Citation Nr: 1603112 Decision Date: 02/01/16 Archive Date: 02/11/16 DOCKET NO. 14-21 821 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Louisville, Kentucky THE ISSUES 1. Entitlement to service connection for basal cell carcinoma, also claimed as skin cancer, to include as due to contaminated water exposure. 2. Entitlement to service connection for scleroderma, to include as due to contaminated water exposure. 3. Entitlement to service connection for heartburn/acid reflux, also claimed as digestive/stomach issues, to include as due to contaminated water exposure. ATTORNEY FOR THE BOARD K. Kordich, Senior Counsel INTRODUCTION The Veteran served on active duty from March 1969 to March 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Louisville, Kentucky. All documents on the Virtual VA paperless claims system and the Veterans Benefits Management System (VBMS) have been reviewed and considered. The issues of entitlement to service connection for heartburn/acid reflux, also claimed as digestive/stomach issues, and for scleroderma are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran served on active duty at Camp Lejeune, and is presumed to have been exposed to contaminated drinking water. 2. The Veteran's basal cell carcinoma, also claimed as skin cancer, did not originate in service or manifest until years thereafter, and is not otherwise related to service, to include exposure to contaminated water therein. CONCLUSION OF LAW Basal cell carcinoma, also claimed as skin cancer, was not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1112, 1113, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence 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). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, as regards the claims herein decided on appeal. The Veteran must not assume that the Board has overlooked any pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the veteran). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the Veteran. Caluza v. Brown, 7 Vet. App. 498, 506 (1995). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Id. VA's Duties to Notify and Assist Upon receipt and prior to consideration of most applications for VA benefits, VA is tasked with satisfying certain procedural requirements outlined in the Veterans Claims Assistance Act of 2000 (VCAA) and its implementing regulations. 38 U.S.C.A. §§ 5103, 5103A (West 2014); 38 C.F.R. § 3.159 (2015). The United States Court of Appeals for Veterans Claims (Court) has mandated that VA ensure strict compliance with the provisions of the VCAA. Quartuccio v. Principi, 16 Vet. App. 183 (2002). Duty to Notify The VCAA and its implementing regulations provide that VA is to notify a claimant and his representative, if any, of the information and medical or lay evidence not previously provided to the Secretary that is necessary to substantiate a claim. As part of the notice, VA is to specifically inform the claimant and his representative, if any, of which portion of the evidence the claimant is to provide and which portion of the evidence VA will attempt to obtain on the claimant's behalf. 38 U.S.C.A. § 5103(a) (West 2014); 38 C.F.R. § 3.159(b) (2015). These notice requirements apply to all five elements of a service connection claim, including: (1) veteran status; (2) existence of disability; (3) a connection between service and disability; (4) degree of disability; and (5) effective date of disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484 (2006). Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484 (2006). Notice provided in support of a service connection claim must inform a claimant that if a claim is granted, VA will assign the service-connected disability a rating and an effective date. Id. at 486. In this case, the RO provided the Veteran VCAA notice on his claims by a letter dated in March 2013. With regard to content, the letter reflects compliance with pertinent regulatory provisions and case law, noted above. Therein, the RO acknowledged the Veteran's claims, notified him of the evidence needed to substantiate the claims, identified the type of evidence that would best do so, notified him of VA's duty to assist and indicated that it was developing his claims pursuant to that duty. The RO also provided the Veteran all necessary information on disability ratings and effective dates. As well, it identified the evidence it had received in support of the Veteran's claims and the evidence it was responsible for securing. The RO noted that it would make reasonable efforts to assist the Veteran in obtaining all other outstanding evidence provided he identified the source(s) thereof. The RO also noted that, ultimately, it was the Veteran's responsibility to ensure VA's receipt of all pertinent evidence. In a July 2013 letter, the RO requested additional information from the Veteran concerning his time stationed at Camp Lejeune. Notice under the VCAA must be provided a claimant prior to an initial unfavorable decision by the agency of original jurisdiction. Pelegrini v. Principi (Pelegrini II), 18 Vet. App. 112, 119-20 (2004). In this case, the RO sent the notice letter timely, before the RO initially decided the Veteran's claims in November 2013. Duty to Assist VA is also to assist a claimant in obtaining evidence necessary to substantiate a claim, but such assistance is not required if there is no reasonable possibility that it would aid in substantiating the claim. 38 U.S.C.A. § 5103A (West 2014); 38 C.F.R. § 3.159(c) (2015). The RO made reasonable efforts to identify and obtain relevant records in support of the Veteran's claims. 