Citation Nr: 18158243 Decision Date: 12/14/18 Archive Date: 12/14/18 DOCKET NO. 16-53 612A DATE: December 14, 2018 ORDER Service connection for squamous cell carcinoma of the anterior two-third left true vocal cord, claimed as cancer, to include fatigue and pain, difficulty with being able to talk and difficulty breathing, to include as secondary to exposure to contaminated water at Camp Lejeune is granted. Service connection for gastroesophageal reflux disease (GERD), claimed as a stomach disorder, is granted. REMANDED ISSUES The issue of entitlement to service connection for migraine headaches, to include as secondary to in-service water contamination, or secondary to service-connected tinnitus and/or bilateral hearing loss, is remanded. The issue of entitlement to service connection for a vestibular disorder, including dizziness, to include as secondary to service-connected hearing loss, tinnitus, and/or migraine headaches. Service connection for scar tissue on the neck, to include as secondary to squamous cell carcinoma, is remanded. Service connection for cataracts is remanded. REFERRED ISSUE The issue of entitlement to service connection for a swallowing disorder, secondary to squamous cell carcinoma, is referred for appropriate action. A May 2016 VA treatment records references delayed laryngeal vestibular closure. See VA treatment record dated May 9, 2016 (see VBMS 07/13/2016 “CAPRI” at PDF pg. 15 of 98). In light of the Veteran’s assertion, as reflected in the December 22, 2014 statement of his wife (see VBMS 01/15/2015 “Buddy / Lay Statement”), that he developed swallowing difficulty as a result of cancer, and in view of the Board’s grant, herein, of service connection for squamous cell carcinoma, the issue of entitlement to service connection for a swallowing disorder, secondary to the service-connected squamous cell carcinoma, is REFERRED to the RO for appropriate action. FINDINGS OF FACT 1. The evidence is in equipoise as to whether the Veteran’s squamous cell carcinoma of the vocal cord is directly related to exposure to contaminated water while on active service at Camp Lejeune. 2. The Veteran’s current GERD was incurred in service. CONCLUSIONS OF LAW 1. The criteria to establish service connection for squamous cell carcinoma of the vocal cord are met. 38 U.S.C. §§ 1131; 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 2. The criteria to establish service connection for GERD are met. 38 U.S.C. §§ 1131; 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1975 to September 1979. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from rating decisions dated July 2014 and July 2015 of the Department of Veterans Affairs (VA) Regional Offices (RO) in Louisville, Kentucky and Salt Lake City, Utah. The Board acknowledges that, in December 2014, the Veteran’s representative submitted what he characterized as a petition to reopen a claim for service connection for squamous cell carcinoma, secondary to exposure to contaminated water at Camp Lejeune, North Carolina with “new and material evidence.” However, as the additional evidence was submitted within one year of the July 2014 rating decision denying service connection, the Board construes the December 2014 submission as a request for reconsideration of the RO’s July 2014 rating decision. As such, the July 2014 rating decision is not a prior, final decision, and the claim need not be reopened through a showing of new and material evidence. See 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). Consequently, the commencement of the period on appeal for the claim of service connection for squamous cell carcinoma is May 28, 2013, the date VA received the Veteran’s claim for service connection. Additionally, the October 2016 Statement of the Case unnecessarily broadened the Veteran’s service connection claim for migraine headaches to include as due to exposure to contaminated water at Camp Lejeune, perhaps due to the Veteran including multiple claims on several lines of the July 2015 Notice of Disagreement under “Specific Issues of Disagreement.” However, a review of the record reveals that the Veteran is claiming service connection for migraines only as due to his service-connected hearing disabilities, and the Board reviews the claim on that basis. Preliminary Matters The Board notes that VA has derived two issues from the Veteran’s single claim for service connection for a vestibular disorder. On review of the record, therefore, the Board recharacterizes the separate issues of entitlement to service connection for (1) a vestibular disorder, and (2) dizziness, to entitlement to service connection for a vestibular disorder, to include dizziness, to include as secondary to service-connected hearing loss, tinnitus, and/or migraine headaches. The Board has limited the discussion below to the relevant evidence required to support its findings of fact and conclusions of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). Service Connection Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e. a nexus, between the current disability and an in-service precipitating disease, injury, or event. See 38 C.F.R. § 3.303; see also Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). In the absence of proof of a present disability, however, there