Citation Nr: 1819745 Decision Date: 04/03/18 Archive Date: 04/12/18 DOCKET NO. 14-16 161 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for keloid formation for mole removal from left axilla (left arm). 2. Entitlement to service connection for a bilateral eye condition to include hyperopia, presbyopia, and pinguequla. 3. Entitlement to service connection for diabetes mellitus. 4. Entitlement to service connection for hypertension. 5. Entitlement to service connection for colon cancer, to include as due to exposure to ionizing radiation. 6. Entitlement to an initial compensable disability evaluation for keloid growth from mole removal of abdomen and left side. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD L.J. Bakke, Counsel INTRODUCTION The Veteran served on active duty from May 1982 to October 2003. This matter comes before the Board of Veterans Appeals (Board) on appeal from 2011 (keloids on abdomen and left side) and 2010 (all other issues) rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). This case was remanded initially in November 2015 and again in March 2017. The March 2017 remand incorporated the directions of the October 2016 Joint Motion for Remand between VA and U.S. Court of Appeals for Veterans Claims (Court) which vacated the Board's November 2015 denial of entitlement to service connection for keloid/mole removal of the left arm and remanded that issue and the issue of entitlement to a higher initial evaluation for the service-connected keloid growth from mole removal of abdomen and left side for further development. The requested development having been completed, the case is now again before the Board. The issue of service connection for keloid formation for mole removal left axilla (left arm) has been recharacterized to more clearly distinguish the area of keloid formation from that already service connected as keloid growth from mole removal abdomen and left side. The issues of service connection for colon cancer, to include as the result of exposure to ionizing radiation, and entitlement to an increased rating are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDINGS OF FACT 1. The evidence supports a finding that the keloid formation from mole removal left axilla (left arm) is the result of active service. 2. The preponderance of the evidence is against a finding that the Veteran has an eye condition, to include hyperopia, presbyopia, and pinguequla, that is the result of active service. 3. The preponderance of the evidence is against a finding that diabetes mellitus is the result of active service. 4. The preponderance of the evidence is against a finding that hypertension is the result of active service. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for keloid growth from mole removal of left axilla (left arm) are met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 2. The criteria for entitlement to service connection for a bilateral eye condition to include hyperopia, presbyopia, and pic are not met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 3. The criteria for entitlement to service connection for diabetes mellitus are not met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2017). 4. The criteria for entitlement to service connection for hypertension are not met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's duties to notify and assist claimants in substantiating a claim for VA benefits are found at 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (2012) and 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2017). In the February 2018 IHP, the Veteran's representative noted that the RO had not issued a supplemental statement of the case (SSOC) for the issues of service connection for keloid growth from mole removal of the left arm or for an increased rating for service-connected keloid growth from mole removal of the abdomen and left side. As the issue of service connection is being granted, no harm will result to the Veteran. As will be discussed below, the claim for an increased rating is being remanded for a SSOC. The Veteran and his representative have not raised any other issues with the duty to notify or duty to assist. See Scott v McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to duty to assist argument). I. Service Connection Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1131 (2012). Generally, the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 391 F.3d 1163, 1166-67 (Fed. Cir. 2004). Where a veteran served for at least 90 days during a period of war, and manifests certain chronic diseases, to include diabetes mellitus and hypertension, to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112 (2012); 38 C.F.R. §§ 3.307, 3.309 (2017). Alternatively, service connection may be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307 and (ii) present manifestations of the same chronic disease, or (b) when a chronic disease is not present during service, evidence of continuity of symptomatology. The U.S. Court of Appeals for the Federal Circuit clarified that the law providing for awards of service connection on the basis of continuity of symptomatology is limited to a "chronic" diseases listed under 38 C.F.R. § 3.309(a), such as diabetes mellitus and hypertension. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In the present case, the Veteran has stated that his skin condition, eye condition, diabetes mellitus, and hypertension had their onset during active service. VA treatment records and VA examination reports from 2003 to 2017 show, in aggregate, observation of keloid development in the left axilla following the removal of a mole and reference to inservice removal of a mole; diagnoses of bilateral eye conditions to include hyperopia, presbyopia, and pinguequla and inservice injury to the right eye with vitreous detachment of the eye; diagnosis of diabetes mellitus in 2005; and diagnosis of hypertension 2008 with inservice periodic findings of high blood pressure. The Board finds that the Veteran has met the first criteria under Shedden for his claimed disabilities. However, evidence of the onset of diabetes mellitus and hypertension to a compensable degree within the presumptive periods, or evidence etiologically relating these disabilities to the Veteran's active service, and evidence etiologically relating his claimed eye conditions to active service is still required to establish service connection. This is the third element of Shedden. a) Keloid formation from mole removal left axilla (left arm) Subsequent to the 2017 Board remand, the Veteran underwent additional VA examination for skin conditions in 2017. The examiner diagnosed keloid formation in the Veteran's left axilla. The keloid formation was described as a raised hyper-pigmented dark lesion inferior to the Veteran's left axilla, measuring 7.8 x 2.0 centimeters. The Veteran reported it was extremely sensitive to pressure and to touch. The examiner noted previous treatment with steroid injections from 2003 through 2009, and current treatment with Clobetasol, a topical corticosteroid. As to the etiology of the keloid formation, the examiner opined that it had its onset during active service. After indicating that the Veteran's clinical records had been carefully reviewed, the examiner provided the following rationale: Veteran has multiple referrals to mole removal in 2000 to 2003 timeframe by multiple dermatologists and VA physicians secondary to the development of significant keloids. It is this examiner's belief that the [V]eteran did have a mole removed from his left axilla/upper abdomen and that it indeed did form significant keloid that has progressed in size. Veteran has subsequent surgical intervention, which result in significant keloid formation in his abdomen. It is therefore not unreasonable (greater than 50% probability) that this [V]eteran would easily develop a significant keloid reaction to a simple excision of a mole. See 2017 VA DBQ Examination for Skin Diseases, p. 8. Given the foregoing, the Board finds that service connection for keloid formation for mole removal left axilla (left arm) is warranted. b) Bilateral eye condition to include hyperopia, presbyopia, and pinguequla As an initial matter, the Board notes that congenital or developmental defects, such as refractive error of the eyes, are not diseases or injuries within the meaning of applicable legislation and, thus, are not disabilities for which service connection may be granted. 38 C.F.R. § 3.303(c); see also 38 C.F.R. § 4.9; Beno v. Principi, 3 Vet. App. 439 (1992). Refractive errors are defined to include astigmatism, myopia, hyperopia, and presbyopia. See M21-1, Part III, Subpart iv, 4.B.10.d. As such, service connection is not available for loss of vision attributable to refractive errors. In this case, the Veteran did sustain an injury to his right eye during active service and was service connected in a 2003 rating decision for those residuals, specifically vitreous detachment, right eye. Nonetheless, VA examiners have consistently also diagnosed hyperopia and presbyopia, where present, as refractive errors. VA separation examination for eyes conducted in May 2003, prior to the Veteran's discharge in October 2003 found the Veteran to have visual acuity at 20/20 for both eyes without correction both near and far. No other defects, findings, or abnormalities were diagnosed at that time and, particularly, conjunctivae were observed to be white and quiet. The examiner diagnosed a history of trauma to the right eye with posterior vitreous detachment with no residual signs of damage and no significant visual sequella. The examiner also diagnosed a history of intermittent diplopia with no signs or complaints of the condition on examination and no inducible tropias or phorias. See 2003 VA Separation Examination/Compensation and Pension Evaluation. A 2010 VA report of examination for eyes shows the Veteran reported splashing glycol into his right eye when working on a cooling unit in 1984, and the onset of presbyopia in 2003 with intermittent headaches. He also reported conjunctivitis in 1988 and subconjunctival hemorrhage with traumatic iritis in 2000, but that both conditions had resolved and required no further treatment. The examiner observed that funduscopic examination for both eyes was normal. On slit lamp test, the sclera and conjunctiva of both eyes showed melanosis nasal pinguequla. Infotemporal pinguequla was also noted in the right eye. No other findings were observed. The examiner diagnosed presbyopia and hyperopia in both eye and mild dry eyes. Noting hyperopia had been detected in 1999, when the Veteran was still in service, the examiner opined that hyperopia and presbyopia were not caused by or the result of active service. The examiner explained: Hyperopia is a condition that requires the eye to accommodate to see clearly at distance. As presbyopia starts to develop the accommodation ability of the eye will decrease, this will require patients to need reading glasses sooner than someone who does not have hyperopia to see clearly when reading. See 2010 VA Examination for Eyes, p. 5. In addition, as noted above, the regulations consider hyperopia and presbyopia, as caused by refractive error, to be congenital defects for which service connection cannot be granted. The examiner further opined that dry eyes was not caused by nor related to active service, citing medical records review and his own clinical knowledge as rationale. See Id., p. 6. The examiner stated he had reviewed the Veteran's claims file, and referred additionally to his clinical knowledge in support of his opinion. In May 2017, the Veteran again underwent VA examination for his eyes. At this time, her reported a history of inservice injury to the right eye that resulting in a detached retina. He further reported the growth of a cyst in the right, which required surgical removal. Following this event, he reported, he gets severe headaches around his eye. The examiner observed uncorrected visual acuity to be 20/40 or better in both eyes without for distance, with uncorrected near vision at 10/2000 in the right eye and 20/200 in the left. Corrected vision was measured at 20/40 or better in both eyes, far and near. The examiner diagnosed nasal pinguequla both eyes, and opined that the condition was less likely than not (less than 50 percent or greater probability) incurred in or caused by active service. The examiner's rationale was that the condition is essentially asymptomatic: [t]he diagnosis of pinguecula is due to UV/sun/wind exposure over time. They are very common in pigmented individuals in sun prone environments. They do not harm the eye and are not visually significant. See 2017 VA DBQ Examination for Eyes, p. 13. Dry eyes was not diagnosed. In sum, although the Veteran did sustain right eye trauma, the totality of the medical evidence does not show that the Veteran's presbyopia or hyperopia is the result of any eye trauma or defect other than refractive error. In addition, while the Veteran has been diagnosed with pinguequla, the condition has been found to asymptomatic and not the result of active military service. Finally, while dry eyes was diagnosed in 2010, it was not found to then be the result of active service, and has not been diagnosed since. There are no medical findings or opinions that tend to show that the Veteran is diagnosed with an eye condition for which service connection may be granted. Consequently, service connection for hyperopia, presbyopia, pinguequla, and dry eyes is not appropriate. c) Diabetes mellitus VA examination for separation conducted in 2003, and VA examinations for eyes conducted in 2003 and 2010 show no complaints, findings or diagnosis concerning diabetes mellitus. The Veteran underwent VA examination in May 2017, at which time the examiner diagnosed diabetes mellitus type II. The examiner remarked that diabetes mellitus type II was not diagnosed until 2005-which is beyond the one year presumptive period for the disease provided in the regulations (see 38 C.F.R. § 3.309(a))-but that onset of symptoms was in 2002, when the Veteran was still on active service. In the May 2017 medical opinion, the examiner listed as pertinent findings a 2015 appeal statement noting diabetes had been established, but not treated, prior to discharge from the service, and that a 2009 private treatment note also indicated that diabetes was present but not treated. The examiner opined that diabetes mellitus was at least as likely as not (50 percent or greater probability) incurred in or caused by active service. As rationale, the examiner explained: As previously mentioned the appeals document states specifically the diagnosis was made prior to discharge. After a review of his prior disability claim, written clearly that the diagnosis of diabetes was made prior to discharge. Therefore, this diagnosis is at least as likely to have been incurred in his service period. See May 2017 VA DBQ Examinations and Medical Opinion, p. 14. The RO requested clarification of the source of the remark that the Veteran's symptoms of diabetes began in 2002. In response, the examiner offered the following statement in an addendum proffered in May 2017: On the appeal statement C+P exam in 2015 the sentence was written that the diagnosis was within 1 year of service but not treated. This is where I got my information that this is service connected. I have no other sources of information than that. See May 2017 Addendum, p. 2. Accordingly, the AOJ concluded that the examiner had based his opinion on a history as reported by the Veteran. Moreover, there is no documentation in the claims file that the Veteran had symptoms of diabetes in 2002. In the June 2015 informal hearing presentation, the Veteran's