Citation Nr: 20046476 Decision Date: 07/13/20 Archive Date: 07/13/20 DOCKET NO. 20-20 306 DATE: July 13, 2020 ORDER Entitlement to service connection for chronic weakness is denied. REMANDED Issue of entitlement to an initial rating higher than 30 percent for coronary artery disease (CAD) is remanded. Issue of entitlement to service connection for celiac disease is remanded. Issue of entitlement to service connection for chronic weight loss, to include an inability to gain weight, is remanded. Issue of entitlement to service connection for dyslipidemia is remanded. Issue of entitlement to service connection for polymyalgia rheumatoid is remanded. Issue of entitlement to service connection for loss of bone density is remanded. Issue of entitlement to service connection for supraventricular tachycardia (SVT) is remanded. Issue of entitlement to service connection for basal cell carcinoma, right cheek, is remanded. FINDING OF FACT The preponderance of the evidence is against finding that the Veteran has a disability manifested by chronic weakness or that the Veteran’s chronic weakness results in a functional loss of earning capacity. CONCLUSION OF LAW The criteria for entitlement to service connection for chronic weakness have not been met. 38 U.S.C. §§ 101(16), (22), (24), 1110, 1131, 5107(b) (2012); 38 C.F.R. §§ 3.6(a), 3.102, 3.303 (2019) REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served in the National Guard from February 1957 to June 1998, with periods of active duty from May 1996 to June 1996, in April 1997, and in April 1998. The Veteran has unverified periods of active duty for training (ACDUTRA) and inactive duty for training (INACDUTRA), but service personnel records show that the Veteran served in the Republic of Vietnam around March 1967, November 1967, and September 1968. See March 1967 Flight order; November 1967 Special orders; September 1968 Special Orders. This appeal to the Board of Veterans’ Appeals (Board) arose from a December 2017 rating decision issued by the Department of Veterans Affairs (VA). See April 2018 Notice of Disagreement (NOD); March 2020 Statement of the Case (SOC); April 2020 Substantive Appeal (VA Form 9). The Board recharacterized the issue of entitlement to service connection for weight loss to include the inability to gain weight, which more accurately capture the Veteran’s current complaints about his condition. This appeal has been advanced on the Board’s docket pursuant to 38 C.F.R. § 20.900(c). 38 U.S.C. § 7107(a)(2). Entitlement to service connection for chronic weakness. The Veteran asserts entitlement to service connection for chronic weakness. September 2017 VA Form 21 526WEZ. The Veteran relates that he experienced gradual and overall physical weakness after his retirement from the National Guard in 1998 and believes this is due to exposure to his in service exposure to Agent Orange herbicide, jet fuel, aircraft lubricants, and jet exhaust. See September 2017 Correspondence; April 2018 NOD; April 2020 VA Form 9. Service connection may be established for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303. Service connection is established when there is competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in service disease or injury. 38 U.S.C. §§ 1110, 1131; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Here, the question for the Board is whether the Veteran has a current disability of chronic weakness. The existence of a current disability is the cornerstone of a claim for VA disability compensation. See, e.g., Degmetich v. Brown, 104 F.3d 1328 (1997). Congress has specifically limited entitlement to service connection for a disease or injury where such instances have resulted in a disability. 38 U.S.C. §§ 1110, 1131. Hence, where the evidence does not support a finding of a current disability upon which to predicate the grant of service connection, there can be no valid claim for this benefit. See Gilpin v. Brown, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). After careful and thorough review of the evidence, the Board finds that the evidence is against finding that the Veteran has a current disability of chronic weakness. The medical evidence supports that the Veteran’s reported weakness is not an abnormality from an injury, disease, or residual condition, but normal thinning of his muscles since his retirement from the National Guard. In October 2010, the Veteran obtained a private medical consultation for his multiple symptom complaints, including chronic weakness. October 2010 Private treatment evidence. Private medical provider W C K, M.D., noted that neurological testing showed the Veteran did not demonstrate “true muscle weakness,” but that he had diffusely thin muscles. Id. A more recent physical examination performed during the period on appeal shows that the Veteran had normal muscle strength and tone. January 2018 VA treatment evidence. During a October 2019 treatment visit, the Veteran denied muscle weakness and the examination showed appropriate musculoskeletal strength and a smooth gait. The Board considered the Veteran’s statements about his chronic weakness. The Veteran is competent to report having experienced symptoms of chronic weakness since his retirement, but the causation of his weakness falls outside of the realm of knowledge of a lay person. Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). While the Board finds the Veteran’s statements that he has less strength than he did at the time of his retirement in 1998 to be probative, whether it is due to an injury or underlying disease is outside the realm of knowledge of a lay person. The Board, instead, finds the opinion and findings by his treatment providers that the Veteran does not have true muscle weakness, but thinning muscles with appropriate strength and tone to be more probative. The Board also considered whether the Veteran’s chronic weakness itself has resulted in a functional impairment that would amount to a disability, but, as discussed above, his physical examinations have shown appropriate strength and normal gait. In addition, the Veteran reported feeling a loss of strength since his retirement from the National Guard, but has not related to specific functional limitations. The Board, thus, finds that the preponderance of the evidence is against finding a current disability of chronic weakness. As the preponderance of the evidence is against the Veteran’s claim, that benefit of the doubt doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). Because the first element of service connection, i.e., a current disability, has not been met, the claim of entitlement to service connection for chronic weakness must be denied. REASONS FOR REMAND 1. Issue of entitlement to an initial rating higher than 30 percent for CAD is remanded. The Board cannot make a fully informed decision on the issue of entitlement to a higher initial rating for CAD because further development is needed by a VA examiner. The Veteran was afforded an October 2017 VA examination for his CAD. The VA examiner opined that the Veteran’s estimated METs level is 5-7 METs based on a 2012 heart catherization showing a 60 percent ejection fraction. October 2017 VA examination for heart conditions. The VA examiner did not perform an exercise stress test because the Veteran’s 2012 left heart catherization was found to reflect his current cardiac condition. However, the Veteran reported symptoms during the VA examination supported an interview based METs level of 3-5. Id. This is inconsistent with the VA examiner’s finding that the 2012 left heart catherization reflects the Veteran’s current heart condition and suggests that the Veteran symptoms may have worsened since then. The Veteran should be provided an opportunity to report for a VA examination to ascertain the current severity and manifestations of his CAD. 2. Issue of entitlement to service connection for celiac disease is remanded. The Board cannot make a fully informed decision on the issue of entitlement to service connection for celiac disease because no VA examiner has opined as to whether the Veteran’s celiac disease is directly due to or otherwise related to his in service exposure to Agent Orange herbicide, jet fuel, aircraft lubricants, or jet exhaust. The Veteran asserts entitlement to service connection for celiac disease as due to in service exposure to Agent Orange herbicide, jet fuel, aircraft lubricants, and jet exhaust. September 2017 Correspondence; April 2018 NOD; April 2020 VA Form 9. The Veteran’s is presumed to have been exposed to Agent Orange herbicide based on his service in the Republic of Vietnam in March 1967, November 1967, and September 1968. In addition, the Veteran’s statement that he was exposed to jet fuel, aircraft lubricants, and jet exhaust is consistent with his duties as an aircraft mechanic, crewman, and flight engineer. However, no VA examiner has opined as to whether the Veteran’s celiac disease is due to or otherwise related to his exposure to Agent Orange herbicide, jet fuel, aircraft lubricants, and jet exhaust. The Board finds that an opinion from a VA examiner is needed. 3. Issue of entitlement to service connection for chronic weight loss, to include an inability to gain weight, is remanded. The Board cannot make a fully informed decision on the issue of entitlement to service connection for weight loss, to include inability to gain weight, because an opinion from a VA examiner is needed as to its nature and cause. The Veteran asserts that his claimed conditions are due to in service exposure to Agent Orange herbicide, jet fuel, aircraft lubricants, and jet exhaust. September 2017 Correspondence; April 2018 NOD; April 2020 VA Form 9. The Veteran’s is presumed to have been exposed to Agent Orange herbicide based on his service in the Republic of Vietnam in March 1967, November 1967, and September 1968; and exposure to jet fuel, aircraft lubricants, and jet exhaust is consistent with his duties as an aircraft mechanic, crewman, and flight engineer. However, it is unclear if the Veteran’s asserted weight loss, to include inability to gain weight, is a current disability. Private treatment evidence prior to the period on appeal indicates that, after he was put on a gluten free diet, the Veteran’s weight was stable around 146 pounds. October 2010 Private treatment evidence. Treatment records eight years later show the Veteran’s weight to be at 145 pounds. September 2018 VA treatment evidence. The Veteran sought treatment by a nutritionist who recommended that the Veteran increase his caloric intake. October 2018 VA treatment evidence. A few months later there was a reported increase in his weight to about 150 pounds. March 2019 VA treatment evidence. More recently, however, the Veteran’s weight was noted to have decreased to 142 pounds. February 2020 VA treatment evidence. If a VA examiner finds that the Veteran’s weight loss or inability to gain weight is a current disability, then an opinion is needed as to whether the Veteran’s weight loss, to include inability to gain weight, is due to or otherwise related to his in service exposure to Agent Orange herbicide, jet fuel, aircraft lubricants, and jet exhaust. 4. Issue of entitlement to service connection for dyslipidemia is remanded. The Board cannot make a fully informed decision on the issue of entitlement to service connection for dyslipidemia because no VA examiner has opined as to whether the Veteran’s dyslipidemia is directly due to or otherwise related to his in service exposure to Agent Orange herbicide, jet fuel, aircraft lubricants, and jet exhaust. VA treatment records show that the Veteran was diagnosed with hyperlipidemia. January 2018 VA treatment evidence. The Veteran asserts entitlement to service connection for dyslipidemia due to in service exposure to Agent Orange herbicide, jet fuel, aircraft lubricants, and jet exhaust. September 2017 Correspondence; April 2018 NOD; April 2020 VA Form 9. The Veteran’s is presumed to have been exposed to Agent Orange herbicide based on his service in the Republic of Vietnam in March 1967, November 1967, and September 1968; and exposure to jet fuel, aircraft lubricants, and jet exhaust is consistent with his duties as an aircraft mechanic, crewman, and flight engineer. However, no VA examiner has opined as to whether the Veteran’s celiac disease is due to or otherwise related to his exposure to Agent Orange herbicide, jet fuel, aircraft lubricants, and jet exhaust. The Board finds that an opinion by a VA examiner is needed as to whether his dyslipidemia, including a diagnosis for hyperlipidemia, is due to or otherwise related to service. 5. Issue of entitlement to service connection for polymyalgia rheumatoid is remanded. The Board cannot make a fully informed decision on the issue of entitlement to service connection for polymyalgia rheumatoid because an opinion from a VA examiner is needed as to its nature and cause. The Veteran asserts entitlement to service connection for polymyalgia rheumatica as due to in service exposure to Agent Orange herbicide, jet fuel, aircraft lubricants, and jet exhaust. September 2017 Correspondence; April 2018 NOD; April 2020 VA Form 9. The Veteran’s is presumed to have been exposed to Agent Orange herbicide based on his service in the Republic of Vietnam in March 1967, November 1967, and September 1968; and exposure to jet fuel, aircraft lubricants, and jet exhaust is consistent with his duties as an aircraft mechanic, crewman, and flight engineer. However, it is unclear if the Veteran’s polymyalgia rheumatoid is a current disability. An October 2010 rheumatology consultation noted that the Veteran had a history of polymyalgia rheumatica, but nothing to suggest recurrence. October 2010 Private treatment evidence. The rheumatologist found normal inflammatory markers, no evidence of synovitis, and no reason to reinstitute prednisone treatment. Id. A VA examiner’s opinion is needed as to whether the Veteran has a current disability of polymyalgia rheumatica. Even if the Veteran’s polymyalgia rheumatica is found to not be a current disability, an opinion is still needed as to whether the Veteran’s history of polymyalgia rheumatoid is due to or otherwise related to his in service exposure to Agent Orange herbicide, jet fuel, aircraft lubricants, and jet exhaust. As discussed further below, there is some evidence suggesting that polymyalgia rheumatica could be a cause of the Veteran’s SVT. 6. Issue of entitlement to service connection for loss of bone density is remanded. The Board cannot make a fully informed decision on the issue of entitlement to service connection for loss of bone density because no VA examiner has opined as to whether the Veteran’s loss of bone density is directly due to or otherwise related to his in service exposure to Agent Orange herbicide, jet fuel, aircraft lubricants, and jet exhaust. Private treatment records show that the Veteran was diagnosed