necessarily can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Service connection may also be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection is also warranted for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Such secondary service connection is warranted for any increase in severity of a nonservice-connected disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(b). In order to prevail under a theory of secondary service connection, there must be: (1) evidence of a current disorder; (2) evidence of a service-connected disability; and, (3) medical nexus evidence establishing a connection between the service-connected disability and the current disorder. See Wallin v. West, 11 Vet. App. 509, 512 (1998). For the showing of chronic diseases in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). In addition, the law provides that, where a veteran served ninety days or more of active service, and certain chronic diseases become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Service connection for a disease associated with exposure to contaminated water at Camp Lejeune may be established on a presumptive basis if the evidences shows the following: (1) that the veteran served at Camp Lejeune for no less than 30 days (either consecutive or nonconsecutive) from August 1, 1953 to December 31, 1987; (2) that the veteran suffered from a disease associated with exposure to contaminants in the water supply at Camp Lejeune enumerated under 38 C.F.R. § 3.309(f); and (3) that the disease process manifested to a degree of 10 percent or more at any time after service. 38 C.F.R. §§ 3.307(a)(7), 3.309(f). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994). Lay assertions may serve to support a claim for service connection by establishing the occurrence of observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C. § 1154(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F. 3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has clarified that lay evidence can be competent and sufficient to establish a diagnosis or etiology when (1) a lay person is competent to identify a medical condition; (2) the lay person 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 (Fed. Cir. 2009). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the claims file. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). 1. Service connection for squamous cell carcinoma. Turning to the merits of the claim, the Veteran asserts that his squamous cell carcinoma of the vocal cord was caused by his exposure Camp Lejeune contaminated water (CLCW) during service. See Claim for compensation received May 28, 2013. Private medical records reflect that the Veteran was diagnosed with squamous cell carcinoma of the left true vocal cord in January 2008, and that he was treated with radiation therapy. Although squamous cell carcinoma is a chronic disease under 38 C.F.R. § 3.309(a) (as a malignant tumor), after a review of all the evidence of record, lay and medical, the Board finds that the Veteran’s cancer was not incurred in-service, did not manifest within one year of discharge from service, and symptoms of lung cancer have not been continuous since service. The Veteran’s service treatment records (STRs) are silent as to complaints or diagnoses of cancer, and the earliest record evidence of carcinoma is not shown until decades after service separation, when the Veteran was diagnosed with a tumor in the left vocal cord in January 2008. Additionally, while the Veteran’s service personnel records show that he served at Camp Lejeune for no less than 30 days, and VA has conceded his exposure to contaminated water at Camp Lejeune, squamous cell carcinoma is not among the diseases identified in 38 C.F.R. § 3.309(f) as being associated with exposure to CLCW. Therefore, the criteria for presumptive service connection under 38 C.F.R. §§ 3.309(a) and 3.309(f) are not for application. Nevertheless, the appellant is not precluded from establishing service connection for the cause of the Veteran’s death through proof of direct causation. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). The Board acknowledges the Veteran’s May 2013 and November 2016 submissions in support of his claim of information and articles from government agency web sites that reflect the continuing study of CLCW, the contaminants involved, and the health effects of exposure to contaminants, as well as a statement that exposure to contaminated drinking water at Camp Lejeune has been shown to cause cancer, including esophageal cancer. A VA medical opinion was obtained in June 2014 from R.T., MD, a member of VA’s Subject Matter Expert Panel CLCW Project. R.T. opined that the Veteran’s squamous cell cancer of the left true vocal cord is not related to his exposure to CLCW. He provided the rationale that the National Cancer Institute has identified two primary risk factors for developing squamous cell laryngeal cancers of the glottis, where the true vocal cords are found, smoking and excessive alcohol ingestion; and the American Cancer Society has identified several risk factors for such cancers, including tobacco use, moderate to heavy alcohol use, poor nutrition, more common occurrences of laryngeal cancers among African Americans and Caucasians, and workplace exposures to paint fumes and asbestos, and GERD may be associated with an increased risk. Additionally, R.T. referenced an Environmental Protection Agency study of exposure to the four solvents found in the drinking water at Camp Lejeune, indicating no increased incidence of squamous cell cancer of the true vocal cord. Finally, citing the Veteran’s age of 50 at the time of diagnosis, his history of tobacco and alcohol use, and his being Caucasian, as a basis for his opinion that the Veteran’s squamous cell carcinoma of the true vocal cord was not caused by exposure to CLCW. In contrast, a medical opinion by the Veteran’s private radiation oncologist C.H., MD dated November 2014, opines that the Veteran’s squamous cell carcinoma was caused by his exposure to CLCW. He provided the rationale that the volatile organic compounds known to have contaminated the water at Camp Lejeune are known carcinogens. Additionally, C.H. explained that although larynx cancer is not specified as one of the proven diagnoses associated with CLCW, lung and esophagus cancers are associated with such exposure, and the larynx receives exposure to all inhaled and swallowed vapors and liquids, and therefore the larynx can be considered the same anatomical pathway of direct topical exposure as the lung and esophagus. Finally, C.H. noted that the larynx would likely receive an even higher exposure than many organs, as it receives exposure from both inhaled vapors and swallowed liquids. The Board finds the June 2014 VA opinion and the November 2014 private opinion competent, credible, and probative. The VA opinion was authored by a licensed physician who has expertise concerning CLCW cases, and who reviewed the Veteran’s claims file and was therefore familiar with the Veteran’s symptoms, diagnoses, and treatment of his cancer; and the opinion was based on a review of the evidence of record. Additionally, the opinion contains clear conclusions with supporting data connected by a reasoned medical explanation. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301-02 (2008). While the November 2014 private medical opinion does not reflect that the Veteran’s claims file was reviewed or specify what, if any, medical literature was considered by C.H., the physician’s opinion indicates familiarity with medical literature upon which the VA regulations are based, and his opinion is accompanied by a detailed rationale. Moreover, his familiarity with the Veteran’s disability, his experience as a radiation oncologist, including successfully treating the Veteran’s specific type of cancer, cannot be ignored. Accordingly, the Board finds both the June 2014 VA medical opinion and the November 2014 private medical opinion highly probative, competent and persuasive medical evidence in this case. In April 2015, VA obtained a rebuttal opinion from R.T., MD to the November 2014 private opinion, which stresses that the theory set forth in the November 2014 private opinion is not generally accepted in the medical community. However, R.T. does not argue that the private physician’s theory has been rejected by the medical community, nor does his rebuttal point to any medical literature or research that demonstrates that the theory is not sound. Additionally, R.T. attempts to bolster his rebuttal with a December 5, 2014 VA treatment record he represents as reflecting that a VA ear, nose, and throat (ENT) physician declined to endorse that the Veteran’s cancer was caused by exposure to CLCW. In this regard, the rebuttal mischaracterizes the evidence. The December 2014 ENT note reflects no opinion or remarks of the ENT physician in regard to whether the Veteran’s cancer was caused by CLCW. Indeed, the ENT physician noted that he would add a copy of the November 2014 private medical opinion to the Veteran’s medical record. Accordingly, the Board assigns the April 2015 VA rebuttal no probative weight. The Board emphasizes that to resolve the issue of a causal link between the Veteran’s cancer and service, the evidence need only be in equipoise. It need not be clearly determined whether a disability was caused by service. 38 C.F.R. § 3.303(a). See Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (noting that in a merits adjudication, the evidence need only reach equipoise). Thus, based on the body of evidence in this case, the Board finds that the November 2014 private medical opinion, itself, places in relative equipoise the issue of whether the Veteran’s squamous cell carcinoma is related to exposure to CLCW during service. Under the benefit of the doubt rule, where there exists “an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter,” the appellant shall prevail upon the issue. Ashley v. Brown, 6 Vet. App. 52, 59 (1993). Accordingly, the Board resolves any doubt in favor of the appellant, and finds that service connection for Veteran’s squamous cell carcinoma is warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 3.303. 2. Service connection for GERD, claimed as a stomach disorder. The Veteran asserts that his gastroesophageal reflux disease (GERD) is related to service. See Claim for compensation received December 18, 2014. The STRs include a September 1975 enlistment examination records that reflect that the Veteran denied stomach or gastrointestinal problems and was negative for such problems on objective examination. However, STRs dated from November 1975 to January 1979 reflect numerous complaints of, and treatment for, stomach cramps and/or diagnoses of gastroenteritis during service. Post-service medical records reflect a current diagnosis of GERD. See e.g. VA examination report dated April 6, 2015; VA treatment record dated January 19, 2018 (GERD stable, medication prescribed). During a VA examination in April 2015, the examiner confirmed a diagnosis of GERD and the examiner opined that the Veteran’s GERD is at least as likely as not related to service. The examiner noted that the Veteran had been having stomach issues for years, including while he was on active service. The examiner indicated that GERD is not directly related to gastroenteritis or stomach cramping directly. However, the examiner also stated that the Veteran’s GERD started at the same time frame as those stomach symptoms in service. The April 2015 VA medical opinion is competent, credible and probative. It was authored by medical professional who reviewed the Veteran’s claims file and was therefore familiar with the Veteran’s symptoms, diagnoses, and treatment of GERD; the opinion was based on a review of the medical evidence and lay statements of the Veteran that are of record. The opinion is consistent with the medical evidence of record, and contains clear conclusions with supporting data connected by a reasoned medical explanation. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301-02 (2008). Notably, there are no medical opinions or other competent medical evidence of record that weighs against the VA examiner’s opinion. Accordingly, the Board finds the April 2015 VA medical opinion highly probative, competent and persuasive medical evidence in this case. In view of the foregoing, the Board concludes that the preponderance of the evidence supports the Appellant’s claim for service connection for GERD. The grant of service connection on a direct basis pursuant to 38 C.F.R. § 3.102 renders moot all other theories of service connection. REASONS FOR REMAND A remand of the service connection claims for migraine headaches, vestibular disorder and dizziness, scar tissue on the neck, and cataracts is necessary, as specified below, to ensure that the Board’s evaluation of the claims is a fully informed one. When VA undertakes to provide a VA examination, it must ensure that the examination is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that once VA undertakes the effort to provide an examination when developing a claim, even if not statutorily obligated to do so, VA must ensure that the examination provided is adequate). Furthermore, the Board may consider only independent medical evidence to support its findings, and may not substitute its own unsubstantiated medical conclusions. Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). In his July 2015 Notice of Disagreement, the Veteran claimed that his migraine headaches are caused by his service-connected tinnitus and hearing loss. In scheduling a VA examination to address this question, the RO requested a medical opinion addressing whether the Veteran’s migraine headaches are proximately due to or the result of hearing loss/tinnitus. However, while the examiner opined that migraine are less likely than not directly related to service or proximately caused by tinnitus, she did not provide an opinion regarding hearing loss. There is also a question as to whether the headaches are etiologically related to the cancer residuals, to include the radiation treatment the Veteran underwent to treat the cancer, or in-service water contamination. Additionally, the Veteran’s STRs reflect that he complained of dizziness in March 1977. In his December 2014 statements submitted in support of his claim of service connection for a vestibular disorder, the Veteran claimed that his tinnitus and migraine headaches affect his balance. A January 2015 statement of the Veteran’s wife asserts that the Veteran experiences dizziness caused by radiation treatment for cancer. Moreover, during an April 2015 VA stomach disorders examination, he reported spontaneous regurgitation that makes it hard to breathe, causing dizziness. Considering that the Veteran is service-connected for hearing loss, tinnitus, and GERD, and that the etiology of the Veteran’s migraines has yet to be fully determined, a VA examination to determine the nature and etiology of a vestibular disorder is warranted. In light of the Board’s grant of service connection for squamous cell carcinoma, and considering that the Veteran asserts he has scar tissue caused by radiation treatments for carcinoma, as well as medical evidence of radiation treatments and photographs that show the head, neck, and chest of a man identified as the Veteran, portraying a discolored patch of skin on the neck, VA examination is warranted to determine the nature and etiology of scar tissue, if any, that is related to the cancer radiation treatments. Finally, the Veteran states that he has had cataract surgery on both eyes, and that the cataracts were caused by radiation treatments for his now service-connected squamous cell carcinoma. Although VA treatment records include references to the Veteran having reported undergoing cataract surgery, there is no medical evidence of record indicating a diagnosis or treatment for cataracts or the etiology of cataracts. Nevertheless, considering that the Veteran’s squamous cell carcinoma is service-connected and that he is competent to report at least the observable symptoms of cataracts, Layno, supra., additional development of the Veteran’s claim of service connection for cataracts is warranted. The matters are REMANDED for the following action: 1. Implement the grant of service connection for squamous cell carcinoma of the vocal cord and GERD contained in this decision, and assign the appropriate disability ratings. 