representative noted a private medical treatment record that indicated that the Veteran had prediabetes in April 2005 with the confirmed diagnosis of diabetes in October 2008. That appears to be the earliest documentation of symptoms of diabetes of record. Thus, the May 2007 opinion is based on an inaccurate factual premise and is afforded decreased probative value. Given the proximity of the diagnosis of the Veteran's diabetes mellitus and his discharge from active service, the AOJ requested a records review examination concerning the etiology of the diagnosed diabetes mellitus and, specifically, as to whether the condition had become compensable within the one-year presumptive period after the Veteran's discharge in 2003. Of record is an October 2017 VA records review examination. The examiner opined that it was less likely than not (less than 50 percent) that the Veteran's diagnosed diabetes mellitus II had its onset during the Veteran's military service, even given the proximity of the diagnosis to his active service. As rationale, the examiner noted that the medical literature consensus for a diagnosis of diabetes mellitus required a fasting plasma glucose (FPG) level at or above 126 mg/dL, AIC at or greater than 6.5 percent, a two-hour value in OGTT at or above 00 mg/dL or a random (or casual) plasma glucose concentration at or above 200 mg/dL in the presence of symptoms. In addition, the examiner observed, the diagnosis of diabetes must be confirmed on a subsequent day by repeat measurement, repeating the same test for confirmation. In light of this criteria, the examiner observed: The military service records do not relay the required glucose values from the available laboratory tests that confirmed the diagnosis of DM in accord with the required criteria. Thus there was no confirmation that the [V]eteran had DM while on active duty. Moreover, some indirect indicators such as the negative commentaries of sugar in the urine on the Reports of Medical History, no DM in the Dental History forms, and the absence of sugar in the urine on the Reports of Medical Examination forms presented no facts that suggested that the [V]eteran may have had DM while on active duty. See October 2017 VA Medical Opinion, p. 5. Furthermore, the examiner stated that: The current information above has stated that the [V]eteran was given a diagnosis of DM in October 2008 which is five years after the [V]eteran left the military service. Since the glucose values prior to October 2008 had not confirmed that diagnosis, there was no evidence seen after the [V]eteran left the military service demonstrating that a continuity of the required elevated glucose values existed. See Id. The examiner noted review of the entire claims file including VA and private treatment records, service treatment records including dental treatment records. The Board finds the October 2017 VA Medical Opinion to be more probative than the May 2017 VA Medical Opinion because the October 2017 opinion is based on a thorough review of the clinical findings, taken in conjunction with the Veteran's assertions, throughout the claims file. A history as reported by the Veteran, without supporting medical evidence, cannot rise to the probative live of a medical diagnosis based on clinical findings-especially where, as here, clinical findings are required to confirm the diagnosis of a condition such as diabetes mellitus. See Curry v. Brown, 7 Vet. App. 59, 68 (1994); Andrea v. Nicholson, 492 F.3d 1372, 1377 n. 4 (Fed. Cir. 2007). There are no findings or other medical opinions tending to show that the Veteran's diabetes mellitus type II was diagnosed during active service, found to be compensable within the one year presumptive period following discharge from active service, or otherwise etiologically related to active service. Therefore, service connection for diabetes mellitus is not warranted. d) Hypertension VA examination for separation conducted in 2003, and VA examinations for eyes conducted in 2003 and 2010 show no complaints, findings or diagnosis concerning hypertension. The Veteran underwent VA examination in May 2017, at which time the examiner diagnosed hypertension with onset in 2002. The examiner remarked that hypertension was not diagnosed until 2005-which is beyond the one year presumptive period for the disease provided in the regulations (see 38 C.F.R. § 3.309(a))-but that onset of symptoms was in 2002, when the Veteran was still on active service. In the May 2017 medical opinion, the examiner listed as pertinent findings a 2015 appeal statement noting hypertension had been established, but not treated, prior to discharge from the service, and a cardiology note in 2008 mentioned left ventricular hypertrophy and ejection fraction of 66 percent. The examiner opined that hypertension was at least as likely as not (50 percent or greater probability) incurred in or caused by active service. As rationale, the examiner explained: As previously mentioned the appeals document states specifically the diagnosis was made prior to discharge. After a review of his prior disability claim, written clearly that the diagnosis of hypertension was made prior to discharge. Therefore, this diagnosis is at least as likely to have been incurred in his service period. See May 2017 VA DBQ Examinations and Medical Opinion, p. 11. The RO requested clarification of the source of the remark that the Veteran's symptoms of diabetes began in 2002. In response, the examiner offered the following statement in an addendum proffered in May 2017: On the appeal statement C+P exam in 2015 the sentence was written that the diagnosis was within 1 year of service but not treated. This is where I got my information that this is service connected. I have no other sources of information than that. See May 2017 Addendum, p. 2. Accordingly, the AOJ concluded that the examiner had based his opinion on a history as reported by the Veteran. Moreover, there is no documentation in the claims file that the Veteran had symptoms of hypertension in 2002. In the June 2015 informal hearing presentation, the Veteran's representative noted a private medical treatment record that indicated that the Veteran had an assessment of hypertension on January 31, 2004. That appears to be the earliest documentation of symptoms of hypertension of record. Given the proximity of the diagnosis of the Veteran's hypertension and his discharge from active service, the AOJ requested a records review examination concerning the etiology of the hypertension and, specifically, as to whether the condition had become compensable within the one-year presumptive period after the Veteran's discharge in 2003. Of record is an October 2017 VA records review examination. The examiner opined that it was less likely than not (less than 50 percent) that the Veteran's diagnosed hypertension had its onset during the Veteran's military service, even given the proximity of the diagnosis to his active service. As rationale, the examiner noted that the medical literature consensus for a diagnosis of hypertension required an average of two more properly measured readings at each of two or more visits after an initial screen. Normal blood pressure is found where systolic measures less than 120 mmHg and diastolic is less than 80 mmHg. Prehypertension is found where systolic measures 120-139 mmHg or diastolic measures 80-89 mmHg. Stage 1 hypertension is found where systolic measures 140-159 mmHg or diastolic measures 90-99 mmHg. Stage 2 hypertension is found where systolic measures equal to or over 160 mmHg or diastolic measures equal to or over 100 mmHg. Isolated systolic hypertension is considered to be present when the blood pressure is equal to or more than 140 over less than 90 mmHG. Isolated diastolic hypertension is considered to be present when the blood pressure is less than 140 over equal to or more than 90 mmHg. Noting that these definitions apply to adults on no antihypertensive medications and who are not acutely ill, the examiner explained: The service records do not demonstrate that the [V]eteran had met the criteria for the diagnosis of hypertension by having consistently elevated blood pressures during the time he was on active duty. The blood pressures that were elevated at times during the military service usually occurred in association with the [V]eteran being ill or injured. Later blood pressure readings did demonstrate that they returned to a normal baseline. For example the [V]eteran did have an elevated blood pressure on July 2003 near the time of his military separation of 138/100. However a repeat blood pressure in the private sector on January 31, 2004 was normal without any directed treatment for his blood pressure. The actual time that the [V]eteran had a diagnosis of hypertension properly established in accord with the guidelines would have been March 2005 as his blood pressure readings were sustained, were not due to some illness or injury, and met the diagnostic criteria for hypertension. This would have been more than a year after the [V]eteran left the military service which was in October 2003. See October 2017 VA Medical Opinion, p. 4. Furthermore, the examiner observed: The importance of the private sector records is that it demonstrates that for some time after the [V]eteran left the military service, he did not persist with sustained elevated blood pressure readings which met the criteria for hypertension. Thus a continuity of the [V]eteran's hypertension could not be established after the [V]eteran left the military. See Id. The examiner noted review of the entire claims file including VA and private treatment records, service treatment records including dental treatment records. The Board finds the October 2017 VA Medical Opinion to be more probative than the May 2017 VA Medical Opinion because the October 2017 opinion is based on a thorough review of the clinical findings, taken in conjunction with the Veteran's assertions, throughout the claims file. A history as reported by the Veteran, as noted above, without supporting medical evidence, cannot rise to the probative level of a medical diagnosis based on clinical findings-especially where, as here, clinical findings are required to confirm the diagnosis of a condition such as hypertension. See Curry, supra, and Andrea, supra. There are no findings or other medical opinions tending to show that the Veteran's hypertension was diagnosed during active service, found to be compensable within the one year presumptive period following discharge from active service, or otherwise etiologically related to active service. Therefore, service connection for hypertension is not warranted. ORDER Service connection for keloid formation for mole removal left axilla (left arm) is granted. Service connection for a bilateral eye condition to include hyperopia, presbyopia, and pinguequla is denied. Service connection for diabetes mellitus is denied. Service connection for hypertension is denied. REMAND The Veteran seeks service connection for colon cancer and argues that his colon cancer is the result of exposure to ionizing radiation from the equipment and instrumentation he worked on, repaired, and taught about during his career of more than 20 years. The evidence shows the Veteran was exposed to ionizing radiation during active service. Service treatment records show that the Veteran was exposed to ionizing radiation while stationed onboard the USS SOUTH CAROLINA (CGN-37) in 1996. The exposure is reported at 9 rem shallow dose equivalent, 10 rem deep dose equivalent photon, 11 rem deep dose equivalent neutron, 12 rem committed effective dose equivalent. Total effective dose equivalent was measured at 13 rem and lifetime total effective dose equivalent was measured at 14 rem. See Record of Occupational Exposure to Ionizing Radiation, NAVMED Form 6470/10, STRs (rec'd 5/11/2014), p. 64. In addition, the medical evidence reflects that the Veteran was diagnosed with colon cancer in 2009. Colon cancer is a cancer specified by the regulations governing exposure to ionizing radiation, and the onset of his colon cancer is more than 5 years after his discharge from active service, also as required. See 38 C.F.R. § 3.311(b)(2) and (4). Accordingly, the AOJ referred the Veteran's claim to the Under Secretary, as directed in 38 C.F.R. § 3.311(c). However, it appears that referral to the Under Secretary was not accomplished, because it was felt that the Veteran had not been exposed to greater than 10 rem during total time in service (or of lifetime if post service radiation exposure is documented). Yet, as noted above, NAVMED Form 6470/10, reflects a total effective dose equivalent of 13 rem and a lifetime total effective dose of 14 rem. This exposure was noted to have occurred in 1996, while the Veteran was assigned to the USS SOUTH CAROLINA. The Veteran has argued that he sustained additional exposure during his 20 years of active service working with jammers and other electronic technological equipment. His service personnel records corroborate his assertions, showing that he served mainly in the field of electronics warfare for that time. In addition, a statement from the Veteran's treating physician in 2011 notes that the Veteran Worked on Electronic Jammers in the Navy for 22 years which emitted high levels of XRT. Radiation is a known carcinogen and could potentially lead to different types of cancers, especially in the region of the body exposed to the radiation. See May 2011 Statement from YN, MD and EFB, ARNP (rec'd 1/18/2012). Therefore, the AOJ must follow the directions for exposures to ionizing radiation totaling greater than 10 rems throughout active service. As noted above, the November 2017 SSOC did not address the claim for an increased rating. Accordingly, the matter is remanded for issuance of a SSOC. Accordingly, the case is REMANDED for the following action: 1. Develop the Veteran's claim for colon cancer as required under 38 C.F.R. § 3.311, including obtaining a dose estimate to account for the total radiation exposure the Veteran incurred throughout his over 20 years on active service. The following should be noted: Service treatment records show that the Veteran was exposed to ionizing radiation while stationed onboard the USS SOUTH CAROLINA (CGN-37) in 1996. The exposure is reported at 9 rem shallow dose equivalent, 10 rem deep dose equivalent photon, 11 rem deep dose equivalent neutron, 12 rem committed effective dose equivalent. Total effective dose equivalent was measured at 13 rem and lifetime total effective dose equivalent was measured at 14 rem. See Record of Occupational Exposure to Ionizing Radiation, NAVMED Form 6470/10, STRs (rec'd 5/11/2014), p. 64. In addition, a statement from the Veteran's treating physician in 2011 notes that the Veteran: Worked on Electronic Jammers in the Navy for 22 years which emitted high levels of XRT. Radiation is a known carcinogen and could potentially lead to different types of cancers, especially in the region of the body exposed to the radiation. See May 2011 Statement from YN, MD and EFB, ARNP (rec'd 1/18/2012). 2. After #1, refer the Veteran's claim for colon cancer to the Under Secretary in accordance with 38 C.F.R. § 3.311 and VA policy. 3 After the above development has been completed, readjudicate the Veteran's claims for service connection for colon cancer and for an initial compensable disability evaluation for keloid growth from mole removal of abdomen and left side. If the benefits sought remain denied, provide the Veteran and his representative a supplemental statement of the case, and return the case to the Board. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ S. HENEKS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs