Citation Nr: 20007952 Decision Date: 01/30/20 Archive Date: 01/30/20 DOCKET NO. 19-17 261 DATE: January 30, 2020 REMANDED The issue of entitlement to service connection for glioblastoma multiforme, to include as due to herbicide agent exposure, or as secondary to service-connected disability, is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1971 to September 1973. The Veteran died in March 2018. The appellant is the Veteran’s surviving spouse. This matter comes before the Board of Veterans’ Appeals (Board) on appeal of a July 2018 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In Schroeder v. West, 212 F. 3d 1265, 1271 (Fed. Cir. 2000), the Federal Circuit held that VA has an obligation to explore all legal theories, including those unknown to the appellant, by which the appellant can obtain the benefit sought. Accordingly, the appellant’s appeal as to service connection for glioblastoma multiforme has been expanded to include entitlement to service connection under the theory of secondary service connection, and has been characterized as stated above. See Roberson v. Principi, 251 F.3d 1378, 1384 (Fed. Cir. 2001); Moody v. Principi, 360 F.3d 1306, 1310 (Fed. Cir. 2004). 1. Entitlement to Service Connection for Glioblastoma Multiforme The appellant contends that the Veteran had glioblastoma multiforme due to his exposure to herbicide agents during the Vietnam era. The Veteran’s claims file was reviewed by a VA examiner in August 2019. VA has a duty to ensure that any medical examination or opinion it provides is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). A medical opinion is adequate where it is based upon consideration of the full medical history and describes a disability in sufficient detail so that the Board’s evaluation will be fully informed. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). Here, the Board finds the August 2019 VA examination is inadequate for decision making purposes. The VA examiner opined that the Veteran’s glioblastoma multiforme is less likely than not proximately due to or the result of the Veteran’s service-connected posttraumatic stress disorder (PTSD) with alcohol use disorder. As rationale, the VA examiner noted that current literature reflects that the etiology of glioblastoma multiforme is unknown. The VA examiner further noted that there is no pathophysiologic association between PTSD/alcohol abuse and brain cancer. The August 2019 VA examiner did not provide an opinion as to whether the Veteran’s glioblastoma multiforme was aggravated by his service-connected PTSD/alcohol abuse. In that regard, the Board notes that an opinion to the effect that one disability is not at least as likely as not “caused by or a result of” another disability does not answer the question of whether it is at least as likely as not that one disability is aggravated by another. See El-Amin v. Shinseki, 26 Vet. App. 136, 140-41 (2013). Because the August 2019 VA examination is inadequate for decision-making purposes, the issue must be remanded for a further VA opinion. Barr, 21 Vet. App. 312. Additionally, the August 2019 VA examiner did not provide an opinion as to whether the Veteran’s glioblastoma multiforme is directly related to his active service, to include his presumed exposure to herbicide agents. The medical evidence of record shows that the Veteran was diagnosed with glioblastoma multiforme. Although the Veteran is presumed to have been exposed to herbicides during service, glioblastoma multiforme is not among those diseases presumptively linked to herbicide exposure under 38 C.F.R. § 3.309 (e). However, the Federal Circuit has determined that the Veterans’ Dioxin and Radiation Exposure Compensation Standards Act, Pub. L. No. 98-542, § 5, 98 Stat. 2724, 2727-29 (1984), does not preclude a veteran from establishing service connection with proof of actual direct causation. Combee v. Brown, 34 F. 3d 1039 (Fed. Cir. 1994). The United States Court of Appeals for Veterans Claims has specifically held that the provisions of Combee are applicable in cases involving Agent Orange exposure. McCartt v. West, 12 Vet. App. 164, 167 (1999). As the August 2019 VA examiner did not provide an opinion as to whether the Veteran’s glioblastoma multiforme was directly related to active service, remand is also necessary to determine whether the Veteran’s glioblastoma multiforme was related to his active military service to include exposure to herbicide agents on a non-presumptive basis. See Combee, 34 F. 3d at 1039. The matter is REMANDED for the following action: 1. Forward the record and a copy of this remand to the examiner who conducted the August 2019 VA examination, or if the examiner is unavailable, another suitably qualified examiner, for completion of an addendum opinion. Following review of the record, the examiner should express an opinion as to: (a.) Provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s glioblastoma multiforme was related to his active service, to include, but not limited to, exposure to herbicides? Rationale must be provided for the opinion proffered. In rendering the requested rationale, the examiner must note that applicable VA law establishes that the legal provision for presumptive service connection does not otherwise preclude an appellant from establishing service connection with proof of actual direct causation on a nonpresumptive direct incurrence basis. (b.) If not, whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s glioblastoma multiforme was proximately due to or the result of his service-connected disabilities, specifically to include his service-connected PTSD with alcohol use disorder. Rationale must be provided for the opinion proffered. In rendering the requested rationale, the examiner must note that it is not required that the glioblastoma multiforme is shown to be “predominantly” due to or result of PTSD/alcohol abuse, but rather, whether there is any contributing degree of etiological relationship to PTSD/alcohol abuse. (c.) If not, whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s glioblastoma multiforme was aggravated beyond natural progression by the Veteran’s service-connected disabilities, specifically to include his service-connected PTSD with alcohol use disorder. Rationale must be provided for the opinion proffered. In rendering the requested rationale, the examiner must note that it is not required that the glioblastoma multiforme is shown to be aggravated beyond natural progression “predominantly” by PTSD/alcohol abuse, but rather, whether there is any contributing degree of aggravation beyond natural progression by the service-connected PTSD/alcohol abuse. 2. After completion of the above, review the expanded record, including the evidence entered since the most recent statement of the case, and determine whether service connection for glioblastoma multiforme may be granted. If the benefit sought remains denied, furnish the appellant and her representative with a supplemental statement of the case. The appropriate period should be allowed for response before the appeal is returned to the Board. U. R. POWELL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. G. LeMoine The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.