2. Ensure that all outstanding VA treatment records are associated with the claims file. 3. Provide the Veteran with the necessary authorization/consent forms to identify any relevant private treatment, to include for cataract surgery. 4. THEN provide a VA examination to determine the nature and etiology of claimed cataracts. The claims file, and a copy of this remand, should be made available to the examiner for review. After a complete review of the claims file, the examiner is asked to respond, with adequate rationale, to the following: (a) Did the Veteran have cataracts at any time during the appeal period? See VA treatment notes showing a history of 2017 cataract surgeries. (b) If so, provide an opinion as to whether it is at least as likely as not (50 percent or higher degree of probability) that the Veteran’s cataracts are (1) related to service; or (2) CAUSED or AGGRAVATED by squamous cell carcinoma of the vocal cord, specifically to include the related radiation treatments. 5. Obtain from the same examiner who conducted the October 2015 VA headaches examination, if available, an addendum medical opinion with regard to the etiology of the Veteran’s migraine headaches. The need for another examination is left to the discretion of the medical professional offering the addendum opinion. The claims file, and a copy of this remand, should be made available to the examiner. After a complete review of the claims file, the examiner is asked to respond to the following: (a) Confirm the presence of migraine headaches diagnosed since the date of claim. (b) Provide an opinion, with adequate rationale, as to whether current migraine headaches are at least as likely as not (50 percent or higher degree of probability) related to in-service water contamination at Camp Lejeune. (c) Provide an opinion, with adequate rationale, as to whether migraine headaches are at least as likely as not (50 percent or higher degree of probability) CAUSED or AGGRAVATED by, the Veteran’s service-connected hearing loss AND the radiation treatment related to THE service-connected squamous cell cancer of vocal cord. 5. Provide a VA examination to determine the nature and etiology of claimed vestibular disorder (i.e. a disorder affecting balance) and dizziness. After a complete review of the claims file, the examiner is asked to respond to the following: (a) Indicate the presence of any vestibular disorder or any other disorder productive of claimed dizziness diagnosed from the date of claim, forward. (b) For any currently diagnosed vestibular disorder or other disability productive of dizziness, provide an opinion as to whether it is at least as likely as not (50 percent or higher degree of probability) (1) related to service; or (2) CAUSED or AGGRAVATED by the service-connected disabilities: (i) hearing loss; (ii) tinnitus; (iii) squamous cell carcinoma, including related radiation treatments; and/or (iv) GERD. **While the entire claims file must be reviewed, the examiner’s attention is directed to the Veteran’s service treatment records, including March 2, 1977 notations in the Chronological Record of Medical Care that reference “Dizziness” (See VBMS 07/19/2011 “STR – Medical” PDF pg. 22). 6. Provide a VA examination to determine the nature and etiology of any scar tissue on the neck. The claims file, and a copy of this remand, should be made available to the examiner for review. After a complete review of the claims file, the examiner is asked to respond, with adequate rationale, to the following: (a) Indicate the presence of any scar tissue on the Veteran’s neck, claimed as secondary to radiation treatment for vocal cord cancer. Describe the signs of any scar tissue. Address the photograph submitted that shows discoloration on the neck. (b) If scar tissue is present or diagnosed, provide an opinion as to whether it is at least as likely as not (50 percent or higher degree of probability) (1) related to service; or (2) CAUSED or AGGRAVATED by squamous cell carcinoma, and/or related radiation treatments. While the entire claims file must be reviewed, the examiner’s attention is directed to the Veteran’s private treatment records for squamous cell carcinoma (See VBMS 07/22/2013 “Medical Treatment Record – Non-Government Facility”; See VBMS 12/18/2014 “Medical Treatment Record – Non-Government Facility” PDF pg. 1; See VBMS 12/23/2014 “Photographs; See VBMS 10/13/2015 “Medical Treatment Records – Furnished by SSA” PDF pgs. 58, 65-85). 7. Thereafter, readjudicate the remanded claims on appeal. S. B. MAYS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Brad Farrell, Associate Counsel