Citation Nr: 18155842 Decision Date: 12/06/18 Archive Date: 12/06/18 DOCKET NO. 14-11 304 DATE: December 6, 2018 ORDER Service connection for leukemia, to include as due to ionizing radiation exposure, is denied. REMANDED Entitlement to service connection for melanoma, to include as due to ionizing radiation exposure, is remanded. FINDINGS OF FACT 1. The Veteran participated in a test involving atmospheric detonation, which is a radiation risk activity, and is, therefore, a radiation-exposed Veteran. 2. The preponderance of the evidence does not show that the Veteran has been diagnosed with leukemia. CONCLUSION OF LAW The criteria for service connection for leukemia, to include as due to exposure to ionizing radiation, have not been met. §§ 1101, 1112, 1113, 1131, 1137, 1154(a), 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.311 (2018). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the Marine Corps from June 1954 to July 1956. This matter is before the Board of Veterans’ Appeals (Board) on appeal of a September 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas, that denied service connection for leukemia and melanoma (listed as cancer), to include as due to ionizing radiation exposure. In May 2016, the Veteran appeared at a Board videoconference hearing before the undersigned Veterans Law Judge. In July 2016, the Board remanded the issues of entitlement to service connection for leukemia, to include as due to ionizing radiation exposure, and entitlement to service connection for melanoma, to include as due to ionizing radiation exposure (listed as cancer, including leukemia and melanoma, to include as due to ionizing radiation exposure), for further development. In March 2018, the Board requested a Veterans Health Administration (VHA) opinion, as to the issue of entitlement to service connection for leukemia, to include as due to ionizing radiation exposure, and the VHA opinion was obtained in May 2018. In May 2018, the Board requested an additional VHA opinion, as to the same issue, and the VHA opinion was obtained in July 2018. In September 2018, the Veteran and his representative were provided with a copy of the July 2018 VHA opinion. In November 2018, the Veteran’s representative submitted additional argument in support of his appeal. The issues have been recharacterized to comport with the evidence of record. Leukemia, to include as due to Ionizing Radiation Exposure Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff’d per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table). Determinations as to service connection will be based on review of the entire evidence of record, to include all pertinent medical and lay evidence, with due consideration to VA’s policy to administer the law under a broad and liberal interpretation consistent with the facts in each individual case. 38 U.S.C. § 1154(a); 38 C.F.R. § 3.303(a). Service connection for a disorder which is claimed to be attributable to radiation exposure during service can be accomplished in three different ways. See Ramey v. Brown, 9 Vet. App. 40, 44 (1996), aff’d, 120 F.3d. 1239 (Fed. Cir. 1997). First, there are specific diseases that may be presumptively service connected if manifest in a radiation-exposed Veteran. 38 U.S.C. § 1112(c); 38 C.F.R. § 3.309(d). A “radiation-exposed” Veteran is one who participated in a radiation-risk activity. A “radiation-risk activity” includes the onsite participation in a test involving the atmospheric detonation of a nuclear device, occupation of Hiroshima or Nagasaki during World War II, or presence at certain specified sites. 38 C.F.R. § 3.309(d)(3). In applying this statutory presumption, there is no requirement for documenting the level of radiation exposure. Second, other “radiogenic” diseases, such as any form of cancer listed under 38 C.F.R. § 3.311(b)(2), found five years or more after service in an ionizing radiation-exposed Veteran may also be service-connected if the VA Under Secretary for Benefits determines that they are related to ionizing radiation exposure while in service, or if they are otherwise linked medically to ionizing radiation exposure while in service. Other claimed diseases may be considered radiogenic if the claimant has cited or submitted competent scientific or medical evidence that supports that finding. 38 C.F.R. § 3.311(b)(4). When it has been determined that: (1) a Veteran has been exposed to ionizing radiation as a result of participation in the atmospheric testing of nuclear weapons; (2) the Veteran subsequently develops a specified radiogenic disease; and (3) the disease first becomes manifest five years or more after exposure, the claim will be referred to the Under Secretary for Benefits for further consideration in accordance with 38 C.F.R. § 3.311(c). When such a claim is forwarded for review, the Under Secretary for Benefits shall consider the claim with reference to 38 C.F.R. § 3.311(e) and may request an advisory medical opinion from the Under Secretary of Health. 38 C.F.R. §§ 3.311(b), (c)(1). The medical adviser must determine whether sound scientific and medical evidence supports a conclusion that it is “at least as likely as not” that the disease resulted from in-service radiation exposure or whether there is “no reasonable possibility” that the disease resulted from in-service radiation exposure. 38 C.F.R. § 3.311(c)(1). Third, direct service connection can be established by showing that the disease or malady was incurred during or aggravated by service, a task which includes the burden of tracing causation to a condition or event during service. See Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Service connection claims based on in-service exposure to radiation may be addressed under 38 C.F.R. § 3.309(d) or § 3.311. In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and recurrence of symptoms. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran’s particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d at 1377 (Fed. Cir. 2007) (holding that “[w]hether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board”). The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C. § 7104(a) (West 2002). Moreover, the United States Court of Appeals for Veterans Claims (Court) has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran’s demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff’d per curiam, 78 F.3d 604 (Fed. Cir. 1996). In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See Id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See Id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (“[A] medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions.”). The Veteran contends that he has leukemia that is related to service, to include as due to ionizing radiation exposure. The Veteran reports that he was treated for leukemia. The Veteran specifically asserts that he was exposed to ionizing radiation while serving during Operation TEAPOT from February 1955 to March 1955. The Veteran served on active duty in the Marine Corps from June 1954 to July 1956. His available service personnel records indicate that he participated in an atomic bomb test, Operation TEAPOT, from February 1955 to March 1955. Therefore, the Veteran participated in a test involving atmospheric detonation, which is a radiation risk activity. It is conceded that the Veteran is a radiation-exposed Veteran. The Veteran’s service treatment records do not show complaints, findings, or diagnoses of leukemia. Post-service VA treatment records also do not show that the Veteran was treated for leukemia. A May 2017 VA hematologic and lymphatic conditions, including leukemia, examination report includes a notation that the Veteran’s claims file was reviewed. The Veteran reported that the date of onset of his symptoms of leukemia was unknown. He stated that his leukemia began with abnormal blood work, and that he did not know what his treatment involved. The Veteran maintained that his condition had improved. The diagnosis was leukemia (leukemia, unspecified, not having achieved remission). The examiner reported that in reviewing the diagnostic test results in regard to the clinical context of the Veteran’s claim, a CBC (Complete Blood Count) was significant for decreased absolute lymphocytes. The examiner indicated that the Veteran’s claimed leukemia was at least as likely as not (50 percent or greater probability) incurred in or caused by the claimed in-service injury, event, or illness. The examiner specifically commented that it was at least as likely as not that the Veteran’s claimed leukemia was incurred due to his conceded exposure to ionizing radiation during military service. The examiner stated that leukemia was known to be caused by exposure to high doses of radiation such as that released by the atomic bombs. The examiner reported that such radiation changed the development of the cells and led to cancer changes in the cells. A March 2018 Veterans Health Administration (VHA) opinion was provided by a specialist in internal medicine. The VHA expert reported that a review of the Veteran’s service treatment records did not reveal that he was diagnosed with, or treated for, leukemia. The expert indicated that leukemia was diagnosed by a bone marrow aspirate and a biopsy using morphologic, cytochemical, immunophenotype, and cytogenic/molecular analysis. The expert stated that a review of the record did not reveal a referral to an oncologist or a bone marrow biopsy. The expert maintained that the only abnormality noted was thrombocytopenia in the CBC. It was noted that a review of the Veteran’s records did not reveal any work-up for thrombocytopenia because his platelet count was normal on other occasions. The expert indicated that his expertise was in internal medicine and that his opinion was limited because he did not have expertise in hematology/oncology. The expert further reported that the Veteran’s treatment records did not reveal a current or past diagnosis of leukemia or any evidence that he was evaluated by an oncologist. The expert indicated that a review of a May 2017 VA hematologic and lymphatic conditions, including leukemia, examination report showed that the examiner diagnosed the Veteran with leukemia unspecified. The expert related that the examiner noted that the Veteran did not know the date of onset of his symptoms or what treatment he received. The expert stated that the remainder of the examination was unremarkable and revealed that the Veteran was asymptomatic with no treatment noted. The expert reported that the