with osteoporosis in his in his lumbar spine and that his hips were in the osteopenic range. See October 2010 Private treatment evidence. The Veteran asserts entitlement to service connection for loss of bone density, diagnosed as osteoporosis and osteopenia, due to in service exposure to Agent Orange herbicide, jet fuel, aircraft lubricants, and jet exhaust. September 2017 Correspondence; April 2018 NOD; April 2020 VA Form 9. The Veteran’s is presumed to have been exposed to Agent Orange herbicide based on his service in the Republic of Vietnam in March 1967, November 1967, and September 1968; and exposure to jet fuel, aircraft lubricants, and jet exhaust is consistent with his duties as an aircraft mechanic, crewman, and flight engineer. However, no VA examiner has opined as to whether the Veteran’s loss of bone density is due to or otherwise related to his exposure to Agent Orange herbicide, jet fuel, aircraft lubricants, and jet exhaust. The Board finds that an opinion by a VA examiner is needed as to whether his loss of bone density, diagnosed as osteoporosis of the lumbar spine and osteopenia of the hips, is due to or otherwise related to service. 7. Issue of entitlement to service connection for SVT is remanded. The Board cannot make a fully informed decision on the issue of entitlement to service connection for SVT because no VA examiner has opined as to whether the Veteran’s SVT is directly due to or otherwise related to his in service exposure to Agent Orange herbicide, jet fuel, aircraft lubricants, and jet exhaust. The Veteran asserts entitlement to service connection for SVT due to in service exposure to Agent Orange herbicide, jet fuel, aircraft lubricants, and jet exhaust. September 2017 Correspondence; April 2018 NOD; April 2020 VA Form 9. The Veteran’s is presumed to have been exposed to Agent Orange herbicide based on his service in the Republic of Vietnam in March 1967, November 1967, and September 1968; and exposure to jet fuel, aircraft lubricants, and jet exhaust is consistent with his duties as an aircraft mechanic, crewman, and flight engineer. An October 2017 VA examiner opined that the Veteran’s SVT was less likely than not due to service because SVT is not a presumptive condition for Agent Orange herbicide exposure and his service treatment records did not show treatment for SVT. October 2017 VA examination medical opinion. Although the October 2017 VA examiner opined on whether SVT is a listed presumptive condition due to Agent Orange herbicide exposure, the examiner did not opinion on whether the Veteran’s SVT is due to his in service exposure to Agent Orange herbicide on a direct basis, or due to exposure to jet fuel, aircraft lubricants, and jet exhaust. In addition, if the Veteran’s polymyalgia rheumatica is found to be a service connected disability, an opinion is needed as to whether the Veteran’s SVT is secondary to polymyalgia rheumatica. Private treatment provider J E, M.D., FACC, opined that it is possible that the Veteran’s “cardiovascular disease” is due to polymyalgia rheumatica. August 2016 Private treatment evidence. However, it is unclear if Dr. J E was referring to the Veteran’s CAD, PVT, or both. Id. Moreover, Dr. J E’s opinion that there is a “possible” connection provides an unclear statement of a relationship. Id. The Board finds that an addendum opinion by a VA examiner is needed for the Veteran’s SVT. 8. Issue of entitlement to service connection for basal cell carcinoma, right cheek is remanded. The Board cannot make a fully informed decision on the issue of entitlement to service connection for basal cell carcinoma because no VA examiner has opined as to whether the Veteran’s basal cell carcinoma is due to or otherwise related to his in service exposure to Agent Orange herbicide, jet fuel, aircraft lubricants, and jet exhaust. In February 2016, the Veteran was seen for a neoplasm of uncertain behavior on his right cheek, which was determined to be basal cell carcinoma, superficial and nodular. May 2016 Private treatment evidence. The Veteran asserts entitlement to service connection for his basal cell carcinoma as due to in service exposure to Agent Orange herbicide, jet fuel, aircraft lubricants, and jet exhaust. See September 2017 Correspondence; April 2018 NOD; April 2020 VA Form 9. The Veteran’s is presumed to have been exposed to Agent Orange herbicide based on his service in the Republic of Vietnam in March 1967, November 1967, and September 1968; and exposure to jet fuel, aircraft lubricants, and jet exhaust is consistent with his duties as an aircraft mechanic, crewman, and flight engineer. However, no VA examiner has opined as to whether the Veteran’s basal cell carcinoma is due to or otherwise related to his exposure to Agent Orange herbicide, jet fuel, aircraft lubricants, and jet exhaust. The Board finds that an opinion by a VA examiner is needed. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected CAD. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. The examiner should perform METs testing unless there is a medical contraindication, the left ventricular ejection fraction is 50 percent or less, when there is congestive heart failure present or there has been more than one episode of congestive heart failure within the past year, or when a 100 percent rating can be assigned on another basis. 2. Obtain an opinion from an appropriate medical professional to determine the nature and cause of the Veteran’s celiac disease. If the medical professional determines that it is necessary, schedule the Veteran for a VA examination (or a telehealth interview, review of the record etc., if an in-person examination is not feasible). The medical professional should respond to the following: (a) Is it at least as likely as not (a 50 percent or greater probability) that the Veteran’s celiac disease began in (or is otherwise related to) the Veteran’s military service? The examiner should consider and discuss the Veteran’s lay testimony and assertions regarding any pertinent complaints and symptoms. The examiner should specifically consider and discuss whether the Veteran’s celiac disease is due to or otherwise related to the Veteran’s exposure to Agent Orange herbicide. This includes an opinion about a direct service connection basis (i.e. in addition to whether it is a condition subject to presumptive service connection). The examiner should consider and discuss the medical treatise evidence cited in the May 2020 Veteran’s VA Form 646 regarding Agent Orange exposure and immune system disorders. The examiner shoulder also specifically consider and discuss whether the Veteran’s celiac disease is due to or otherwise related to his exposure to jet fuel, aircraft lubricants, and jet exhaust. The examiner should consider and discuss the medical treatise evidence in the cited in the May 2020 VA Form 646 as well as the Safety Data Sheets, medical treatise, and articles submitted by the Veteran. A detailed explanation (rationale) is requested, including citing to supporting clinical data (and/or medical literature), as appropriate. (b) If celiac disease is deemed to be unrelated to service, the examiner should, if possible, identify the cause considered more likely and explained why that is so. 3. Obtain an opinion from an appropriate medical professional to determine the nature and cause of the Veteran’s weight loss, to include inability to gain weight. If the medical professional determines that it is necessary, schedule the Veteran for a VA examination (or a telehealth interview, review of the record etc., if an in person examination is not feasible). The medical professional should respond to the following: (a) Does the Veteran have a current disability of weight loss or inability to gain weight separate and distinct from his celiac disease? Does the Veteran’s weight loss during the period on appeal result in a functional loss in earning capacity? Consider the Veteran’s lay statements that he has lost weight since his 1998 retirement from the National Guard and that he has been unable to gain weight. Consider and discuss the Veteran’s VA treatment with a nutritionist from September 2018 to at least February 2020. (b) Is it at least as likely as not (a 50 percent or greater probability) that the Veteran’s weight loss and inability to gain weight began in (or is otherwise related to) the Veteran’s military service? The examiner should consider and discuss the Veteran’s lay testimony and assertions regarding any pertinent complaints and symptoms. The examiner should specifically consider and discuss whether the Veteran’s weight loss or inability to gain weight is due to or otherwise related to the Veteran’s exposure to Agent Orange herbicide. This includes an opinion about a direct service connection basis (i.e. in addition to whether it is a condition subject to presumptive service connection). The examiner shoulder also specifically consider and discuss whether the Veteran’s weight loss or inability to gain weight is due to or otherwise related to his exposure to jet fuel, aircraft lubricants, and jet exhaust. The examiner should consider and discuss the Safety Data Sheets, medical treatise, and articles submitted by the Veteran. A detailed explanation (rationale) is requested, including citing to supporting clinical data (and/or medical literature), as appropriate. (c) If weight loss or inability to gain weight is deemed to be unrelated to service, the examiner should, if possible, identify the cause considered more likely and explained why that is so. 4. Obtain an opinion from an appropriate medical professional to determine the nature and cause of the Veteran’s dyslipidemia, diagnosed hyperlipidemia. If the medical professional determines that it is necessary, schedule the Veteran for a VA examination (or a telehealth interview, review of the record etc., if an in person examination is not feasible). The medical professional should respond to the following: (a) Identify any evidence of a current dyslipidemia disability, including hyperlipidemia. (b) Is it at least as likely as not (a 50 percent or greater probability) that the Veteran’s dyslipidemia condition began in (or is otherwise related to) the Veteran’s military service? The examiner should consider and discuss the Veteran’s lay testimony and assertions regarding any pertinent complaints and symptoms. The examiner should specifically consider and discuss whether the Veteran’s dyslipidemia is due to or otherwise related to the Veteran’s exposure to Agent Orange herbicide. This includes an opinion about a direct service connection basis (i.e. in addition to whether it is a condition subject to presumptive service connection). The examiner shoulder also specifically consider and discuss whether the Veteran’s dyslipidemia is due to or otherwise related to his exposure to jet fuel, aircraft lubricants, and jet exhaust. The examiner should consider and discuss the Safety Data Sheets, medical treatise, and articles submitted by the Veteran. A detailed explanation (rationale) is requested, including citing to supporting clinical data (and/or medical literature), as appropriate. (c) If dyslipidemia is deemed to be unrelated to service, the examiner should, if possible, identify the cause considered more likely and explained why that is so. 5. Obtain an opinion from an appropriate medical professional to determine the nature and cause of the Veteran’s polymyalgia rheumatoid, to include inability to gain weight. If the medical professional determines that it is necessary, schedule the Veteran for a VA examination (or a telehealth interview, review of the record etc., if an in person examination is not feasible). The medical professional should respond to the following: (a) Does the Veteran have a current disability of polymyalgia rheumatoid or residuals of polymyalgia rheumatoid? Consider the October 2010 private treatment evidence showing that the Veteran had a rheumatology consultation which found no recurrence of polymyalgia rheumatica. (b) Even if polymyalgia rheumatoid is not a current disability, opine on whether it at least as likely as not (a 50 percent or greater probability) that the Veteran’s history of polymyalgia rheumatoid began in (or is otherwise related to) the Veteran’s military service? The examiner should consider and discuss the Veteran’s lay testimony and assertions regarding any pertinent complaints and symptoms. The examiner should specifically consider and discuss whether the Veteran’s polymyalgia rheumatoid is due to or otherwise related to the Veteran’s exposure to Agent Orange herbicide. This includes an opinion about a direct service connection basis (i.e. in addition to whether it is a condition subject to presumptive service connection). The examiner shoulder also specifically consider and discuss whether the Veteran’s polymyalgia rheumatoid is due to or otherwise related to his exposure to jet fuel, aircraft lubricants, and jet exhaust. The examiner should consider and discuss the Safety Data Sheets, medical treatise, and articles submitted by the Veteran. A detailed explanation (rationale) is requested, including citing to supporting clinical data (and/or medical literature), as appropriate. (c) If polymyalgia rheumatoid is deemed to be unrelated to service, the examiner should, if possible, identify the cause considered more likely and explained why that is so. 6. Obtain an opinion from an appropriate medical professional to determine the nature and cause of the Veteran’s loss of bone density, including osteoporosis in the lumbar spine and osteopenia in the hips. If the medical professional determines that it is necessary, schedule the Veteran for a VA examination (or a telehealth interview, review of the record etc., if an in person examination is not feasible). The medical professional should respond to the following: (a) Is it at least as likely as not (a 50 percent or greater probability) that the Veteran’s loss of bone density began in (or is otherwise related to) the Veteran’s military service? The examiner should consider and discuss the Veteran’s lay testimony and assertions regarding any pertinent complaints and symptoms. The examiner should specifically consider and discuss whether the Veteran’s loss of bone density is due to or otherwise related to the Veteran’s exposure to Agent Orange herbicide. This includes an opinion about a direct service connection basis (i.e. in addition to whether it is a condition subject to presumptive service connection). The examiner shoulder also specifically consider and discuss whether the Veteran’s loss of bone density is due to or otherwise related to his exposure to jet fuel, aircraft lubricants, and jet exhaust. The examiner should consider and discuss the Safety Data Sheets, medical treatise, and articles submitted by the Veteran. A detailed explanation (rationale) is requested, including citing to supporting clinical data (and/or medical literature), as appropriate. (b) If loss of bone density, including osteoporosis of the lumbar spine or osteopenia of the hips, is deemed to be unrelated to service, the examiner should, if possible, identify the cause considered more likely and explained why that is so 7. Obtain an opinion from an appropriate medical professional to determine the nature and cause of the Veteran’s SVT. If the medical professional determines that it is necessary, schedule the Veteran for a VA examination (or a telehealth interview, review of the record etc., if an in-person examination is not feasible). The medical professional should respond to the following: (a) Is it at least as likely as not (a 50 percent or greater probability) that the Veteran’s SVT began in (or is otherwise related to) the Veteran’s military service? The examiner should consider and discuss the Veteran’s lay testimony and assertions regarding any pertinent complaints and symptoms. The examiner should specifically consider and discuss whether the Veteran’s SVT is due to or otherwise related to the Veteran’s exposure to Agent Orange herbicide. This includes an opinion about a direct service connection basis (i.e. in addition to whether it is a condition subject to presumptive service connection). The examiner shoulder also specifically consider and discuss whether the Veteran’s SVT is due to or otherwise related to his exposure to jet fuel, aircraft lubricants, and jet exhaust. The examiner should consider and discuss the medical treatise evidence in the cited in the May 2020 VA Form 646 as well as the Safety Data Sheets, medical treatise, and articles submitted by the Veteran. A detailed explanation (rationale) is requested, including citing to supporting clinical data (and/or medical literature), as appropriate. (b) The examiner should also provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s current SVT is proximately due to or the result of his polymyalgia rheumatoid. If not proximately due to or the result of polymyalgia rheumatoid, is it at least as likely as not (50 percent or greater probability) that the Veteran’s SVT is aggravated (an increase more than the natural disease progression, even if temporary) by his polymyalgia rheumatoid. The examiner shoulder consider and discuss the August 2016 opinion from J E, M.D., FACC, that it is possible the Veteran’s cardiovascular disease could be related to polymyalgia rheumatica. (c) If SVT is deemed to be unrelated to service, the examiner should, if possible, identify the cause considered more likely and explained why that is so. 8. Obtain an opinion from an appropriate medical professional to determine the nature and cause of the Veteran’s right cheek basal cell carcinoma. If the medical professional determines that it is necessary, schedule the Veteran for a VA examination (or a telehealth interview, review of the record etc., if an in person examination is not feasible). The medical professional should respond to the following: (a) Is it at least as likely as not (a 50 percent or greater probability) that the Veteran’s basal cell carcinoma began in (or is otherwise related to) the Veteran’s military service? The examiner should consider and discuss the Veteran’s lay testimony and assertions regarding any pertinent complaints and symptoms. The examiner should specifically consider and discuss whether the Veteran’s basal cell carcinoma is due to or otherwise related to the Veteran’s exposure to Agent Orange herbicide. This includes an opinion about a direct service connection basis (i.e. in addition to whether it is a condition subject to presumptive service connection). The examiner shoulder also specifically consider and discuss whether the Veteran’s basal cell carcinoma is due to or otherwise related to his exposure to jet fuel, aircraft lubricants, and jet exhaust. The examiner should consider and discuss the Safety Data Sheets, medical treatise, and articles submitted by the Veteran. A detailed explanation (rationale) is requested, including citing to supporting clinical data (and/or medical literature), as appropriate. (b) If basal cell carcinoma, is deemed to be unrelated to service, the examiner should, if possible, identify the cause considered more likely and explained why that is so. (Continued on next page)   9. Review the record and ensure that all development sought in this remand has been completed. Arrange for any further development indicated by the results of the development requested above if deemed warranted by the Agency of Original Jurisdiction (AOJ), and re-adjudicate the claims. If a claim is denied, supply the Veteran and his representative with a supplemental statement of the case and allow an appropriate period of time for response. Thereafter, the claims folder should be returned to the Board for further appellate review, if otherwise in order. DEBORAH W. SINGLETON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Lin, Mao Ching 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.