38 U.S.C.A. § 5103A(a), (b), (c) (West 2014). Specifically, the RO secured and associated with the claims file all evidence the Veteran identified as being pertinent to his appeal, including service treatment records, post-service treatment records, and private treatment records. A VA examination was conducted in October 2013 as to the skin cancer claim. In reviewing the examination report, the Board finds that it is adequate for the purpose of adjudicating that issue. In summary, the facts relevant to this appeal have been properly developed and there is no further action to be undertaken to comply with the provisions of 38 U.S.C.A. §§ 5103(a), 5103A or 38 C.F.R. § 3.159. Therefore, the Veteran will not be prejudiced as a result of the Board proceeding to the merits of the appeal. See Bernard v. Brown, 4 Vet. App. 384, 392-94 (1993). Service Connection Criteria Service connection may be granted if the evidence demonstrates that a current disorder resulted from an injury or disease that was incurred in or aggravated by the Veteran's active military service. 38 U.S.C.A. §1110, 38 C.F.R. § 3.303(a). Stated somewhat differently, to establish entitlement to service connection, there must be: (1) a diagnosis of a current disorder; (2) medical or, in certain cases, lay evidence of in-service occurrence of a disease or injury, or aggravation of a pre-existing disease or injury; and, (3) evidence of a nexus between an in-service injury or disease and the current disorder. Hickson v. West, 12 Vet. App. 247, 252 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd 78 F.3d 604 (Fed. Cir. 1996). Service connection may also be granted for any disease diagnosed after the military discharge, when all the evidence, including that pertinent to the period of military service, establishes that the disease was incurred during the active military service. 38 U.S.C.A. § 1113(b); 38 C.F.R. § 3.303(d). Service connection for certain chronic diseases, including malignant tumors, will be presumed if they manifest to a compensable degree within one year following the active military service. This presumption, however, is rebuttable by probative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Presumptive periods are not intended to limit service connection to diseases so diagnosed when the evidence warrants direct service connection. The presumptive provisions of the statute and VA regulations implementing them are intended as liberalizations applicable when the evidence would not warrant service connection without their aid. 38 C.F.R. § 3.303(d). For the showing of a chronic disease in service, there must be a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. If chronicity in service is not established, evidence of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. § 3.303(b). However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a) and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The determination as to whether the requirements for service connection are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. 38 U.S.C.A. § 7104(a) (West 2014); Baldwin v. West, 13 Vet. App. 1 (1999); see 38 C.F.R. § 3.303(a). In claims for VA benefits, VA shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b) (West 2014); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53-54 (1990). In this decision, the Board has considered the lay evidence as it pertains to the issue. In rendering a decision on appeal, 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. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). A veteran is competent to report symptoms that he experiences at any time because this requires only personal knowledge as it comes to him through his senses. Layno, 6 Vet. App. at 470; Barr v. Nicholson, 21 Vet. App. 303, 309 (2007) (when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation). The absence of contemporaneous medical evidence is a factor in determining credibility of lay evidence, but lay evidence does not lack credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (lack of contemporaneous medical records does not serve as an "absolute bar" to the service connection claim); Barr v. Nicholson, 21 Vet. App. 303 (2007) ("Board may not reject as not credible any uncorroborated statements merely because the contemporaneous medical evidence is silent as to complaints or treatment for the relevant condition or symptoms"). In determining whether statements submitted by a veteran are credible, the Board may consider internal consistency, facial plausibility, and consistency with other evidence, and statements made during treatment. Caluza v. Brown, 7 Vet. App. 498 (1995). The Federal Circuit has recognized the Board's "authority to discount the weight and probity of evidence in light of its own inherent characteristics and its relationship to other items of evidence." Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). VA is free to favor one medical opinion over another provided it offers an adequate basis for doing so. See Owens v. Brown, 7 Vet. App. 429 (1995). It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case with all reasonable doubt to be resolved in favor of the claimant; however, the reasonable doubt rule is not a means for reconciling actual conflict or a contradiction in the evidence. 38 C.F.R. § 3.102 (2015). When there is an approximate balance of positive and negative evidence regarding a material issue, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); see 38 C.F.R. §§ 3.102. If the Board determines that the preponderance of the evidence is against the claim, it has necessarily found that the evidence is not in approximate balance, and the benefit of the doubt rule is not applicable. Ortiz, 274 F.3d at 1365. Regarding the Veteran's assertion that his alleged disability was due to his in-service exposure to water contamination while he was stationed at Camp Lejeune, VA acknowledges that there was contamination of the ground water at Camp Lejeune from 1957-1987. Specifically, in the early 1980s, it was discovered that two on-base water-supply systems were contaminated with the volatile organic compounds (VOCs) trichloroethylene (TCE), a metal degreaser, and perchloroethylene (PCE), a dry cleaning agent. The main source of TCE contamination was on-base industrial activities, while the main source of PCE was an off-base dry cleaning facility. 