Veteran’s CBC in May 2017 was unremarkable except for decreased absolute lymphocytes. The expert related that the examiner did not report any atypical cells. The expert maintained that it was impossible to determine the examiner’s reasoning regarding the diagnosis of leukemia that was unsupported by medical evidence and documentation based on the available records. The expert indicated that further questioning of the examiner was needed to determine how she arrived at her conclusion. The expert stated that he recommended that the Veteran’s case be reviewed by a hematologist/oncologist. A July 2018 VHA opinion was provided by a specialist in hematology-oncology. The VHA expert discussed the Veteran’s medical history in some detail. The expert reported that the Veteran’s medical records were reviewed, and that his blood counts reveal slightly decreased lymphocyte counts and one episode of mild thrombocytopenia. The expert stated that a slightly low lymphocyte count, in the absence of other abnormal findings in the blood (blasts, left shift, a significant drop in other cell counts), did not indicate leukemia and that it was noted that the Veteran had none of those abnormal findings. The expert indicated that no evidence was found of leukemia, to include chronic lymphocytic leukemia, or any other type of leukemia, or any residuals of leukemia. The examiner maintained that, consequently, the question of any relationship between the Veteran’s radiation exposure and the onset of leukemia was a moot point. The first question before the Board is whether the Veteran meets the criteria for qualification as a radiation-exposed Veteran. As discussed above, the Veteran’s available service personnel records indicate that he participated in an atomic bomb test, Operation TEAPOT, from February 1955 to March 1955. Therefore, the Veteran participated in a test involving atmospheric detonation, which is a radiation risk activity, and he is a radiation-exposed Veteran. As the Veteran is considered a radiation-exposed Veteran, in order to qualify for service connection for leukemia as a result of exposure to ionizing radiation, there must be a diagnosis of leukemia, other than chronic lymphocytic leukemia. The Board observes that leukemia, other than chronic lymphocytic leukemia, is one of the diseases that shall be service-connected if it becomes manifest in a radiation-exposed Veteran. See 38 C.F.R. § 3.309(d). Therefore, the next question before the Board is whether the Veteran has been diagnosed with leukemia, other than chronic lymphocytic leukemia. The probative value of medical opinion evidence “is based on the medical expert’s personal examination of the patient, the physician’s knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches.... As is true with any piece of evidence, the credibility and weight to be attached to these opinions [are] within the province of the adjudicators...” Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). The determination of credibility is the province of the Board. It is not error for the Board to favor the opinion of one competent medical expert over that of another when the Board gives an adequate statement of reasons or bases. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). The Board notes that the examiner, pursuant to the May 2017 VA hematologic and lymphatic conditions, including leukemia, examination report diagnosed the Veteran with leukemia (leukemia, unspecified, no having achieved remission). The examiner reported that in reviewing the diagnostic test results in regard to the clinical context of the Veteran’s claim, a CBC was significant for decreased absolute lymphocytes. The examiner, following a review of the claims file, indicated that it was at least as likely as not that the Veteran’s claimed leukemia was incurred due to his conceded exposure to ionizing radiation during military service. The Board notes that although the examiner diagnosed the Veteran with leukemia (leukemia, unspecified, not having achieved remission), there are no other diagnoses of leukemia, and/or evidence of treatment for leukemia, of record. The examiner appeared to base her diagnosis on the fact that a CBC was significant for decreased absolute lymphocytes. The Board notes that the examiner did not provide any further explanation regarding the basis for her diagnosis of leukemia, or address why there was no other evidence of, or treatment for, leukemia of record prior to the May 2017 VA hematologic and lymphatic conditions, including leukemia, examination. In light of the lack of a diagnosis of leukemia, other than pursuant to the May 2017 VA hematologic and lymphatic conditions, including leukemia, examination report, and the subsequent July 2018 VHA opinion, the Board finds that the diagnosis of leukemia by the examiner, as well as her provided opinions, are not probative in this matter. The Board notes that a VHA expert, pursuant to a March 2018 VHA opinion, indicated that a review of the Veteran’s service treatment records did not reveal that he was diagnosed with, or treated for, leukemia. The expert indicated that leukemia was diagnosed by a bone marrow aspirate and a biopsy using morphologic, cytochemical, immunophenotype, and cytogenic/molecular analysis. The expert stated that a review of the record did not reveal a referral to an oncologist or a bone marrow biopsy. The expert maintained that the only abnormality noted was thrombocytopenia in the CBC, and that a review of the Veteran’s records did not reveal any work-up for thrombocytopenia because the Veteran’s platelet count was normal on other occasions. The expert further reported that the Veteran’s treatment records did not reveal a current or past diagnosis of leukemia or any evidence that he was evaluated by an oncologist. The expert maintained that it was impossible to determine the reasoning regarding the diagnosis of leukemia by the examiner, pursuant to the May 2017 VA hematologic and lymphatic conditions, including leukemia, examination report, that was unsupported by medical evidence and documentation based on the available records. The Board notes that the expert indicated that his expertise was in internal medicine and that his opinion was limited because he did not have expertise in hematology/oncology. The expert also stated that he recommended that the Veteran’s case be reviewed by a hematologist/oncologist. As the expert indicated that his opinion was limited and that the case should be reviewed by a hematologist/oncologist, the Board finds that the opinions provided by the expert, pursuant to the March 2018 VHA opinion, are less probative in this matter. The Board observes that the July 2018 VHA opinion was provided by an expert in hematology-oncology. The expert indicated that no evidence was found of leukemia, to include chronic lymphocytic leukemia, or any other type of leukemia, or any residuals of leukemia. The examiner maintained that, consequently, the question of any relationship between the Veteran’s radiation exposure and the onset of leukemia was a moot point. The Board observes that the expert reviewed the Veteran’s claims file, discussed his medical history, and provided rationales for her conclusions. Therefore, the Board finds that the opinions provided by the expert, pursuant to July 2018 VHA opinion, are the most probative in this matter. See Wensch v. Principi, 15 Vet. App. 362 (2001). The Board notes that the requirement for service connection that a current disability be present is satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim even though the disability resolves prior to the Secretary’s adjudication of the claim. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). However, Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. See 38 U.S.C. §§ 1110; 1131. In the absence of proof of present disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Degmetich v. Brown, 104 F.3d 1328 (1997) (38 U.S.C. § 1131 requires existence of present disability for VA compensation purposes). Here, the probative evidence indicates that the Veteran does not have a current diagnosis of leukemia. Thus, service connection for leukemia, to include as due to ionizing radiation exposure, is not warranted. See also 38 C.F.R. §§ 3.309, 3.311; Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). The Veteran has alleged that he has leukemia that had its onset during his period of service, to include as result of ionizing radiation exposure. The Board observes that the Veteran is competent to report symptoms he thought were due to leukemia during service, or after service, but, as a lay person, he does not have the education, training and experience to offer a medical diagnosis or an opinion as to the onset or etiology of this condition. See Kahana, see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (holding that “[l]ay evidence can be competent and sufficient to establish a diagnosis when... a lay person is competent to identify the medical condition” and providing, as an example, that a layperson would be competent to identify a condition such as a broken leg, but would not be competent to identify a form of cancer); Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir. 2010) (recognizing that in some cases lay testimony “falls short” in proving an issue that requires expert medical knowledge); Waters v. Shinseki, 601 F.3d 1274, 1278 (Fed. Cir. 2010) (concluding that a veteran’s lay belief that his schizophrenia aggravated his diabetes and hypertension was not of sufficient weight to trigger the Secretary’s duty to seek a medical opinion on the issue). The preponderance of the evidence is against the claim for entitlement to service connection for leukemia, to include as due to ionizing radiation exposure; there is no doubt to be resolved; and service connection for leukemia, to include as due to ionizing radiation exposure, is not warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND The remaining issue on appeal is entitlement to service connection for melanoma, to include as due to ionizing radiation exposure. This case was previously remanded by the board in July 2016, partly to schedule the Veteran for a VA examination to determine the onset and etiology of his claimed melanoma, to include as due to ionizing radiation exposure. The examiner was to diagnose any cancer or cancer residuals, to include melanoma. The examiner also was to provide an opinion as to whether it was at least as likely as not that any currently diagnosed cancer or cancer residuals, to include melanoma, were related to, and/or had their onset during, the Veteran’s period of service, to specifically include as due to his conceded in-service exposure to ionization radiation. Pursuant to the July 2016 Board remand, the Veteran was afforded a VA skin diseases examination in May 2017. There was a notation that the Veteran’s claims file was reviewed. The Veteran reported that his melanoma began with a physician noticing a spot on his back. He stated that he had three operations for melanoma and that the condition had stayed the same. The diagnoses were dermatitis or eczema; seborrheic keratosis; and melanoma. The examiner indicated that the date of onset for the Veteran’s melanoma was 1956. The examiner specifically reported that the Veteran was currently undergoing treatment for melanoma and that he was in watchful, waiting status. The examiner stated that the Veteran underwent two surgeries in the last five years and that the dates of the surgeries were unknown. The examiner indicated that the claimed condition was at least as likely as not (50 percent or greater probability) incurred in, or caused by, the claimed in-service injury, event, or illness. The examiner specifically maintained that the Veteran’s melanoma/cancer was incurred as a result of his conceded exposure to ionizing radiation during service. The examiner reported that 95 percent of melanoma cancers were caused too much Ultraviolet (UV) radiation. The examiner stated that the UV light changes the normal appearance of the skin cells by causing genetic damage and made them cancerous. The Board observes that the examiner diagnosed the Veteran with melanoma and related that condition to his conceded exposure to ionizing radiation during service. The Board notes, however, that there is no evidence of record that the Veteran was actually treated for, or diagnosed with, melanoma. The Board observes that the VA treatment reports of records refer to the Veteran having a family history of melanoma, and include diagnoses of rule out melanoma, but there are no actual diagnoses of melanoma in the claims file, other than pursuant to the May 2017 VA skin diseases examination report. Additionally, the Board notes that the examiner indicated that the Veteran underwent surgery on two occasions for melanoma, but that the dates of those surgeries were unknown. The Board observes that there is no evidence of surgery for melanoma of record. The Board notes, therefore, that it is unclear whether the examiner reviewed the Veteran’s entire claims file. In light of the above, the Board finds that the Veteran has not been afforded a VA examination, with the opportunity to obtain responsive etiological opinions, following a thorough review of the entire claims folder, as to his claim for service for melanoma, to include as due to ionizing radiation exposure. Such an examination must be accomplished on remand. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also Stegall v. West, 11 Vet. App. 268, 271 (1998). The matter is REMANDED for the following action: 1. Ask the Veteran to identify all medical providers who have treated him for melanoma since November 2017. After receiving this information and any necessary releases, obtain copies of the related medical records which are not already in the claims folder. Document any unsuccessful efforts to obtain the records, inform the Veteran of such, and advise him that he may obtain and submit those records himself. 2. Notify the Veteran that he may submit lay statements from himself and from other individuals who have first-hand knowledge, and/or were contemporaneously informed of any in-service and post-service symptomatology regarding his claimed melanoma, to include as due to ionizing radiation exposure. The Veteran should be provided an appropriate amount of time to submit this lay evidence. 3. Schedule the Veteran for an appropriate VA examination to determine the onset and/or etiology of his claimed melanoma, to include as due to ionizing radiation exposure. The entire claims file must be reviewed by the examiner. The examiner must specifically indicate if the Veteran has diagnosed melanoma, or residuals of melanoma. Based on a review of the claims file, examination of the Veteran, and generally accepted medical principles, the examiner must provide a medical opinion, with adequate rationale, as to whether it is as at least as likely as not that any currently diagnosed melanoma, or residuals of melanoma, are related to, and/or had their onset during, his period of service, to specifically include as due to his conceded in-service exposure to ionization radiation. The examiner must specifically acknowledge and discuss any reports by the Veteran of skin problems, including melanoma, during service and since service. The examiner must also comment on the opinions provided by the examiner, pursuant to the May 2017 VA skin diseases examination report. The examination report must include a complete rationale for all opinions expressed. 4. As necessary, the RO must develop the Veteran’s claim in accordance with the provisions of 38 C.F.R. § 3.311. The RO should document all actions that are taken and any determinations that are made. STEVEN D. REISS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. D. Regan, Counsel