Citation Nr: 18158099 Decision Date: 12/14/18 Archive Date: 12/14/18 DOCKET NO. 09-18 371 DATE: December 14, 2018 REMANDED Entitlement to service connection for diabetes mellitus, to include as due to radiation exposure, is remanded. Entitlement to service connection for vision problems, to include as due to radiation exposure, is remanded. Entitlement to service connection for residuals of a stroke, to include as due to radiation exposure, is remanded. Entitlement to service connection for bilateral foot rash (tinea cruris), to include as due to radiation exposure, is remanded. Entitlement to service connection for residuals of tumors (lipomas), to include as due to radiation exposure, is remanded. Entitlement to service connection for loss of sense of smell, to include as due to radiation exposure, is remanded. Entitlement to service connection for multiple joint and bone pain, to include as due to radiation exposure, is remanded. Entitlement to service connection for hypertension, to include as due to radiation exposure, is remanded. Entitlement to service connection for cardiomyopathy, to include as due to radiation exposure, is remanded. Entitlement to service connection for right hand numbness, to include as due to radiation exposure, is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1960 to October 1963. In June 2015, the Board issued a decision denying the Veteran’s claims for service connection. The Veteran appealed the decision to the United States Court of Appeals for Veterans Claims (Court). In November 2016, the Court issued a Memorandum Decision which vacated and remanded the June 2015 Board decision. In September 2017, the Board remanded the appeal to the AOJ to obtain VA examinations and review of the case by the Under Secretary for Health. The appeal has now been returned to the Board for further adjudication. 1. Entitlement to service connection for diabetes mellitus, to include as due to radiation exposure, is remanded. 2. Entitlement to service connection for vision problems, to include as due to radiation exposure, is remanded. 3. Entitlement to service connection for residuals of a stroke, to include as due to radiation exposure, is remanded. 4. Entitlement to service connection for bilateral foot rash (tinea cruris), to include as due to radiation exposure, is remanded. 5. Entitlement to service connection for residuals of tumors (lipomas), to include as due to radiation exposure, is remanded. 6. Entitlement to service connection for loss of sense of smell, to include as due to radiation exposure, is remanded. 7. Entitlement to service connection for multiple joint and bone pain, to include as due to radiation exposure, is remanded. 8. Entitlement to service connection for hypertension, to include as due to radiation exposure, is remanded. 9. Entitlement to service connection for cardiomyopathy, to include as due to radiation exposure, is remanded. 10. Entitlement to service connection for right hand numbness, to include as due to radiation exposure, is remanded. Unfortunately, there has not been substantial compliance with the Board’s previous remand directives regarding the issues on appeal. Another remand is required. Stegall v. West, 11 Vet. App. 268, 271 (1998). First, the Board’s September 2017 remand contained the following instruction regarding lipomas: Schedule the Veteran for appropriate examination to determine the nature and etiology of his lipomas. In particular, the examiner is requested to determine whether the Veteran’s lipomas may be medically classified as a form of “lymphoma.” The examiner’s attention is directed towards May 2002 and August 2003 pathology reports diagnosing lipomas (emphasis added). A November 2017 examiner noted that the Veteran had lipomas that had been excised, and determined there was no pathological relationship between lipomas and ionizing radiation. However, the examiner did not address whether the Veteran’s lipomas may be medically classified as a form of “lymphoma.” The AOJ must obtain an additional VA opinion addressing this issue. Second, the Board’s September 2017 remand contained the following instruction regarding bilateral foot rash: The examiner should accept the Veteran’s testimony of manifesting a foot rash in service although not documented as well as the August 1963 Report of Medical History and Report of Medical Examination. The examiner is requested to explain whether there is any medical reason to accept or reject the Veteran’s belief that his current bilateral foot rash had an in-service onset or is otherwise related to service (emphasis in original). The November 2017 examiner determined that the current bilateral foot dermatitis was less likely than not related to radiation exposure. The examiner indicates that the “Veteran states that he has not seen the same skin rash on his feet as he did while he was in service.” No additional rationale was provided. On remand, the AOJ must obtain an additional VA opinion that provides a rationale regarding the etiology of the bilateral foot rash, and address whether there is any medical reason to accept or reject the Veteran’s previous statements that the current disorder is related to service. Finally, the Board’s September 2017 remand instructed the AOJ to obtain a further review of the Veteran’s claims from the Under Secretary for Benefits after obtaining a dose estimate total of the Veteran’s ionizing radiation exposure from the Under Secretary of Health. The claims file contains a comprehensive radiation exposure review from the entity authorized by the Under Secretary of Health. See February 2018 and March 2018 Memorandums. While the March 2018 memorandum notes the opinion of the entity authorized by the Under Secretary of Health that the Veteran’s radiation dose did not cause the Veteran’s current health problems, the opinion does not address treatment records in the claims file with a positive nexus opinion. Additionally, the claims file does not contain a review of the Veteran’s claims from the Under Secretary for Benefits. On remand, the AOJ should obtain further review by the Under Secretary for Benefits. The matters are REMANDED for the following action: 1. Forward the Veteran’s claims file to the November 2017 examiner or another qualified examiner for an addendum opinion addressing whether the Veteran’s lipomas may be medically classified as a form of “lymphoma.” The examiner should note May 2002 and August 2003 pathology reports diagnosing lipomas. A complete rationale must be provided for these opinions. If an examination is needed to provide a complete opinion, one should be scheduled. If the examiner opines that any question cannot be answered without resorting to speculation, then a detailed medical explanation as to why causation is unknowable must be provided. 2. Forward the Veteran’s claims file to the November 2017 examiner or another qualified examiner for an addendum opinion addressing the etiology of the Veteran’s bilateral foot rash. The examiner should accept the Veteran’s testimony of manifesting a foot rash in service as true. The examiner is requested to explain whether there is any medical reason to accept or reject the Veteran’s statements that his current bilateral foot rash had an in-service onset or is otherwise related to services. A complete rationale must be provided for these opinions. If an examination is needed to provide a complete opinion, one should be scheduled. If the examiner opines that any question cannot be answered without resorting to speculation, then a detailed medical explanation as to why causation is unknowable must be provided. 3. Forward the Veteran’s claims file to the Under Secretary for Benefits pursuant to 38 C.F.R. § 3.311(c). In particular, the Under Secretary for Benefits is advised that the Veteran was first diagnosed with diabetes mellitus in approximately 1991, recurrent headaches since approximately 1991 and was later treated for his other disorders. The Under Secretary for Benefits should consider the significance of an October 2008 opinion from Dr. A.H. attributing the Veteran’s hypertension, cardiovascular disorders and diabetes mellitus to ionizing radiation exposure with citation to treatise records, a January 2009 statement from Dr. S.M. stating that the Veteran’s bilateral retinopathy may be more persistent due to ionizing radiation exposure, and a February 2011 opinion from Dr. R.W. attributing the Veteran’s illnesses to ionizing radiation exposure. The Under Secretary for Benefits should also consider the February and March 2018 memorandums prepared by entity authorized by the Under Secretary of Health. 4. Thereafter, readjudicate the claims. If any benefit sought on appeal remains denied, furnish the Veteran and his representative a supplemental statement of the case and an appropriate period of time to respond. T. MAINELLI Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. Howell, Associate Counsel