Citation Nr: 18151162 Decision Date: 11/16/18 Archive Date: 11/16/18 DOCKET NO. 16-35 267A DATE: November 16, 2018 REMANDED Entitlement to service connection for bladder cancer is remanded. REASONS FOR REMAND The Veteran served in the U.S. Air Force from April 1970 to June 1974. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a December 2014 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran filed a notice of disagreement (NOD) with the rating decision in January 2015. A statement of the case (SOC) was issued in June 2016, and the Veteran perfected his appeal in July 2016. The Veteran testified at a Board hearing before the undersigned Veterans Law Judge in February 2017; a transcript of that hearing is associated with the claims file. The Veteran contends that he is entitled to service connection for bladder cancer. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303(a) (2017). “To establish a right to compensation for a present disability, a Veteran must show: ‘(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service’ – the so-called ‘nexus’ requirement.” Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may also be granted for disability which is proximately due to, the result of, or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310 (2017). This is referred to as a “secondary service connection” theory of entitlement. The Board has determined that additional development is necessary prior to the adjudication of the Veteran’s claim of service connection for bladder cancer. First, the Veteran’s VA examination from December 2014 is not adequate regarding service connection for bladder cancer. If VA undertakes the effort to provide the Veteran with a medical examination, it must ensure that such examination is an adequate one. See 38 C.F.R. § 4.2 (2017); Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); Kowalski v. Nicholson, 19 Vet. App. 171, 179 (2005). At the December 2014 VA examination, the VA examiner determined that the Veteran’s bladder cancer was less likely than not to have been caused by the Veteran’s service-connected diabetes mellitus, type II. The VA examiner’s rationale was that she could find nothing in current medical literature that supports diabetes mellitus as a causative factor in bladder or urinary tract cancer. However, although the VA examiner addressed whether the Veteran’s bladder cancer was at least as likely as not caused by his service-connected diabetes mellitus, type II, the VA examiner did not address whether the Veteran’s bladder cancer was at least as likely as not chronically worsened beyond its natural progression (aggravated) by his service-connected diabetes mellitus, type II, for purposes of secondary service connection. Consequently, the Board finds that a remand is necessary in order to obtain a VA examination that adequately addresses whether the Veteran’s bladder cancer was at least as likely as not to have been chronically worsened beyond its natural progression (aggravated) by his service-connected diabetes mellitus, type II. See 38 C.F.R. §§ 3.310, 4.2 (2017); Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); Kowalski v. Nicholson, 19 Vet. App. 171, 179 (2005). Secondly, the Veteran asserts that his bladder cancer was due to his exposure to herbicides while serving in Vietnam. The Veteran supports this assertion with a May 2015 opinion from his private urologist, saying that there is a “very significant likelihood” that exposure to Agent Orange contributed to the Veteran’s development of bladder cancer. The Board reflects that the Veteran is presumed exposed to herbicide agents as a result of his service in the Republic of Vietnam from September 1970 to May 1971. See 38 C.F.R. § 3.307(a)(6)(iii) (2017). Service connection was previously service connected for diabetes mellitus, type II, based on this presumed herbicide exposure. Bladder cancer is not currently among the listed diseases for which there is a presumption of service connection based on exposure to herbicide agents under 38 C.F.R. § 3.309 (2017). However, the lack of an available presumption does not preclude proving a nexus just as in any other claim. Because of the aforementioned May 2015 medical opinion from the Veteran’s private urologist, the low threshold for obtaining a medical opinion has been met. See 38 U.S.C. § 5103A(d) (2012); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). Thus, a remand is necessary in order to obtain a VA examination that addresses whether the Veteran’s bladder cancer was at least as likely as not to have been caused by or the result of his in-service herbicide exposure. Accordingly, the case is REMANDED for the following action: Ensure that the Veteran is scheduled for a VA examination in order to determine whether his bladder cancer is due to his active service or service-connected disability. The examination should be conducted by an examiner who has not previously examined the Veteran. The claims file must be made available to and be reviewed by the examiner in conjunction with the examination. All findings should be reported in detail, and all opinions must be accompanied by a clear and complete rationale. The Board requires an opinion based on medical principles. For example, a medical opinion that relies solely on the fact that bladder cancer is not currently on the list of diseases associated with herbicide exposure under 38 C.F.R. § 3.309 (2017) would not be an adequate opinion, as it does not address the questions asked. The examiner’s opinion must include consideration of any in-service herbicide exposure, as well as the Veteran’s service-connected diabetes mellitus, type II. The examiner should consider the Veteran’s lay statements regarding onset of symptomatology and any continuity of symptomatology since onset and/or since discharge from service. The examiner should consider any other pertinent evidence of record, as appropriate. The examiner is requested to provide the following: (a) Is it as least as likely as not (a 50 percent probability or greater) that any diagnosed bladder cancer is related to the Veteran’s active service? (b) Is it as least as likely as not (a 50 percent probability or greater) that the Veteran’s bladder cancer was chronically worsened beyond its natural progression (aggravated) by his service-connected diabetes mellitus, type II? (c) Is it as least as likely as not (a 50 percent probability or greater) that the Veteran’s bladder cancer was caused by or the result of his in-service herbicide exposure? JAMES G. REINHART Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Dawn A. Leung, Associate Counsel