Citation Nr: 18157678 Decision Date: 12/14/18 Archive Date: 12/13/18 DOCKET NO. 12-01 053 DATE: December 14, 2018 REMANDED Entitlement to service connection for residuals of a right femur fracture, to include as secondary to service-connected prostate cancer is remanded. Entitlement to service connection for a gastrointestinal disorder is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1972 to June 1974. In January 2014, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge. A transcript of the hearing is in the record. This case was previously before the Board in May 2017, at which time the claims were remanded for additional development. Another remand is needed before the Board can adjudicate the Veteran’s claims. 1. Entitlement to service connection for residuals of a right femur fracture, to include as secondary to service-connected prostate cancer is remanded. The Board remanded the Veteran’s claim in May 2017 to afford the Veteran a VA examination, in part, to determine what residual conditions the Veteran experienced relating to his May 2008 right femur fracture. A June 2018 VA examination report noted that the Veteran experienced pain in the right hip with limited motion. However, the examiner did not actually state whether this functional impairment resulted from the Veteran’s past femur fracture. No other residual condition related to the Veteran’s femur fracture was identified. Further, the examiner incorrectly restated and answered the question presented from the Board’s remand as “whether the fracture of the femur is related to military service,” when the May 2017 remand instructions specifically asked the examiner to provide an opinion on whether it was at least as likely as not that any residuals of the Veteran’s right femur fracture were caused or aggravated by his osteopenia. In light of these deficiencies, remand is needed for a new VA examination, preferably with a different VA examiner, that answers the questions presented in the May 2017 Board remand. See Stegall v. West, 11 Vet. App. 268 (1998). 2. Entitlement to service connection for a gastrointestinal disorder is remanded. There are opinions dated in September 2017 and June 2018 regarding this issue. However, neither opinion adequately addresses the Veteran’s lay statements concerning the onset and continuity of his symptoms. As such, an addendum opinion is needed, preferably from a different VA examiner. Since the claims file is being returned it should be updated to include any outstanding VA treatment records. See 38 C.F.R. § 3.159 (c)(2); see also Bell v. Derwinski, 2 Vet. App. 611 (1992). The matters are REMANDED for the following action: 1. Obtain and associate with the claims file any outstanding VA treatment records regarding the Veteran dated from September 2017 to the present. 2. Then schedule the Veteran for an appropriate VA examination – preferably with a different VA examiner – to determine the nature and likely etiology regarding his residuals of a right femur fracture. The examiner should review the claims file and conduct all appropriate tests and studies. All clinical findings should be reported in detail. After a review of the Veteran’s claims file, the examiner is asked to address the following questions: (a) Please identify all residual conditions relating to the Veteran’s May 2008 right femur fracture. (b) Is it at least as likely as not (i.e., probability of 50 percent or greater) that any residuals of the Veteran’s right femur fracture were caused or aggravated by his osteopenia? The examiner should specifically comment on whether it is at least as likely as not that osteopenia would predispose the Veteran to suffering a bone fracture. In answering this question, the examiner should consider and discuss as necessary the following: (i) medical records related to his May 2008 bicycle accident; (ii) the June 2008 DXA scan results which noted “fracture risk is moderate;” and (iii) as well as a March 2011 VA opinion that it is likely that the Veteran’s osteopenia was related to his service-connected prostate cancer A full rationale is to be provided for all stated medical opinions. If the examiner concludes that the requested opinion cannot be provided without resort to speculation, the examiner should so state and explain why this opinion would be speculative and what, if any, additional evidence would permit such an opinion to be made. 3. Then obtain an addendum opinion regarding the Veteran’s service connection claim for a gastrointestinal disorder. The claims file, to include a copy of this Remand, must be made available to the examiner for review prior to the exam. If the opinion provider determines that an opinion cannot be provided without an examination, the Veteran should be scheduled for an appropriate examination. Based on the examination, if deemed necessary, and review of the record, the examiner is requested to provide an opinion addressing the following question: Is it at least as likely as not (50 percent or higher probability) that the Veteran’s diagnosed irritable bowel syndrome had its onset in or is otherwise related to active duty service? The opinion provided thus far on this determinative issue has not included the required level of explanation or rationale. To wit, in attempting to comment on this determinative issue of causation, the September 2014 VA examiner impermissibly relied on the absence of indication of actual treatment during the Veteran’s active duty service, such as would be reflected in service treatment records (STRs). The VA examiner cannot rely exclusively on the absence of relevant treatment in the medical records for concluding instead that the Veteran’s gastrointestinal problems are not related to his active duty service. In answering this question, the examiner should consider and discuss as necessary the following: (i) the Veteran’s lay statements concerning the onset and frequency of his symptoms; (ii) service treatment records documenting that the Veteran was admitted in November 1973 to the emergency room of Cutler Army Hospital at Ft. Devens with “crampy abdominal pain of approximately 24 hours duration.” He was diagnosed with probable small bowel obstruction secondary to adhesions. A full rationale is to be provided for all stated medical opinions. If an opinion cannot be made without resort to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. M. E. Larkin Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Jack S. Komperda, Counsel