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 contaminated wells supplying the water systems were identified and shut down by February 1985. The Agency for Toxic Substances and Disease Registry (ATSDR), a branch of the 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 effects from consumption of the contaminated water. In 2008, the National Academy of Sciences' National Research Council (NRC) and ATSDR initiated studies. NRC undertook 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), NRC reviewed previous work done by 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, NRC focused on diseases associated with TCE, PCE, and other VOCs. Based on analyses of scientific studies involving these chemicals, NRC provided an assessment of the potential association between certain diseases and exposure to the chemical contaminants. The NRC analysis utilized 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, fourteen diseases were placed into the category of limited/suggestive evidence of an association. A number of diseases were also identified that fell into the category of inadequate/insufficient evidence to determine whether an association exists. NRC indicated that placement of diseases in these categories was based primarily on studies of highly exposed industrial workers, where the amount and duration of toxic chemical exposure greatly exceeded that experienced by individuals at Camp Lejeune. The specific diseases with limited/suggestive evidence of an association include: esophageal cancer; lung cancer; breast cancer; bladder cancer; kidney cancer; adult leukemia; multiple myeloma; myelodysplastic syndromes; renal toxicity; hepatic steatosis; female infertility miscarriage, with exposure during pregnancy; scleroderma; and, neurobehavioral effects. ATSDR responded to the NRC report in August 2009 with a plan for additional studies, supported by the Navy, to assess the human health risks associated with the Camp Lejeune water contamination. The plan included: a continuation of water flow computer modeling studies to generate potential contaminant exposure rates and durations; a re-analysis of data collected on birth outcomes; studies on birth defects and childhood cancers; and, further epidemiological studies based on mortality and health surveys that would be distributed to former Camp Lejeune residents. ATSDR also initiated a series of public hearings to receive input from individuals who had served at Camp Lejeune. In a 2010 letter to the Navy, ATSDR again responded to the NRC report, indicating its belief that the 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." ATSDR pointed out 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. ATSDR has 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 NRC. However, to date, the results of any additional studies have not been made available. As noted, a number of diseases have been identified as being associated with exposure to the specific Camp Lejeune water contaminants, based on human and experimental animal studies. Manifestation of any of those diseases is considered to be sufficient to initiate a VA medical examination and request an opinion regarding its relationship to Camp Lejeune service. However, this is not an exclusive list. Medical evidence provided by a Veteran indicating that some other disease may be related to the known water contaminants could also be sufficient to initiate a VA examination. It is important to note that to date, no definitive scientific studies have provided 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. Many unanswered questions remain regarding the levels of water contamination at various base locations, the amount and type of exposure experienced by any given Veteran who served there, and the scientific probability that a Veteran's particular claimed disease resulted from the service at Camp Lejeune rather than from some other source. As a result, there are currently no "presumptive" diseases attributed to service at Camp Lejeune by statute, regulation, or VA policy. The Board notes that in December 2015, VA announced plans to propose expanded disability compensation eligibility for Veterans exposed to contaminated drinking water while assigned to Camp Lejeune. However, none of the conditions that will be subject to the creation of a presumption of service connection include skin cancer or any skin disorder other than scleroderma. Accordingly, when VA receives a claim based on chemical exposure at Camp Lejeune, VA first must determine if the Veteran was stationed at Camp Lejeune and if so for how long and in what capacity. Here, the evidence establishes that the Veteran was stationed at Camp Lejeune during a portion of his active military service from October 1969 to March 1971, as documented on his DD-214 Form and service treatment records (STRs). The next step is to verify, with medical evidence obtained through a VA medical examination or other authoritative medical sources, whether a claimed current disease or disability is at least as likely as not a result of exposure to the chemical compounds present in the water at Camp Lejeune. The Veteran contends that his basal cell carcinoma (skin cancers) is the result of his active military service, to include as due to in-service exposure to contaminated water at Camp Lejeune. Service treatment records are silent for any treatment, findings or diagnosis of basal