Citation Nr: 18155578 Decision Date: 12/04/18 Archive Date: 12/04/18 DOCKET NO. 16-23 097 DATE: December 4, 2018 ORDER The Board having determined a 50 percent disability rating is warranted for the Veteran’s acquired psychiatric disorder for the period prior to April 12, 2017, the benefit sought on appeal is granted to this extent, subject to the criteria applicable to the payment of monetary benefits. Entitlement to a rating higher than 50 percent for an acquired psychiatric disorder for the period beginning April 12, 2017, is denied. The Board having determined a 10 percent rating is warranted for the Veteran’s right knee disability for the period prior to October 29, 2009, the benefit sought on appeal is granted to this extent, subject to the criteria applicable to the payment of monetary benefits. Entitlement to a rating higher than 20 percent for a left knee disability based on limited range of motion, the period prior to June 15, 2015, is denied. Entitlement to a rating higher than 30 percent for a left knee disability based on limitation of motion and/or post-surgery residuals, for the period beginning August 1, 2016, is denied. The Board having determined a separate 20 percent rating is warranted for left knee instability for the period beginning February 7, 2011, the benefit sought on appeal is granted to this extent, subject to the criteria applicable to the payment of monetary benefits. Reopening of the claim for service connection for prostate cancer is granted. Reopening of the claim for service connection for nasal cancer is granted. Reopening of the claim for service connection for compensation under 38 U.S.C. § 1151 for a back condition resulting from VA treatment is granted. REMANDED Entitlement to service connection for prostate cancer is remanded. Entitlement to service connection for nasal cancer is remanded. Entitlement to compensation under 38 U.S.C. § 1151 for a back condition resulting from VA treatment is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is remanded. FINDINGS OF FACT 1. Throughout the period of the claim, the Veteran’s acquired psychiatric disorder has been productive of occupational and social impairment with reduced reliability and productivity; it has not been productive of occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood; it has not been productive of total occupational and social impairment. 2. For the period prior to October 29, 2009, the Veteran’s right knee disability was productive of painful motion. 3. For the period prior June 30, 2015, the Veteran’s left knee disability did not manifest as extension limited to 20 degrees or more or flexion limited to 15 degrees or less. 4. For the period beginning August 1, 2016, the Veteran’s left knee disability qualified for the minimum rating based on post-knee replacement residuals; the left knee disability did not manifest as chronic residuals consisting of severe painful motion or weakness in the affected extremity; it did not manifest as extension limited to 30 degrees or more. 5. For the period beginning February 7, 2011, the Veteran’s left knee disability was productive of moderate instability; it was not productive of severe instability. CONCLUSIONS OF LAW 1. For the period prior to April 12, 2017, the criteria for a 50 percent rating, but not higher, for an acquired psychiatric disorder, were met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Codes (DCs) 9411, 9434 (2017). 2. For the period beginning April 12, 2017, the criteria for a rating higher than 50 percent, for an acquired psychiatric disorder, have not been met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.7, 4.130, DCs 9411, 9434 (2017). 3. For the period prior to October 29, 2009, the criteria for a 10 percent rating, but not higher, for a right knee disability, were met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.59, 4.71a, DC 5260 (2017). 4. For the period prior to June 30, 2015, the criteria for a rating higher than 20 percent for the Veteran’s left knee disability, based on limitation of motion, were not met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.7, 4.71a, DCs 5260-5261 (2017). 5. For the period beginning August 1, 2016, the criteria for a rating higher than 30 percent for the Veteran’s left knee disability, based on limitation of motion and/or surgery residuals, have not been met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.7, 4.130, DCs 5055, 5260-5261 (2017). 6. For the period beginning February 7, 2011, the criteria for a separate 20 percent rating for the Veteran’s left knee disability, but not higher, have been met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.7, 4.130, DC 5257 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Introduction The Veteran served on active duty from June 1974 to June 1977 and from February 2004 to January 2005. This matter comes before the Board of Veterans’ Appeals (Board) on appeal of rating decisions issued by the Department of Veterans Affairs (VA) Regional Offices (ROs). In December 2015, the Board remanded this case for additional development. The case has now been returned to the Board for further appellate consideration. The scope of a mental health claim includes any mental disability that may reasonably be encompassed by the claimant’s description of the claim, reported symptoms, and other information of record. Clemons v. Shinseki, 23 Vet. App. 1 (2009). The record shows the Veteran’s psychiatric symptoms have been variously diagnosed. As such, the Board refers to the Veteran’s psychiatric condition broadly, as an acquired psychiatric disorder, herein. The Veteran’s claims for service connection for prostate cancer and nasal cancer were originally denied in a February 2010 rating decision on the basis that the conditions were neither incurred in nor related to service. The February 2010 decision became final because the Veteran did not submit a Notice of Disagreement or new evidence in connection with the claims within the appeal period. See 38 C.F.R. § 3.156(b) (2017). In connection with the Veteran’s claims to reopen, he has submitted additional evidence, to include medical articles detailing the health risks, to include cancer, of exposure to burn pits and other toxins. Under these circumstances, the Board finds that new and material evidence has been received sufficient to reopen the Veteran’s previously denied claims. See 38 C.F.R. § 3.156(a) (2017); Shade v. Shinseki, 24 Vet. App. 110, 117-18 (2010); Justus v. Principi, 3 Vet. App. 510, 513 (1992). The Veteran’s claim for compensation under 38 U.S.C. § 1151 for a back condition resulting from VA treatment was originally denied in a June 2013 rating decision on the basis that the medical care provided by VA was proper. The June 2013 decision became final because the Veteran did not submit a Notice of Disagreement or new evidence in connection with the claims within the appeal period. See 38 C.F.R. § 3.156(b) (2017). In connection with the Veteran’s claim to reopen, he has submitted additional evidence, to include March 2018 arguments by his representative further detailing the claimed connection between his back disability and VA treatment. Under these circumstances, the Board finds that new and material evidence has been received sufficient to reopen the Veteran’s previously denied claim. See 38 C.F.R. § 3.156(a) (2017); Shade v. Shinseki, 24 Vet. App. 110, 117-18 (2010); Justus v. Principi, 3 Vet. App. 510, 513 (1992). General Legal Criteria Disability evaluations are determined by the application of VA’s Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2017). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.321 (a), 4.1 (2017). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2017). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary 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. § 5107 (2012); 38 C.F.R. § 3.102 (2017); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Background and Analysis The Board has reviewed all of the evidence of record, with an emphasis on the evidence relevant to the Veteran’s claims. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate and the Board’s analysis below will focus specifically on what the evidence shows, or fails to show, as to the Veteran’s claims. Increased rating for an acquired psychiatric disorder The Veteran’s acquired psychiatric disorder is rated under the General Rating Formula for Mental Disorders. Under this formula, in pertinent part, a 10 percent rating is warranted for occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. A 30 percent rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood; anxiety; suspiciousness; panic attacks (weekly or less often); chronic sleep impairment; and mild memory loss (such as forgetting names, directions, or recent events). A 50 percent rating is warranted for 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 (e.g., 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. A 70 percent rating is warranted for 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 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 worklike setting); and inability to establish and maintain effective relationships. A 100 percent rating is warranted for total occupational and social impairment due to such symptoms as: gross impairment in thought process or communication; 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 or place; and memory loss for names of close relatives, own occupation, or own name. See 38 C.F.R. § 4.130, DCs 9411, 9434 (2017). The symptoms considered in determining the level of impairment under the General Rating Formula for Mental Disorders are not restricted to the symptoms provided in the diagnostic code. Instead, VA must consider all symptoms of a claimant’s condition that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). Mauerhan v. Principi, 16 Vet. App. 436 (2002). The Veteran is currently assigned a staged rating for his service-connected acquired psychiatric disorder. For the period beginning January 8, 2005, he is assigned a 10 percent rating. For the period beginning December 23, 2010, he is assigned a 30 percent rating. For the period beginning April 12, 2017, he is assigned a 50 percent rating. The Veteran was afforded a VA psychiatric examination in March 2006. He reported he was quite active and liked to run and cycle, that he lived alone in an apartment, and that he worked odd jobs, which he did not like. It was noted, however, that he did not report any occupational impairment. His symptoms were noted to include being easily startled, difficulty sleeping, feeling detached, and re-experiencing distressing events. A “mild to moderate” anxiety disorder was diagnosed. The Veteran was afforded an additional VA psychiatric examination in October 2009. He reported his primary symptoms were that he was startled very easily and that he had problems sleeping due to nightmares and/or loud noises. He also reported having occasional flashbacks, and that he had problems with anger. The Veteran reported he had a small group of close friends, including a best friend who served in Iraq with him. He also reported being close with his mother, although he did not visit her when it was hot because her location in Tucson reminded him of Iraq. The Veteran further reported that his life was not very full, and that he basically just sat around and watched television. He reported that he regularly volunteered with a VA Clinic and an environmental organization, and had no problems or disciplinary actions in either of these positions, but was frustrated he was not earning any money. The examiner diagnosed mild posttraumatic stress disorder (PTSD) and stated that, regarding functional impairment, the Veteran did not report a large problem in his daily life, and denied having any occupational problems. The examiner noted, however, that any potential impairment could be limited due to the fact the Veteran was only volunteering. The examiner further stated there was some indication that the Veteran’s social life was impaired, but stated that it was difficult to determine the level of impairment since the Veteran also reported having few friends prior to his deployment to Iraq. The Veteran was afforded an additional VA psychiatric examination in November 2012. The Veteran reported he experienced dreams and nightmares involving mortar attacks in Iraq, and that he had become more hypervigilant than reported at his last evaluation. It was noted the Veteran had one brother, two sisters, and a mother, and that he got along with one sister. He also reported he had three close friends he saw on a weekly basis, and that he enjoyed taking aqua aerobics classes through the VA and making canes as a hobby. The examiner indicated the Veteran’s symptoms included depressed mood, anxiety, and chronic sleep impairment, and stated he continued to suffer mild to moderate PTSD with secondary symptoms of depression. The examiner further elaborated, stating the Veteran suffered from mild social impairment due to his need to avoid crowds, and at least mild occupational impairment due to concentration problems. The Veteran was afforded an additional VA psychiatric examination in January 2013. The examiner indicated the Veteran had 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. The examiner indicated the Veteran’s symptoms included depressed mood, anxiety, and chronic sleep impairment. The Veteran was afforded a final VA psychiatric examination in April 2017. He reported he had been feeling restless, uneasy, overwhelmed, and stressed in relation to limited mobility caused by his service-connected knee replacements. He stated he was able to relax by watching television or playing mahjong, and that he found acupuncture helped as well. He denied any significant depressive symptoms, and reported his sleep was good. He did report that he avoided crowds, for example by going to the grocery store on weekdays instead of on weekends, due to heightened anxiety in crowded places. He reported he occasionally woke up feeling awful, but that his service dog helped him stay calm. He reported having flashbacks and holding a lot of anger inside, as well as feeling detachment from others, but he stated this was getting better. He further reported he lived with his service dog, and had been occupied recently taking care of his elderly mother. He reported enjoying walking his dog, tending to his home, pruning his trees, and traveling occasionally. The examiner indicated the Veteran had 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. The Board has thoroughly reviewed the foregoing and the entire record, to include all of the Veteran’s post-service outpatient psychiatric records. After careful consideration, the Board has determined that for the period prior to April 12, 2017, the Veteran’s service-connected acquired psychiatric disorder was productive of occupational and social impairment with reduced reliability and productivity. In this regard, the Board notes that the Veteran’s reported symptoms during this period included depressed mood, anxiety, sleep impairment, and hypervigilance. These symptoms caused the Veteran to self-isolate and to avoid crowded places, and thus, clearly resulted in at least a moderate level of occupational and social impairment. Based on the foregoing, the Board finds a 50 percent rating is warranted for the Veteran’s acquired psychiatric disorder for the period prior to April 12, 2017. However, upon a review of the record, there is no evidence at any time during the period of the claim of suicidal ideation, obsessional rituals which interfere with routine activities, illogical, obscure, or irrelevant speech, near-continuous panic or depression, impaired impulse control, spatial disorientation, or neglect of personal appearance and hygiene. In addition, although the evidence shows some level of impairment with respect to adapting to stressful circumstances and in establishing and maintaining effective relationships, the record shows the Veteran has maintained successful social relationships with friends and family throughout the period of the claim. In addition, the Board notes there is no evidence during the period of the claim of gross impairment in thought process or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others, intermittent inability to perform activities of daily living, disorientation to time or place, or memory loss for names of close relatives, or own occupation, or own name. In sum, the Board finds the evidence does not show the Veteran’s acquired psychiatric disorder has been productive of occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, or that it has been productive of total occupational and social impairment, at any time during the period of the claim. Accordingly, the Board has determined a rating higher than 50 percent for the Veteran’s acquired psychiatric disorder is not warranted either before or after April 12, 2017. Compensable rating for a right knee disability prior to October 29, 2009 The Veteran filed a claim for service connection for a right knee disability in October 2007. Service connection for right knee degenerative joint disease was granted in a September 2009 rating decision, and the RO assigned a noncompensable rating pending the scheduling of a VA examination to determine the severity of the condition. A VA examination was provided on October 29, 2009. The examiner noted the Veteran experienced right knee pain during activities, to include walking, using stairs, or stepping onto a curb. At this juncture, the Board notes that under 38 C.F.R. § 4.59, painful joints are entitled to at least the minimum compensable rating applicable to the disability at issue. Pursuant to § 4.59, the RO assigned a 10 percent rating for the Veteran’s right knee disability in a June 2013 rating decision. The 10 percent rating was made effective on October 29, 2009, the date of the Veteran’s VA examination. Correspondence of record – to include April 2014, May 2015, May 2016, and May 2017 documents – makes clear that the Veteran seeks to appeal only the RO’s decision not to assign a compensable rating for his right knee disability prior to October 29, 2009. He has not appealed the rating assigned for the period beginning October 29, 2009. In this regard, the Board observes the record shows the Veteran’s right knee degenerative joint disease was confirmed by X-rays as early as July 31, 2007. At his October 2009 examination, the Veteran reported right knee pain. There is no indication in the examination report that the knee pain had originated recently. Based on the foregoing, and after having resolved reasonable doubt in favor of the Veteran, the Board finds the evidence is in equipoise as to whether the Veteran experienced painful right knee joint motion throughout the period prior to October 29, 2009. Accordingly, granting of a 10 percent rating for the Veteran’s right knee disability for the period prior to October 29, 2009, is in order. After a review of the record, there is no evidence prior to October 29, 2009, of limitation of flexion of the right leg to 30 degrees or less, limitation of extension of the right leg to 15 degrees or more, or of right knee instability. Accordingly, a rating higher than 10 percent for the period prior to October 29, 2009, is not warranted. See 38 C.F.R. § 4.71a, DCs 5257, 5260-5261 (2017). Increased rating for a left knee disability The Veteran is currently assigned a staged disability rating for his left knee disability. A 20 percent rating is assigned for the period beginning January 8, 2005. The Veteran underwent left knee replacement surgery on June 15, 2015. Thus, a 100 percent rating is assigned beginning June 15, 2015. A 30 percent rating is assigned for the period beginning August 1, 2016. The Veteran’s left knee disability has been rated under 38 C.F.R. § 4.71a, DCs 5055 and 5260-5261. Under DC 5055, a 100 percent rating is warranted for one year following knee replacement surgery. Thereafter, 30 percent is the minimum rating. A 60 percent rating is warranted for chronic residuals consisting of severe painful motion or weakness in the affected extremity. Under DC 5260, a 20 percent rating is warranted for leg flexion limited to 30 degrees. A 30 percent rating is warranted for leg flexion limited to 15 degrees. Under DC 5261, a 20 percent rating is warranted for leg extension limited to 15 degrees. A 30 percent rating is warranted for leg extension limited to 20 degrees. A 40 percent rating is warranted for leg extension limited to 30 degrees. A 50 percent rating is warranted for leg extension limited to 45 degrees. The Veteran was afforded a VA examination in February 2006. The examiner noted range of motion was from 0 to 135 degrees actively and passively, and stated it was within reason to believe the Veteran would lose between 10 and 15 degrees of range of motion due to his left knee disability. On the basis of the February 2006 examination results, the RO granted service connection for the Veteran’s left knee disability in an August 2007 rating decision and assigned a 20 percent rating. The Veteran was afforded an additional VA examination in February 2009. Range of motion testing revealed negative 5 degrees of extension and 130 degrees of flexion. The Veteran was afforded an additional VA examination in October 2009. Range of motion testing showed 5 degrees of hyperextension, and 130 degrees of flexion. The Veteran was afforded an additional VA examination in February 2011. Range of motion testing showed there was left knee flexion to 130 degrees, and extension was normal. The examiner also noted the Veteran’s reports that his symptoms included pain, popping, occasional stiffness, giving way, and a feeling of instability. The examiner indicated “YES” for instability. The examiner indicated the Veteran’s left knee disability caused moderate effects in the areas of exercise, sports, recreation, and traveling. The Veteran was afforded an additional VA examination in November 2012. Left knee flexion was 125 degrees, and extension was normal. The Veteran was afforded an additional VA examination in January 2013. Left knee flexion was 135 degrees, and extension was normal. The Veteran was afforded a final VA examination in April 2017. Left knee flexion was to 140 degrees, and extension as normal. The Board has carefully reviewed the foregoing and the entire record, to include all post-service outpatient treatment records. First, regarding the period prior to June 15, 2015, there is no medical evidence showing limitation of flexion of the left leg to 15 degrees or less, or of limitation of extension of the leg to 20 degrees or more. Accordingly, the Board finds a rating higher than 20 percent for the Veteran’s left knee disability based on limitation of motion is not warranted for the period prior to June 15, 2015. Regarding the period beginning August 1, 2016, the Board observes there is no medical evidence showing limitation of extension of the left leg to 30 degrees or more. In addition, there is no medical evidence indicating chronic residuals from the Veteran’s left knee replacement surgery consisting of severe painful motion or weakness in the affected extremity. Accordingly, the Board finds a rating higher than 30 percent for the Veteran’s left knee disability based on limitation of motion and/or the severity of post-surgery residuals is not warranted for the period beginning August 1, 2016. The Board observes, however, that the Veteran’s representative has asserted the Veteran is entitled to a separate rating based on left knee instability. In this regard, the Board notes that under 38 C.F.R. § 4.71a, DC 5257, a 10 percent rating is warranted for slight knee instability, a 20 percent rating is warranted for moderate knee instability, and a 30 percent rating is warranted for severe knee instability. Upon review of the February 2011 VA examination report referenced above, the examiner clearly indicated the Veteran had left knee instability. Although the examiner did not appear to assess the severity of the instability itself, he indicated the overall effects of the Veteran’s left knee symptoms were moderate. After careful consideration, and after having resolved reasonable doubt in favor of the Veteran, the Board finds his left knee disability has manifested as moderate instability for the period beginning February 7, 2011, the date of the examination discussed above. Accordingly, the Board finds a separate 20 percent rating for left knee instability is warranted beginning February 7, 2011. REMAND The Board finds additional development is required before the Veteran’s remaining claims are decided. At the outset, the Board notes that VA must provide a medical examination or obtain a medical opinion when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service, or establishing that certain diseases manifested during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran’s service or with another service-connected disability, but (4) there is insufficient competent medical evidence on file for the Secretary to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also 38 U.S.C. § 5103A(d)(2) (2012); 38 C.F.R. § 3.159(c)(4)(i) (2017). The third prong, which requires that the evidence of record “indicate” that the claimed disability or symptoms “may be” associated with the established event, disease or injury is a low threshold. McLendon, 20 Vet. App. at 83. In addition, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). To be considered adequate, a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). In addition, a medical examiner is not free to simply ignore a veteran’s lay statements recounting symptoms or events. Dalton v. Nicholson, 21 Vet. App. 23 (2007). Service connection for prostate and nasal cancer The record shows the Veteran has been diagnosed with prostate cancer, and underwent a prostatectomy. The record also shows he has been diagnosed with nasal cancer. He has contended both conditions were caused by in-service exposure to depleted uranium and/or toxic chemicals emanating from burn pits while he was stationed in Iraq. The Veteran has not been afforded a VA examination to assess the etiology of his nasal cancer. He was afforded a VA examination regarding his prostate cancer in December 2009. The examiner noted the Veteran had been diagnosed with prostate cancer, and noted his claims of exposure to depleted uranium as well as pesticides and noxious fumes from burn pits (including medical waste, rubber, and human waste) while stationed in Kuwait. Ultimately, the examiner opined he could not provide any definitive opinion regarding cause and effect without resorting to mere speculation. The Board first notes that the examiner appears to have employed a heightened standard of proof in providing his opinion. That is, whereas VA requested the examiner determine whether it was at least as likely as not the Veteran’s prostate cancer was associated with his service, the examiner failed to provide an opinion because he determined he could not do so with certainty. In addition, upon review, the Board observes that in support of his opinion, although the examiner discussed medical literature regarding exposure to ionizing radiation, he provided no discussion of literature or any other medical explanation related to the Veteran’s claimed burn pit exposure. In this regard, the Board notes that subsequent to the examination, the Veteran’s representative submitted medical literature addressing the detrimental health effects, including cancer, associated with exposure to dioxins from burning trash, benzene, and burn pits in general. Under these circumstances, the Board finds the October 2009 VA examination report is inadequate for adjudication purposes. Thus, the Board finds a remand is warranted for additional VA opinions, following examinations, if indicated, regarding the etiology of the Veteran’s prostate and nasal cancers. Compensation under 38 U.S.C. § 1151 The record shows the Veteran underwent a prostatectomy at a VA facility in February 2010. He subsequently developed back pain and night sweats, which led to a May 2010 emergency department diagnosis of compression/burst fracture of T12 suggestive of underlying osseous destructive process, such as malignancy or infection. He subsequently underwent surgery in which, apparently, several of his vertebrae had to be fused. The Veteran filed a claim for compensation for his lower back disability under 38 U.S.C. § 1151 in July 2010. In this regard, the Board notes that when a veteran suffers additional disability or death as the result of training, hospital care, medical or surgical treatment, or an examination by VA, disability compensation shall be awarded in the same manner as if such additional disability or death were service-connected. 38 U.S.C. § 1151 (2012); 38 C.F.R. § 3.361 (2017). To substantiate a claim for disability compensation under 38 U.S.C. § 1151 filed on or after October 1, 1997, as here, it must be shown that the VA treatment in question resulted in additional disability or death and that the proximate cause of the disability was carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA’s part in furnishing the medical or surgical treatment, or that the proximate cause of additional disability or death was an event which was not reasonably foreseeable. See VAOPGCPREC 40-97; 38 U.S.C. § 1151 (2012); 38 C.F.R. § 3.361 (2017). To establish actual causation, the evidence must show that the hospital care or medical or surgical treatment resulted in the veteran’s additional disability or death. Merely showing that a veteran received care, treatment, or examination and that he had additional disability or died does not establish cause. 38 C.F.R. § 3.361(c) (2017). To establish that fault on the part of VA caused the additional disability or death, it must be shown that VA hospital care, medical or surgical treatment or examination caused a veteran’s additional disability and that VA failed to exercise the degree of care expected of a reasonable health care provider, or furnished the hospital care, medical treatment, or surgery without the veteran’s informed consent. Whether the proximate cause of a veteran’s additional disability or death was an event not reasonably foreseeable is to be determined based on what a reasonable health care provider would have seen. The event need not be completely unforeseeable or unimaginable but must be one that a reasonable health-care provider would not have considered to be an ordinary risk of the treatment provided. In determining whether an event was reasonably foreseeable, VA will consider whether the risk of that event was the type of risk that a reasonable health-care provider would have disclosed in connection with the informed consent procedures of 38 C.F.R. § 17.32. 38 C.F.R. § 3.361(d)(2) (2017). The Veteran was afforded a VA examination in January 2013. The examiner diagnosed degenerative disc and joint disease with spinal stenosis, as well as osteomyelitis (bone infection) at T11-T12, following February 2010 prostate surgery. The examiner ultimately opined it was less likely than not the Veteran’s back condition was caused by or became worse as a result of carelessness, negligence, lack of skill, or similar incidence of fault on the part of the attending VA personnel. In support of his opinion, the examiner simply stated the medical record documented appropriate medical care. The examiner further opined it was less likely than not that the Veteran’s back condition resulted from an event that could not have reasonably been foreseen by a reasonable healthcare provider, or from failure on the part of VA to timely diagnose and/or properly treat the back injury. In support of his opinion, the examiner stated there was no evidence identified in the medical record that timely diagnosis and/or proper treatment was delayed or not carried out. Upon review of the foregoing, the Board observes the January 2013 opinion appears to be based entirely on a lack of evidence showing improper care by VA personnel. The examiner does not, however, provide any medical explanation for his opinion that the VA care in question was proper, such as, for example, by explaining the procedures from a medical standpoint, to include their foreseeable risks. The examiner, instead, provides only a cursory and conclusory statement that VA care was proper, with no medical explanation. For this reason, the Board finds the January 2013 medical opinion is inadequate for adjudication purposes. As such, a remand for an additional opinion, following an examination, if indicated, is warranted. TDIU The Veteran has claimed entitlement to a TDIU. A review of the record, however, shows he has not submitted a VA Form 21-8940 (Application for Increased Compensation Based on Unemployability), or otherwise provided a detailed employment history. As such, the Board finds a remand is warranted in order to solicit a completed VA Form 21-8940 from the Veteran detailing his work history and current employment status, along with any other evidence relevant to the issue of entitlement to a TDIU. The matter is REMANDED for the following actions: 1. Undertake appropriate development to obtain any outstanding records pertinent to the Veteran’s claims. If any requested records are not available, the record should be annotated to reflect such and the Veteran notified in accordance with 38 C.F.R. § 3.159(e). 2. Solicit a completed VA Form 21-8940 (Application for Increased Compensation Based on Unemployability) from the Veteran, in addition to any other evidence relevant to the issue of entitlement to a TDIU. 3. Forward the Veteran’s claims file to a qualified examiner for an opinion regarding the etiology of his prostate cancer. If the examiner determines an additional examination is indicated, such an examination should be scheduled. Following a review of the relevant records and lay statements, and an additional examination if indicated, the examiner should state whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s prostate cancer originated during or is otherwise etiologically related to his military service. In providing his or her opinion, the examiner should address the Veteran’s contention that his prostate cancer is associated with his in-service exposure to depleted uranium and/or dioxins, benzene, and other toxins emanating from burn pits he was exposed to in Iraq. The examiner must also address the medical literature submitted by the Veteran detailing the health risks, to include cancer, linked with dioxins, benzene, and other toxins associated with burn pits. The examiner must provide a rationale for any proffered opinion. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 4. Forward the Veteran’s claims file to a qualified examiner for an opinion regarding the etiology of his nasal cancer. If the examiner determines an additional examination is indicated, such an examination should be scheduled. Following a review of the relevant records and lay statements, and an additional examination if indicated, the examiner should state whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s nasal cancer originated during or is otherwise etiologically related to his military service. In providing his or her opinion, the examiner should address the Veteran’s contention that his nasal cancer is associated with his in-service exposure to depleted uranium and/or dioxins, benzene, and other toxins emanating from burn pits he was exposed to in Iraq. The examiner must also address the medical literature submitted by the Veteran detailing the health risks, to include cancer, linked with dioxins, benzene, and other toxins associated with burn pits. The examiner must provide a rationale for any proffered opinion. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 5. Forward the Veteran’s claims file to a qualified examiner to fully assess the nature and etiology of his claimed back disability caused by a staph infection associated with a prostatectomy performed at a VA facility. If the examiner determines an examination is indicated, such an examination should be scheduled. Following a review of the relevant records and lay statements, and an additional VA examination if indicated, the examiner should identify all back disabilities (to include osteomyelitis, degenerative disc disease, and degenerative joint disease) that were caused by a staph infection resulting from the Veteran’s February 2010 prostatectomy performed at a VA facility. Then, with respect to each identified back disability, the examiner should state whether it is at least as likely as not (50 percent probability or greater) that the additional disability or some portion of the additional disability is due to carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA’s part in providing the February 2010 surgery or other treatment. In providing this opinion, the examiner should consider whether VA failed to exercise the degree of care expected of a reasonable health care provider. If the examiner answers the above question in the negative, he or she should state whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s back disability was an event which was not reasonably foreseeable. In providing his or her opinion, the examiner is advised that the event/disability need not be completely unforeseeable or unimaginable, but must be one that a reasonable health-care provider would not have considered to be an ordinary risk of the treatment provided. In determining whether an event was reasonably foreseeable, the examiner should consider whether the risk of the Veteran’s current back disability was the type of risk that a reasonable health-care provider would have disclosed in connection with the informed consent procedures. The examiner must provide a rationale for any proffered opinion. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 6. Undertake any other development determined to be warranted. 7. Then, readjudicate the issues on appeal. If the benefits sought on appeal are not granted to the Veteran’s satisfaction, the Veteran and his representative should be furnished an appropriate supplemental statement of the case and be afforded the requisite opportunity to respond. Thereafter, the case should be returned to the Board for further appellate consideration. T. REYNOLDS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Hampton, Associate Counsel