of sufficient evidence of a causal relationship or sufficient evidence of an association with the chemical contaminants. However, 14 diseases were placed into the category of limited/suggestive evidence of an association. Colon polyps and benign carcinoid polyps are not among the 14 diseases. See VBA Training Letter 11-03 (Revised) (November 29, 2011), Appendix B. According to VBA Training Letter 11-03 (April 27, 2011), the ATSDR, in a 2010 letter to the Navy, indicated its belief that the NRC report minimized the potential long-term health effects of exposure to the water contamination. The letter stated the view that "there was undoubtedly a hazard associated with drinking the contaminated water at Camp Lejeune." The ATSDR noted that, although the NRC report found only limited/suggestive evidence for any diseases associated with the contaminated water, other scientific organizations considered the contaminants to be carcinogenic. For example, regarding TCE and PCE, the International Agency for Research on Cancer (IARC) classifies them as "probable human carcinogens" while the National Toxicology Program (NTP) refers to them as "reasonably anticipated to be a human carcinogen." Additionally, both IARC and NTP label benzene and vinyl chloride as "known human carcinogens." Although the ATSDR letter emphasizes the fact that the water contaminants themselves have been generally associated with potential carcinogenic health outcomes in humans, there is currently only speculation as to the extent of exposure and actual effects on the population at Camp Lejeune. However, the ATSDR indicated that its planned studies, making use of computerized water flow modeling and the epidemiological mortality and health survey, will provide a higher level of exposure predictability and definable health outcomes than are recognized as possible by the NRC. According to Training Letter 11-03, scientific organizations, including the NRC and the ATSDR, have determined that some evidence is available that suggests a possible association between development of certain diseases and exposure to the chemicals known to have contaminated the water at Camp Lejeune. To date, there are no definitive scientific studies that can provide conclusive evidence that an individual who served at Camp Lejeune during the period of water contamination developed a particular disease as a result of that service. Therefore, until scientific evidence shows otherwise, it will be assumed by VA that any veteran who served at Camp Lejeune was potentially exposed in some manner to the full range of chemicals known to have contaminated the water there between 1957 and 1987. Service connection for any disability claimed to have resulted from contaminated water exposure at Camp Lejeune requires sufficient medical evidence that the disability is related to that exposure. That medical evidence will generally come from a competent and qualified medical examiner who provides an opinion establishing a rational nexus or link between the claimed disability and the exposure. Some diseases have been scientifically associated to a greater or lesser extent with exposure to the chemical contaminants in the water at Camp Lejeune. However, that does not mean that service connection can presumptively be established for a Camp Lejeune veteran claiming one of these diseases. It is up to a competent medical authority, based on each veteran's individual case, to determine whether it is at least as likely as not that the claimed disease or disability has resulted from the contaminant exposure at Camp Lejeune. Sufficient medical evidence to establish the required nexus may come from a private physician or other competent private medical authority. The Veteran underwent a VA intestines examination in November 2011. The examiner noted that the Veteran had been diagnosed with intestinal neoplasm and benign carcinoid of the colon. At his examination, he reported bright right blood per rectum and thin, formed stools with rectal burning. The examiner noted that he had a history of benign polyps noted on colonoscopy in 2003 and that he was diagnosed with a benign carcinoid in his sigmoid colon in 2010. The examiner concluded that the Veteran's carcinoid of the colon was not caused by his in-service exposure to contaminated water at Camp Lejeune. The examiner explained that "[c]arcinoid tumors are derived from primitive stem cells...." The examiner noted that the etiology of carcinoid tumors is unknown, "...but genetic abnormalities are suspected." The Board finds the VA examiner's opinion and rationale to be probative evidence against the Veteran's claim. The Board notes that the August 2011 VA psychiatric examiner stated that the Veteran "...became ill, perhaps because of the water..." at Camp Lejeune. Medical opinions that are speculative, general, or inconclusive in nature do not provide a sufficient basis upon which to support a claim. Jones v. Shinseki, 23 Vet. App. 382, 389-90 (2010). Applicable regulations also provide that a finding of service connection may not be based on a resort to speculation or a remote possibility. See 38 C.F.R. § 3.102 (2014). Further, speculative language such as "perhaps" does not create an adequate nexus for the purposes of establishing service connection, as it does little more than suggest a possibility of a relationship. See Warren v. Brown, 6 Vet. App. 4, 6 (1993); Utendahl v. Derwinski, 1 Vet. App. 530, 531 (1991); Stegman v. Derwinski, 3 Vet. App. 228, 230 (1992); Obert v. Brown, 5 Vet. App. 30, 33 (1993). A medical opinion is speculative and of little probative value when it uses equivocal language such as "could" or "might." Hood v. Shinseki, 23 Vet. App. 295, 298-99 (2009). Therefore, the opinion is not probative. In support of his claim, the Veteran submitted an opinion from Dr. R. L., a private physician. He noted that the Veteran had been diagnosed with a carcinoid tumor in July 2010. However, he did not provide an opinion or discussion of whether the carcinoid tumor was related to exposure to contaminated water at Camp Lejeune. Dr. R. L.'s opinion does not provide evidence either for or against the Veteran's claim. The Veteran has provided his lay opinion in support of his claim. He asserts that his colon condition was caused by his in-service exposure to contaminated drinking water at Camp Lejeune. Because there is no universal rule as to competence on this issue, the Board must determine on a case-by-case basis whether a particular condition is the type of condition that is within the competence of a lay person to provide an opinion as to etiology. See Jandreau v. Nicholson, 492 F.3d 1372, 1376 -77 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24 Vet. App. 428, 433 n.4 (2011). Lay persons are competent to provide opinions on some medical issues. See Kahana, 24 Vet. App. at 435. However, the specific issue in this case, the origin of his colon condition, falls outside the realm of common knowledge of a lay person. See Jandreau, 492 F .3d at 1377 n.4. Determining the etiology of the Veteran's colon condition requires medical inquiry into biological processes, pathology, and involves interpretation of diagnostic tests such as colonoscopies. Such internal physical processes are not readily observable and are not within the competence of the Veteran in this case, who has not been shown by the evidence of record to have medical training or skills. As a result, the persuasive value of his lay assertion is low and is outweighed by the medical evidence of record. The Veteran has submitted news and Internet articles in support of his claim. Medical treatise evidence can, in some circumstances, constitute competent medical evidence. See 38 C.F.R. § 3.159(a)(1) (2014). It can provide important support when combined with an opinion of a medical professional if the article or treatise evidence discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least "plausible causality" based upon objective facts rather than on an unsubstantiated lay medical opinion. Sacks v. West, 11 Vet. App. 314 (1998); see also Wallin v. West, 11 Vet. App. 509 (1998). The majority of the treatises the Veteran submitted address the issue of whether a person's exposure to contaminated drinking water at Camp Lejeune could cause birth defects in his or her children. They are not relevant to the issue on appeal. He also submitted articles from the ATSDR website describing the chemicals that contaminated the water at Camp Lejeune. These articles are not probative evidence in support of a nexus between his colon condition and his exposure to contaminated water. Lastly, he submitted a March 2006 article from the LA Times entitled, "Cancer Stalks a 'Toxic Triangle,'" about contaminated water at Kelly Air Force Base in San Antonio, Texas, which used some of the chemicals also found at Camp Lejeune. The article suggested that TCE is "...most often linked to liver and kidney cancer...." This article is not relevant to the issue on appeal; the Veteran is not claiming service connection for liver or kidney cancer. The treatise evidence in this case is not relevant to the issue on appeal and is therefore not probative. Additionally, generic medical literature which does not apply medical principles regarding causation or etiology to the facts of an individual case does not provide competent evidence to establish a nexus. See Libertine v. Brown, 9 Vet. App. 521, 523 (1996). None of the material submitted in this case appears to meet the standard set forth in Wallin because it does not delve into an association between the Veteran's service and his currently demonstrated colon condition. These articles and submitted by the Veteran are less probative than other evidence of record as not one of them applies the specific facts to this specific case, or even addresses a colon condition. Sacks v. West, 11 Vet. App. 314, 317 (1998). For these reasons, the Board finds that the preponderance of the probative evidence of record weighs against the claim of service connection for a colon condition. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, that doctrine is not applicable where, as here, there is not an approximate balance of positive and negative evidence. See 38 U.S.C.A. § 5107(b) (West 2014); 38 C.F.R. § 3.102 (2014). Service connection for a colon condition is denied. ORDER New and material evidence having been received, the claim for service connection for a colon condition is reopened; the appeal is granted to this extent only. Service connection for a colon condition, claimed as blood in stool, colon polyps, hemorrhoids, and gastrointestinal bleeding, is denied. REMAND Remand is necessary in this case for the following reasons. With regard to the Veteran's claim for inflammation of the colon, in December 2014, Dr. R. L. stated that ulcerative colitis is an inflammatory disease with an autoimmune component. He stated that the ATSDR noted that vinyl chloride had an adverse effect on the immune systems of animals. Additionally, another study noted that the autoimmune disease Diffuse Systemic Sclerosis developed in a human after exposure to two of the other chemicals found in Camp Lejeune's water. Dr R. L. stated that "[t]herefore, it is not out of the realm of possibility that this claimant, already known and confirmed to have been exposed to this contaminated water, developed early