cell carcinoma or skin cancer. The Veteran's Report of Medical Examination in March 1971 when he was released from active duty showed normal clinical evaluation of the skin and lymphatic systems. An operative report from Atlanta West Dermatology dated in August 2004 noted the excision of right upper back basal cell carcinoma. The Veteran was seen in September 2004 for follow-up of his status post excision of basal cell carcinoma. He reported the excision site was healed with no problems. The physician noted a well healed scar on the right upper back with slight protrusion on the right distal end, otherwise excellent result with no evidence of recurrence. The records show that in July 2005, the Veteran had a surgical excision of basal cell carcinoma on the right lower leg. The Veteran was seen for follow-up in August 2005 for post-surgical excision of a basal cell carcinoma on the right lower leg. The physician noted well healed scars present on the right lower leg and right upper back, with no evidence of recurrence and excellent cosmetic result. At the Veteran's October 2013 VA examination, the examiner noted the two excisions for basal cell carcinoma in 2004 and 2005. As to basal cell carcinoma, the examiner explained that basal cell carcinoma (BCC) is a common skin cancer arising from the basal layer of the epidermis and its appendages. She noted that BCC is particularly common in Caucasians, and that in white populations in the United States, the incidence of BCC has increased by more than 10 percent per year, and that the lifetime risk of developing a BCC is 30 percent. The incidence in men is 30 percent higher than in women, and that the incidence of BCC increases with age; persons aged 55 to 75 have about a 100-fold higher incidence of BCC than those younger than 20. She explained that both environmental and genetic factors contribute to the development of BCC. Exposure to ultraviolet (UV) radiation in sunlight is the most important. Other established risk factors include chronic arsenic exposure, therapeutic radiation, immunosuppression, and the basal cell nevus syndrome. She noted that Gulf War and Health, Volume 2, is the second in a series of congressionally-mandated studies by the Institute of Medicine that provides a comprehensive assessment of the available scientific literature on potential health effects of exposure to certain biological, chemical, and environmental agents associated with the Gulf War. When looking at the association between solvent exposure and non-melanoma skin cancer, the committee concluded, from its assessment of the epidemiologic literature, that there is inadequate/insufficient evidence to determine whether an association exists between the two. She noted that the veteran has other known risk factors of increasing age, Caucasian race and gender. The examiner opined that the diagnosis of basal cell carcinoma of the right upper back and right lower extremity was not caused by or a result of the Veteran's exposure to Camp Lejeune contaminated water. Upon review of the record, the Board finds the preponderance of the competent, credible, and probative evidence is against the claim. Service treatment records do not reference any symptoms, treatment, or diagnosis of basal cell carcinoma or any other skin cancer. Clinical evaluation of the skin and lymphatic system was normal at the separation examination in March 1971. The first evidence of skin cancer is many years after service. The Board notes that the Veteran apparently served at Camp Lejeune during the period of potential exposure; thus, he is presumed to have been exposed to contaminated drinking water. Further, as noted above, the Veteran has been diagnosed with basal cell carcinoma of the right upper back and right lower extremity. What is missing from the record is competent evidence showing that the skin cancers may be causally related to the Veteran's presumed exposure to contaminated water in service. As noted above, the VA examiner in October 2013 rendered a negative opinion, with rational, opining that the Veteran's basal cell carcinomas were not caused by or a result of exposure to contaminated water at Camp Lejeune. The Board finds that the VA examiner's opinion was based on a review of the record and pertinent medical and scientific literature such as Up to Date, and is probative and persuasive on the issue of whether the claimed condition is related to active service. Notably, the Veteran has not submitted competent medical evidence suggesting a relationship of skin cancer to contaminated water at Camp Lejeune, or otherwise to service. The Board recognizes the Veteran contends that his basal cell carcinoma is related to exposure to contaminated water during his service at Camp Lejeune. While his exposure to contaminated water is presumed, and lay statements may be competent to support a claim for service connection by supporting the presence of disability or symptoms of disability subject to lay observation, as a lay person, the Veteran is not competent to report that his current disorder is related to exposure to contaminated water in service. 38 U.S.C.A. § 1153(a); 38 C.F.R. §§ 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Particularly where the matter of the health effects of contaminated water at Camp Lejeune are the subject of scientific studies, the Board finds that the question of the relationship of skin cancer and water contamination is far outside the realm of lay expertise. The Board notes that the Veteran does not contend that he developed skin cancer while in service. As noted above, service treatment records are silent for any treatment, findings or diagnosis of basal cell carcinoma or skin cancer. The Veteran's Report of Medical Examination in March 1971 when he was released from active duty showed normal clinical evaluation of the skin and lymphatics. The Veteran developed basal cell carcinoma in 2004, decades after service. The Board again notes that the Veteran himself, through his statements, is not competent to establish a connection between his basal cell carcinoma and his service. The Veteran as a lay person has not been shown to be capable of making medical conclusions, especially as to complex medical diagnoses and opinions of etiology. Without evidence of a chronic disease with an onset in service, continuity of pertinent symptomatology since active duty, or competent evidence of an association between the basal cell carcinoma and active duty, service connection for basal cell carcinoma is not warranted on a direct basis, nor is it warranted due to exposure to contaminated water at Camp Lejeune. The preponderance of the evidence is therefore against the claim of service connection for basal cell carcinoma. The benefit-of-the-doubt rule does not apply and the claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet.App. 49, 55 (1990). ORDER Entitlement to service connection for basal cell carcinoma also claimed as skin cancer, to include as due to contaminated water exposure, is denied. REMAND With respect to the service connection claim for heartburn/acid reflux, also claimed as digestive/stomach issues, there has been no VA examination with an opinion which could provide an adequate basis for the Board to make a fully informed assessment of the Veteran's claim. On remand, a VA examination with opinion pertaining to the Veteran's heartburn/acid reflux disability must be obtained. As to the claimed scleroderma, VA treatment records are silent for any reference to the disorder. The October 2013 VA examiner did not reference scleroderma, but the Board points out that the examiner made it clear she was only assessing BCC in the Veteran. Currently, there is no presumption of service connection for scleroderma based on exposure to contaminated drinking water at Camp Lejeune. As noted previously, in December 2015, VA announced plans to propose expanded disability compensation eligibility for veterans exposed to contaminated drinking water while assigned to Camp Lejeune. VA indicated that it would propose creation of a presumption of service connection for several conditions, including scleroderma. Given VA's proposal, the Board finds that a VA examination is necessary to determine whether the Veteran in fact has scleroderma. Accordingly, the case is REMANDED for the following action: 1. After securing any necessary authorization from the Veteran, obtain all outstanding VA and private treatment records concerning the Veteran's heartburn/acid reflux (also claimed as digestive/stomach issues) and claimed scleroderma. 2. After completion of the foregoing, schedule the Veteran for an appropriate VA examination to determine the nature and etiology of any heartburn/acid reflux or digestive/stomach disorders. The entire claims file, to include relevant electronic records, must be reviewed by the examiner. Based on the examination and review of the record, the examiner should address the following: (A) Diagnose any heartburn/acid reflux or digestive/stomach disorders present. (B) As to each diagnosed condition, provide an opinion as to whether it is at least as likely as not (i.e., probability equal to or greater than 50 percent) that the disability: (i) had onset in service or within one year of separation; or (ii) is etiologically related to military service, including conceded exposure to, and consumption of contaminated water while stationed at Camp Lejeune. The provided examination report must reflect consideration of both the medical and lay evidence of record and set forth a complete rationale for all findings and conclusions. All tests deemed necessary by the examiner must be performed. If the examiner cannot provide an opinion without resort to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. 3. Schedule the Veteran for a VA examination by an examiner with appropriate expertise to determine the nature and etiology of any scleroderma. Based on the examination and review of the record, the examiner should address the following: (A) Diagnose any scleroderma present. (B) As to each diagnosed condition, provide an opinion as to whether it is at least as likely as not (i.e., probability equal to or greater than 50 percent) that the disability: (i) had onset in service or within one year of separation; or (ii) is etiologically related to military service, including conceded exposure to, and consumption of contaminated water while stationed at Camp Lejeune. The provided examination report must reflect consideration of both the medical and lay evidence of record and set forth a complete rationale for all findings and conclusions. All tests deemed necessary by the examiner must be performed. If the examiner cannot provide an opinion without resort to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. 4. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran's remaining claims should be readjudicated based on the entirety of the evidence. If the claims remain denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. The purpose of this REMAND is to obtain additional evidence and ensure that the Veteran is afforded all due process of law. The Board intimates no opinion, either factual or legal, as to the conclusion warranted in this case. No action is required by the Veteran until contacted. Thereafter, return the case to the Board, if otherwise in order. The appellant has the right to submit additional evidence and argument on the 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). ______________________________________________ JOHN Z. JONES Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs