Citation Nr: 20037052 Decision Date: 06/01/20 Archive Date: 06/01/20 DOCKET NO. 13-28 552 DATE: June 1, 2020 ORDER Entitlement to service connection for carcinoid syndrome and tumors is granted. FINDING OF FACT The Veteran’s carcinoid syndrome is related to herbicide agent exposure during service. CONCLUSION OF LAW The criteria for service connection for carcinoid syndrome and tumors have been satisfied. 38 U.S.C. §§ 1110, 1112, 1116, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from March 1964 to December 1966, to include service in the Republic of Vietnam. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a rating decision by a Department of Veterans Affairs (VA) Regional Office. In May 2018, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript of this testimony is associated with the claims file. The case was previously before the Board in July 2018, when it was remanded for examination of the Veteran and medical opinions. The requested development has been completed. Generally, to establish service connection, a claimant must show: (1) a present disability; (2) an 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, the so-called “nexus” requirement. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303; see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). VA has established certain rules and presumptions for chronic diseases, such as malignant tumors. See 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a); Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). With chronic diseases shown as such in service so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless attributable to intercurrent causes. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. § 3.303(b). In addition, for veterans who have served 90 days or more of active service during a war period or after December 31, 1946, chronic diseases are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 C.F.R. §§ 3.307(a)(3), 3.309(a). The Veteran is presumed to have been exposed to herbicide agents as during his service in the Republic of Vietnam. 38 C.F.R. § 3.307(a)(6)(iii). VA presumes certain diseases are related to herbicide agent exposure; however, carcinoid syndrome is not one of those diseases. 38 C.F.R. § 3.309(e). Accordingly, service connection on the presumptive basis because of herbicide agent exposure during service cannot be established. Service connection can still be established with proof of actual direct causation. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). The Veteran has a current diagnosis of carcinoid syndrome. He has submitted four medical opinions which link his claimed carcinoid syndrome to herbicide agent (Agent Orange) exposure during service. An opinion dated March 2012 from an internal medicine practice states that the Veteran is a patient being treated for carcinoid syndrome which is “at least as likely to have been caused by his exposure to Agent Orange as not.” A May 2018 letter from the same physician states it “is given that there is a relationship between the exposure to agent orange and many cancers including gastrointestinal diseases. Although no specific study has concluded any direct cause for carcinoid tumors, it is ‘at least as likely as not’ that the agent orange exposure to that [the Veteran] experienced was the cause for his carcinoid problems.” In August 2019 a VA medical opinion from a nurse practitioner stated that it was less likely than not that the claimed condition was related to an in-service injury, event, or illness. The narrative indicated that the prior positive medical opinions had been reviewed and that “there is no clinical evidence connecting the diagnose to Agent Orange. There are several presumptive cancers connected to Agent Orange but no GI or Endocrine cancers are presumptive. No tumor or cancer on the presumptive list of cancers caused by Agent Orange have been found after numerous scans and testing since 2002.” The nurse practitioner also found it significant that the Veteran did not experience any symptoms during service or in the two years following service. The Veteran submitted two medical opinions in April 2020, one from a Dr. N and one from a Dr. C. Both physicians are identified as oncologists, and both link the Veteran’s carcinoid syndrome to Agent Orange exposure. The Board understands that the private medical opinions linking the Veteran’s carcinoid syndrome to Agent Orange exposure during service provide little if any rationale. However, all four are rendered by physicians two of whom are identified as oncologists. The single VA medical opinion indicating that the Veteran’s cancer is not related to Agent Orange exposure during service is from a nurse practitioner who also does not provide rationale beyond stating that the Veteran’s cancer is not one of the presumptive diseases which warrant presumptive service connection on the basis of Agent Orange exposure under 38 C.F.R. § 3.309(e). This is not enough to rebut the private medical opinions. The Veteran served in Vietnam and is presumed to have been exposed to Agent Orange; he has a current diagnosis of carcinoid syndrome. Three physicians, including two oncologists, indicate that the current disability is related to the Agent Orange exposure during service. Accordingly, service connection is warranted, and the appeal is granted. Nathan Kroes Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Havelka, Counsel 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.