Citation Nr: 20043095 Decision Date: 06/25/20 Archive Date: 06/25/20 DOCKET NO. 15-10 363 DATE: June 25, 2020 REMANDED Entitlement to service connection for monoclonal gammopathy of undetermined significance (MGUS), claimed as multiple myeloma, is remanded. Entitlement to service connection for rheumatoid arthritis is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Marine Corps from November 1968 to March 1970, to include service in the Republic of Vietnam. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a July 2013 rating decision issued by a Regional Office (RO) of the Department of Veterans Affairs (VA). In May 2018, the Veteran testified at a Board hearing via videoconference before the undersigned Veterans Law Judge. This matter was remanded in July 2018 for additional evidentiary development. 1. Entitlement to service connection for monoclonal gammopathy is remanded. The Veteran asserts that his MGUS (claimed as multiple myeloma) is directly related to his service in Vietnam including due to exposure to herbicides or alternatively is secondary to his service-connected non-Hodgkin’s lymphoma. His military personnel records show combat service in the Republic of Vietnam from May 1969 to March 1970, thus exposure to herbicides is presumed. The Veteran was afforded a VA contract examination in April 2019 where the examiner determined, “per most recent (11/18 and 12/18) lab work … veteran does not currently have multiple myeloma, and in fact is still diagnosed with MGUS. Given the veteran’s MGUS has not progressed to multiple myeloma, it is less likely than not that the veteran’s T-cell lymphoma has aggravated the course of veteran’s MGUS.” However, the examiner’s opinion is inconsistent with the Veteran’s VA treatment records indicating a diagnosis of multiple myeloma or “MGUS/Multiple Myeloma” as reflected in April 2016. Additionally, VA treatment record of September 2015 show MGUS was diagnosed approximately 2000 and “remains a symptomatic”. Further, there is no medical opinion of record addressing etiology for the diagnosed MGUS including whether it is at least as likely as not related to the Veteran’s herbicide agent exposure. To that end, there is at least some evidence that herbicide agents may be connected to MGUS. See, e.g., “Agent Orange Exposure and Monoclonal Gammopathy of Undetermined Significance: An Operation Ranch Hand Veteran Cohort Study” JAMA Oncol. 2015 Nov;1(8):1061-8. doi: 10.1001/jamaoncol.2015.2938, abstract available at https://www.ncbi.nlm.nih.gov/pubmed/26335650. Additionally, VA recently issued a final rule revising 38 C.F.R. § 4.117, the portion of the Rating Schedule which addresses disabilities of the hematological and lymphatic systems. 83 Fed. Reg. 54,250, 54,253 (October 29, 2018). The new rule added Diagnostic Code (DC) 7712 (multiple myeloma). Note (1) to DC 7712 indicates that “Current validated biomarkers of symptomatic multiple myeloma and asymptomatic multiple myeloma, smoldering, or monoclonal gammopathy of undetermined significance (MGUS) are acceptable for the diagnosis of multiple myeloma as defined by the American Society of Hematology (ASH) and International Myeloma working group.” Accordingly, a supplemental opinion is required reflecting consideration of the revised regulation and recent study for whether MGUS resulted from exposure to herbicide agents. 2. Entitlement to service connection for rheumatoid arthritis is remanded. Likewise, the Veteran maintains that his chronic joint pains are directly related to service including exposure to herbicides or alternatively secondary to his service-connected non-Hodgkin’s lymphoma. The record reflects that the Veteran was diagnosed with MGUS in 2000, gout in 2010, rheumatoid arthritis in 2012, and non-Hodgkin’s lymphoma in 2014. The Veteran was afforded a VA contract examination in April 2019 where the examiner indicated that “it is less likely than not that veteran’s cutaneous T-cell lymphoma is underlying etiology for [rheumatoid arthritis], gout or inflammatory polyarthropathy.” Although the examiner indicated that medical literature notes autoimmune inflammatory conditions such as rheumatoid arthritis as a specific risk factor for development of lymphomas, the reverse was not valid. Meaning, there is no correlation for T-cell lymphoma as an underlying cause for rheumatoid arthritis. However, the Board finds that the issue of rheumatoid arthritis is inextricably intertwined with the development ordered above as autoimmune manifestations may be associated with multiple myeloma and MGUS; thus, must be remanded as well. Harris v. Derwinski, 1 Vet. App. 180 (1991). The matters are REMANDED for the following action: 1. Obtain an opinion from an appropriate medical professional to determine the etiology of the Veteran’s MGUS claimed as multiple myeloma. The Veteran’s electronic claims file must be made accessible to the examiner along with any other information the medical professional deems pertinent. The examiner should clarify whether the Veteran’s diagnosis of monoclonal gammopathy of undetermined significance is a form of multiple myeloma or precursor to multiple myeloma. The examiner should also consider the applicability of the revised regulations to the Veteran’s case. The examiner is also asked to address whether it at least as likely as not (a 50 percent or greater probability) that the Veteran’s diagnosed monoclonal gammopathy is caused by, related to, or otherwise etiologically the result of the Veteran’s active service, to include presumed exposure to herbicide agents? In formulating his or her opinion, the examiner’s attention is directed to the latest research of “Agent Orange Exposure and Monoclonal Gammopathy of Undetermined Significance: An Operation Ranch Hand Veteran Cohort Study” JAMA Oncol. 2015 Nov;1(8):1061-8. doi: 10.1001/jamaoncol.2015.2938, abstract available at https://www.ncbi.nlm.nih.gov/pubmed/26335650. An explanation for all opinions expressed must be provided. If the examiner determines that an opinion cannot be rendered without result to mere speculation then it should be clear in the examiner’s remarks whether it cannot be determined from current medical authority or if an opinion could be rendered if additional facts were known. If additional facts are needed, the examiner shall state what facts, if known, would impact his or her ability to render an opinion and how. Simply stating that an opinion cannot be provided without resort to mere speculation is not acceptable without a detailed reason as to why this is so. 2. After completing the requested actions, and any additional development deemed warranted, readjudicate the claims in light of all pertinent evidence and legal authority. If the claim remains denied, a supplemental statement of the case must be provided to the Veteran. After the Veteran and any representative have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. KELLI A. KORDICH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. A., Associate 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.