ulcerative colitis from this exposure...." This opinion provides an indication that the Veteran's inflammation of the colon may be associated with service. Therefore, an examination is necessary. See McLendon v. Nicholson, 20 Vet. App. 79, 86 (2006). With regard to the Veteran's acquired psychiatric disorder, the August 2011 VA examiner provided a positive etiology opinion between the Veteran's physical disabilities and his depression. However, the examiner did not state which of the Veteran's physical disabilities caused his psychiatric disorder. Therefore, it is unclear whether the VA examiner was referring to the Veteran's inflammation of the colon. Dr. R. L. suggested that the Veteran's ulcerative colitis and his depression were linked. Therefore, the outcome of his claim for service connection for inflammation of the colon will have a substantial effect on the merits of his claim for service connection for an acquired psychiatric disorder. Therefore it is inextricably intertwined and remanded with the Veteran's claim for service connection for inflammation of the colon. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991); see also Tyrues v. Shinseki, 23 Vet. App. 166, 178 (2009). An addendum opinion should be obtained for his psychiatric condition if and only if the VA examiner who addresses the Veteran's inflammation of the colon finds that it is related to service. 1. Schedule the Veteran for an examination with an appropriate clinician for his inflammation of the colon. The entire claims file and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. a. The examiner must take a detailed history from the Veteran. If there is any clinical or medical basis for corroborating or discounting the reliability of the history provided by the Veteran, the examiner must so state, with a complete explanation in support of such a finding. b. Although an independent review of the claims file is required, the Board calls the examiner's attention to the following: i. The report of the November 2011 VA intestines examination. ii. Dr. R. L.'s December 2014 opinion. c. The examiner must provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's inflammation of the colon, including ulcerative colitis, diverticulitis, and/or diverticulosis began during active service, or is related to an incident of service, including his in-service exposure to contaminated drinking water at Camp Lejeune. d. In providing this opinion, the examiner must discuss Dr. R. L.'s private opinion as it relates to inflammation of the colon. e. The examiner must provide all findings, along with a complete rationale for his or her opinion(s), in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion, as well as specifically explain whether there is any potentially available information that, if obtained, would allow for a non-speculative opinion to be provided. 2. IF AND ONLY IF the examiner who provided the opinion regarding inflammation of the colon finds that it is related to service, provide the Veteran's claims file to a qualified clinician to address the Veteran's psychiatric disorder. A new examination is only required if deemed necessary by the examiner. The entire claims file and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. a. If a new examination is warranted, the examiner must take a detailed history from the Veteran. If there is any clinical or medical basis for corroborating or discounting the reliability of the history provided by the Veteran, the examiner must so state, with a complete explanation in support of such a finding. b. The examiner must provide opinions as to the following: i. Whether it is at least as likely as not (50 percent or greater probability) that the Veteran's psychiatric disorder was proximately due to or the result of his inflammation of the colon. ii. Whether it is at least as likely as not that his psychiatric disorder was aggravated beyond its natural progression by his inflammation of the colon. iii. If the examiner finds that the Veteran's psychiatric disorder was not caused or aggravated by his inflammation of the colon, determine whether it is at least as likely as not that the Veteran's psychiatric disorder began during active service, or is related to an incident of service, including exposure to contaminated water at Camp Lejeune. c. The examiner must provide all findings, along with a complete rationale for his or her opinion(s), in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion, as well as specifically explain whether there is any potentially available information that, if obtained, would allow for a non-speculative opinion to be provided. 3. The AOJ must review the claims file and ensure that the foregoing development action has been completed in full. If any development is incomplete, appropriate corrective action must be implemented. If any report does not include adequate responses to the specific opinions requested, it must be returned to the providing examiner for corrective action. 4. Thereafter, and after undertaking any additional development deemed necessary, readjudicate the issues on appeal. If the benefits sought on appeal remain denied, in whole or in part, the Veteran and his representative must be provided with a Supplemental Statement of the Case and be afforded a reasonable opportunity to respond. The case should then be returned to the Board for further appellate review, if otherwise in order. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. 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. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ____________________________________________ K. PARAKKAL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs