Citation Nr: 18144962 Decision Date: 10/25/18 Archive Date: 10/25/18 DOCKET NO. 16-18 425 DATE: October 25, 2018 ORDER New and material evidence having been received, the claim of service connection for metastatic gastric cancer, to include as due to herbicide agent exposure and exposure to contaminants at Camp Lejeune, is reopened; to this extent only the appeal is granted. The application to reopen a previously denied claim of service connection for hypertension is denied. Entitlement to an initial compensable rating for bilateral hearing loss is denied. Entitlement to an initial rating in excess of 50 percent for posttraumatic stress disorder (PTSD) is denied. REMANDED Entitlement to service connection for metastatic gastric cancer, to include as due to herbicide agent exposure and exposure to contaminants at Camp Lejeune, is remanded. FINDINGS OF FACT 1. The Veteran’s claims for service connection for metastatic gastric cancer and hypertension were previously denied by a November 2008 rating decision; the Veteran did not appeal the decision and documentation constituting new and material evidence was not actually or constructively received within the one-year appeal period. 2. Additional evidence received since the November 2008 rating decision is not cumulative or redundant of the evidence of record at the time of that decision, relates to an unestablished fact necessary to substantiate the claim for service connection for metastatic gastric cancer, and raises a reasonable possibility of substantiating the claim. 3. Additional evidence received since the November 2008 rating decision is cumulative or redundant of the evidence of record at the time of that decision, does not relate to an unestablished fact necessary to substantiate the claim for service connection for hypertension, and does not raise a reasonable possibility of substantiating the claim. 4. Throughout the appeal period, the Veteran’s bilateral hearing loss has been shown at worst with Level II hearing acuity in the right ear and Level I hearing acuity in the left ear. 5. The Veteran’s PTSD has been manifested by occupational and social impairment with reduced reliability and productivity for the entire appeal period. CONCLUSIONS OF LAW 1. The November 2008 rating decision denying service connection for metastatic gastric cancer and hypertension is final. 38 U.S.C. § 7105; 38 C.F.R. §§ 20.200, 20.201, 20.302, 20.1103. 2. Evidence received since the November 2008 rating decision is new and material to reopen the claim for service connection for metastatic gastric cancer. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 3. Evidence received since the November 2008 rating decision is not new and material, and the criteria for reopening of the claim for entitlement to service connection for hypertension have therefore not been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 4. The criteria for an initial compensable rating for the Veteran’s service-connected bilateral hearing loss are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.85, 4.86, Diagnostic Code 6100. 5. The criteria for an initial rating in excess of 50 percent for the Veteran’s service-connected PTSD are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty with the United States Marine Corps from January 1964 to January 1968. These matters are before the Board of Veterans’ Appeals (Board) on appeal from a May 2013 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In his April 2016 VA Form 9, Appeal to Board of Veterans’ Appeals, the Veteran requested to appear at a hearing before the Board. In subsequent correspondence received in May 2016, he withdrew his hearing request. Duties to Notify and Assist VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. § 3.159. Neither the Veteran nor his representative has raised any issues with the duty to notify. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board”). Regarding the duty to assist, in a statement received by VA in April 2013, the Veteran stated that his service treatment records showing his high blood pressure have not been obtained. However, a detailed review of the record illustrates the Veteran’s service treatment records, including an exit examination showing normal blood pressure, are in the record. Thus, appellate review of the Veteran’s claims, including his petition to reopen his claim of service connection for hypertension, may proceed without prejudice to the Veteran, as all identified records have been obtained. Neither the Veteran nor his representative has raised any other issues with the duty to assist. Scott, 789 F.3d at 1381; Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). New and Material Evidence Claims for service connection for a metastatic gastric cancer and hypertension were originally denied in a November 2008 rating decision. The RO denied the claim of service connection for metastatic gastric cancer on the basis that the Veteran’s gastric cancer is not a condition warranting presumptive service connection based on exposure to herbicide agents in Vietnam, and that there was no evidence the condition began in service. The RO denied the claim of service connection for hypertension on the basis that the Veteran’s hypertension neither occurred in nor was caused by service and did not manifest to a compensable degree within one year of his service. The Veteran did not appeal the decision, nor was any new and material evidence actually or constructively received within a year following the decision; therefore, the decision became final. 38 U.S.C. § 7105(c); 38 C.F.R. §§ 3.156, 20.200, 20.201, 20.302, 20.1103. The Veteran’s petitions currently before the Board to reopen his claims for metastatic gastric cancer and hypertension were received by the RO in December 2012. The RO granted the petition to reopen the claims and denied the claims on the merits in a May 2013 rating decision. Although the RO reopened the claims in the May 2013 rating decision, the Board must independently consider the question of whether new and material evidence has been received because it goes to the Board’s jurisdiction to reach the underlying claims and adjudicate the claims de novo. See Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001); Barnett v. Brown, 83 F.3d 1380, 1384 (Fed. Cir. 1996). Generally, a claim which has been denied may not thereafter be reopened and allowed based on the same record. 38 U.S.C. §§ 7104, 7105. However, pursuant to 38 U.S.C. § 5108, if new and material evidence is presented or secured with respect to a claim which has been disallowed, the VA Secretary shall reopen the claim and review the former disposition of the claim. New evidence is defined as existing evidence not previously submitted to agency decision makers. Material evidence is defined as existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. 38 C.F.R. § 3.156(a). 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. Id. In determining whether evidence is “new and material,” the credibility of the new evidence must be presumed. Fortuck v. Principi, 17 Vet. App. 173, 179-80 (2003); Justus v. Principi, 3 Vet. App. 510, 513 (1992). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is “low.” See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). Furthermore, in determining whether this low threshold is met, VA should not limit its consideration to whether the newly received evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering the VA Secretary’s duty to assist or through consideration of an alternative theory of entitlement. Shade, 24 Vet. App. at 118 (2010). If the Board determines that the evidence submitted is both new and material, it must reopen the case and evaluate the claim in light of all the evidence. Justus, 3 Vet. App. at 512 (1992). Such evidence is presumed to be credible for the purpose of determining whether the case should be reopened; once the case is reopened, the presumption as to the credibility no longer applies. Id. at 513. 1. Metastatic Gastric Cancer The Board finds the Veteran has submitted new and material evidence since the November 2008 rating decision denying service connection for metastatic gastric cancer. The Veteran submitted a private opinion dated January 2013 from Dr. S.C. who opined that the Veteran’s stomach cancer is more likely than not related to his exposure to contaminants at Camp Lejeune. In addition, the Veteran submitted a “Challenge to BVA on Toxic Chemical Associations to Stomach Cancer in Our Vietnam Veterans” received by VA in October 2015. This document provides a discussion of medical literature linking stomach cancer to exposure to herbicide agents. This medical nexus opinion and the chemical associations evidence were not before adjudicators when the Veteran’s claim was last denied in November 2008, and the evidence is not cumulative or redundant of the evidence of record at the time of that decision. The evidence also relates to an unestablished fact necessary to substantiate the claim for service connection for metastatic gastric cancer and raises a reasonable possibility of substantiating the claim. Accordingly, the claim is reopened. 2. Hypertension The Board finds the Veteran has not submitted new and material evidence since the November 2008 rating decision denying service connection for hypertension. Relevant evidence since the November 2008 rating decision includes VA treatment records received in May 2013, August 2013, January 2014, and March 2016. Additional relevant evidence includes private treatment records from Community Medical Center received in October 2015 and November 2015. The VA treatment records and the private treatment records include multiple diagnoses of hypertension from December 2008 onward and blood pressure readings beginning in December 2007. In addition, the VA treatment records illustrate the Veteran has been prescribed Enalapril Maleate and Hydrochlorothiazide for his hypertension. These diagnoses and evidence that the Veteran takes blood pressure medications do not relate to an unestablished fact necessary to substantiate the merits of the claim as it was previously determined that the Veteran had a current hypertension disability. The additional evidence does not indicate that the Veteran’s hypertension began in service, nor does the evidence link the Veteran’s current hypertension to service. It also does not indicate that the Veteran had hypertension to a compensable level within a year of his service discharge or that he has had continuity of symptoms of hypertension since his discharge from service. The evidence received since the November 2008 rating decision is essentially cumulative of the evidence of record at the time of the November 2008 rating decision. Thus, the evidence, by itself or when considered in conjunction with the evidence previously of record is not new and material. Therefore, reopening of the claim for service connection for hypertension is not warranted. The benefit-of-the-doubt doctrine is not applicable to applications to reopen a claim unless the threshold burden of submitting new and material evidence has been met. Annoni v. Brown, 5 Vet. App. 463, 467 (1993). Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4. The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. A Veteran’s entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Board acknowledges that with respect to a claim for an increased rating for an already service-connected disability, a Veteran may experience multiple distinct degrees of disability that might result in different levels of compensation. See Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). The following analysis is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. 1. Bilateral Hearing Loss The Veteran and his representative generally contend the Veteran is entitled to a compensable rating for his bilateral hearing loss. In evaluating service-connected hearing loss, disability ratings for a hearing impairment are derived by a mechanical application of the Rating Schedule to the numeric designations assigned after audiometric evaluations are rendered. See Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). Hearing loss disability evaluations range from noncompensable to 100 percent based on organic impairment of hearing acuity, as measured by controlled speech discrimination tests (Maryland CNC) in conjunction with the average hearing threshold, as measured by pure tone audiometry tests in the frequencies of 1000, 2000, 3000, and 4000 Hertz cycles per second (Hertz or Hz). The Rating Schedule establishes 11 auditory acuity levels designated from Level I, for essentially normal hearing acuity, through Level XI, for profound deafness. VA audiometric examinations are conducted using a controlled speech discrimination test together with the results of a pure tone audiometry test. The vertical lines in Table VI (in 38 C.F.R. § 4.85) represent nine categories of the percentage of discrimination based on the controlled speech discrimination test. The horizontal columns in Table VI represent nine categories of decibel loss based on the pure tone audiometry test. The numeric designation of impaired hearing (Levels I through XI) is determined for each ear by intersecting the vertical row appropriate for the percentage of discrimination and the horizontal column appropriate to the pure tone decibel loss. The percentage evaluation is found from Table VII (in 38 C.F.R. § 4.85) by intersecting the vertical column appropriate for the numeric designation for the ear having the better hearing acuity and the horizontal row appropriate to the numeric designation level for the ear having the poorer hearing acuity. For example, if the better ear has a numeric designation Level of “V” and the poorer ear has a numeric designation Level of “VII,” the percentage evaluation is 30 percent. See 38 C.F.R. § 4.85. The provisions of 38 C.F.R. § 4.86(a) provide that when the pure tone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) is 55 decibels or more, the rating specialist will determine the Roman numeral designation for a hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral. Each ear will be evaluated separately. The provisions of 38 C.F.R. § 4.86(b) provide that when the pure tone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz, the rating specialist will determine the Roman numeral designation for the hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral. That numeral will then be elevated to the next higher Roman numeral. Each ear will be evaluated separately. A May 2013 VA examination revealed the following pure tone thresholds, in decibels: HERTZ CNC 1000 2000 3000 4000 Avg % RIGHT 5 20 55 55 34 96 LEFT 10 20 50 55 34 100 The average pure tone threshold at 1000, 2000, 3000, and 4000 Hertz was 34 decibels in the right ear and 34 decibels in the left ear. Using the Maryland CNC word list, the speech recognition score was 96 percent in the right ear and 100 percent in the left ear. The examiner noted the Veteran’s bilateral hearing loss does not impact ordinary conditions of daily life, including his ability to work. However, the examiner noted the Veteran reported difficulty in group listening situations. Applying the results from the May 2013 audiological examination to the Rating Schedule shows Level I hearing acuity bilaterally using Table VI. See 38 C.F.R. § 4.85, Table VI, Diagnostic Code 6100. Applying these findings to 38 C.F.R. § 4.85, Table VII of the Rating Schedule, results in a noncompensable rating for bilateral hearing loss under Diagnostic Code 6100. These results do not reflect an exceptional pattern of hearing impairment, as such Table VIa is not applicable. The Veteran attended an additional VA examination in October 2015. That examination revealed the following pure tone thresholds, in decibels: HERTZ CNC 1000 2000 3000 4000 Avg % RIGHT 20 40 65 70 49 88 LEFT 20 45 65 70 50 92 The average pure tone threshold at 1000, 2000, 3000, and 4000 Hertz was 49 decibels in the right ear and 50 decibels in the left ear. Using the Maryland CNC word list, the speech recognition score was 88 percent in the right ear and 92 percent in the left ear. The examiner noted the functional impact of the Veteran’s bilateral hearing loss is that the Veteran has difficulty hearing conversation when more than one person is speaking and in the presence of background noise. Further, the Veteran reported he frequently says “what” because he cannot catch all parts of the conversation. In addition, the Veteran reported he just goes along with the conversation and shakes his head in agreement even though he has not heard everything that was said. Applying the results from the October 2015 audiological examination to the Rating Schedule shows Level II hearing acuity in the right ear and Level I hearing acuity in the left ear using Table VI. See 38 C.F.R. § 4.85, Table VI, Diagnostic Code 6100. Applying these findings to 38 C.F.R. § 4.85, Table VII of the Rating Schedule, results in a noncompensable rating for bilateral hearing loss under Diagnostic Code 6100. These results do not reflect an exceptional pattern of hearing impairment, as such Table VIa is not applicable. In addition to the medical evidence addressed above, the Board has considered the Veteran’s report in his June 2013 notice of disagreement that he needs hearing aids. However, even with considering the Veteran’s statements regarding his hearing loss, the evidence of record shows no distinct periods of time during the appeal period when the Veteran’s service-connected bilateral hearing loss disability varied to such an extent that a compensable rating is warranted. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Regarding whether referral for an extraschedular rating is appropriate, such has not been raised by the claimant or reasonably raised by the record and will not be further discussed herein. Doucette v. Shulkin, 28 Vet. App. 366, 369−70 (2017). In summary, the Board finds that a preponderance of the evidence is against a finding that the Veteran is entitled to an initial compensable rating for his bilateral hearing loss. The Board has considered the benefit-of-the-doubt rule; however, since a preponderance of the evidence is against the Veteran’s claim, the benefit-of-the-doubt rule is not for application. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 2. PTSD The Veteran and his representative generally contend the Veteran is entitled to a rating in excess of 50 percent for his service-connected PTSD. The Veteran’s service-connected PTSD has been assigned a 50 percent rating throughout the appeal period pursuant to the criteria of Diagnostic Code 9411, which is included under the General Rating Formula for Rating Mental Disorders. 38 C.F.R. § 4.130. Based on a review of the relevant evidence and the applicable law and regulations, it is the Board’s conclusion that the preponderance of the evidence is against a finding of a higher than 50 percent rating throughout the appeal period. Under Diagnostic Code 9411, a 50 percent disability rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory, for example, retention of only highly learned material, forgetting to complete tasks; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 70 percent rating is warranted when there is objective evidence demonstrating occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control, such as unprovoked irritability with periods of violence; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances, including work or a work-like setting; and the inability to establish and maintain effective relationships. Id. A maximum 100 percent rating is warranted when there is total occupational and social impairment, due to such symptoms as: persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene; disorientation to time and place; memory loss for names of close relatives, own occupation, or own name. Id. The list of symptoms in the General Rating Formula for Mental Disorders is not intended to constitute an exhaustive list, but rather provides examples of the type and degree of symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). However, “a [V]eteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration.” Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). Furthermore, when evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126. Turning to the evidence of record, the Veteran attended VA examinations in May 2013 and October 2015 for an evaluation of his PTSD. At the May 2013 VA examination, the examiner diagnosed the Veteran with PTSD and alcohol abuse, and the examiner indicated it was not possible to differentiate what symptoms are attributable to each diagnosis. The VA examiner indicated the Veteran’s psychiatric symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication. Regarding the Veteran’s psychiatric diagnoses, the examiner reported the symptoms that apply to the Veteran’s diagnoses are anxiety, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The mental status examination revealed the Veteran was fully oriented, his mood was euthymic, he had a full and appropriate affect, his speech was goal-directed, he denied suicidal and homicidal ideation, and he denied hallucinations. The examiner noted the Veteran had fair insight and judgment. The Veteran reported that he enjoys his retirement, he spends his time visiting and camping with friends, and gardening. In addition, the Veteran reported his drinking is variable. At the October 2015 VA examination, the VA examiner diagnosed the Veteran with PTSD and no other psychiatric disorders. The VA examiner indicated the level of occupational and social impairment to be occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. Regarding the Veteran’s PTSD diagnosis, the examiner reported the symptoms that apply to the Veteran’s PTSD are anxiety, depressed mood, suspiciousness, chronic sleep impairment, mild memory loss, impaired abstract thinking, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The mental status examination revealed the Veteran was dressed in neat, casual attire, he made good eye contact, and he had a depressed and anxious mood. The Veteran reported that his relationship with his wife “has been cruising along okay,” he has a very good relationship with his brother, he does not really talk to his two sisters anymore, he has very few friends, and he reported he prefers to be alone most of the time. The Veteran reported for recreational activities he gardens and walks his dog. Further, he reported he likes to cook and go to the local VFW where he is an officer. In addition to the 2013 and 2015 VA examinations, the Veteran attended two private psychological evaluations at A&W Psychology Services in April 2013 and August 2015. During the mental status examinations at those two evaluations, the Veteran had clear speech, he was open and cooperative, his thoughts were logical and goal-directed, his affect was constricted, his mood was depressed and anxious, his long-term memory was good but his short-term memory was somewhat compromised, he displayed rather weak concentration and attention skills, his impulse control and judgment were mildly compromised, and he denied suicidal and homicidal ideations. The Veteran reported at the evaluations that he has disturbing nightmares of incidents that occurred in Vietnam two to three times a month. He reported his spouse complains about his level of detachment and isolation. In addition, the Veteran reported he has ongoing difficulties managing his feelings of anger, rage, hostility, and resentment. He reported that he has broken objects in his home. VA mental health treatment notes from 2014 through 2016 illustrate that during mental status examinations the Veteran denied suicidal ideation, homicidal ideation, and hallucinations. In addition, the Veteran had a normal mood and full affect, his speech was normal, and he had normal psychomotor activity. In addition, the Veteran reported in January 2016 that he had adequate control of his PTSD symptoms. After review of the evidence of record, the Board finds that the severity of the symptoms and disability picture of the Veteran’s PTSD does not warrant a rating in excess of 50 percent. In this regard, the Veteran’s symptoms do not more nearly approximate a rating of 70 percent, as they are not of such a severity, frequency or duration to result in occupational and social impairment with deficiencies in most areas. Specifically, the most recent VA examination report reflects the Veteran’s occupational and social impairment is characterized as an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily. Further, there is no evidence the Veteran has suicidal ideation, obsessional rituals that interfere with routine activities, illogical speech, near-continuous pain or depression affecting his ability to function independently, spatial disorientation, or that he neglects his personal appearance or hygiene. The Board acknowledges that the record reflects the Veteran reported at the 2013 and 2015 private psychological evaluations at A&W Psychology Services that he had periods of impaired impulse control to the extent that he has broken objects in his home. However, the May 2013 and October 2015 VA examinations and the VA mental health treatment notes from 2014 to 2016 reflect no indication the Veteran has impaired impulse control. In addition, the record reflects that the Veteran has had difficulty maintaining personal relationships. However, the record also reflects that the Veteran has an okay relationship with his spouse, a good relationship with his brother, and that he is an officer at the local VFW. As such, the Veteran’s overall disability picture, including when considering the frequency, duration, and severity of symptoms of impaired impulse control and difficulty establishing and maintaining effective relationships, does not cause his occupational and social impairment to be more reflective of deficiencies in most areas; rather his symptoms reflect that they are of the frequency, duration, and severity to cause occupational and social impairment with reduced reliability and productivity. There are no other symptoms, either listed in the rating criteria or otherwise reflected in the record, throughout the appeal period of such frequency, duration, and severity that are reflective of occupational and social impairment with deficiencies in most areas. Therefore, a preponderance of the evidence is against the claim, and a rating in excess of 50 percent is denied. REASONS FOR REMAND Entitlement to service connection for metastatic gastric cancer, to include as due to herbicide agent exposure and exposure to contaminants at Camp Lejeune, is remanded. The Veteran has alleged that his metastatic gastric cancer is due to exposure to herbicide agents from his service in Vietnam or exposure to contaminants at Camp Lejeune. Regarding the theory of entitlement that gastric cancer is due to exposure to herbicide agents, such exposure has been conceded as the Veteran has served in Vietnam. The Board cannot make a fully-informed decision on this issue because no VA examiner has opined whether the Veteran’s metastatic gastric cancer is directly related to service, to include exposure to herbicide agents. Therefore, remand is necessary for an opinion as to the etiology of the Veteran’s metastatic gastric cancer. The matter is REMANDED for the following actions: 1. Obtain and associate with the Veteran’s electronic record VA records from March 2016 to the present. Contact the Veteran and afford him the opportunity to identify or submit any pertinent evidence in support of his claim, to include records of any private treatment. Based on his response, attempt to procure copies of all records which have not been obtained from identified treatment sources. If any of the records requested are unavailable, clearly document the claims file to that effect and notify the Veteran of any inability to obtain these records, in accordance with 38 C.F.R. § 3.159(e). 2. After completing the development requested in item 1, obtain a VA opinion to determine the nature, extent, and etiology of the Veteran’s metastatic gastric cancer. His electronic claims file, including a copy of this decision and remand, must be made available to the opinion provider for review. The VA medical expert should provide an opinion on the following: Is it at least as likely as not (50 percent or greater probability), that the Veteran’s metastatic gastric cancer is related or attributable to his military service, to include presumed exposure to herbicide agents? In addressing this question, the clinician is to specifically discuss the “Challenge to BVA on Toxic Chemical Associations to Stomach Cancer in Our Vietnam Veterans” received by VA October 2015. The clinician must fully explain the rationale for all opinions, with citation to supporting clinical data/lay statements, as deemed appropriate. If the clinician cannot provide the requested opinion without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. M. SORISIO Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD N. Breitbach, Associate Counsel