Citation Nr: 21002198 Decision Date: 01/13/21 Archive Date: 01/13/21 DOCKET NO. 20-27 187 DATE: January 13, 2021 REMANDED Entitlement to service connection for a gastrointestinal stromal tumor, to include as due to exposure to herbicide agents, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Navy from August 1965 to August 1969. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a November 2018 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In November 2020, the Veteran and his spouse testified before the undersigned Veterans Law Judge at a Board hearing. A transcript of the hearing is of record. Unfortunately, for the reasons described below, this matter must be remanded for additional development. Although the Board regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide this claim so that the Veteran is afforded every possible consideration. Entitlement to service connection for a gastrointestinal stromal tumor, to include as due to exposure to herbicide agents, is remanded. The Veteran seeks entitlement to service connection for a gastrointestinal stromal tumor, which he contends was caused by exposure to herbicide agents during service. The Board notes that VA has conceded the Veteran’s exposure to herbicide agents. Post-service private treatment records submitted by the Veteran show that he underwent a removal of a gastrointestinal stromal tumor in November 2015. Biopsy revealed the tumor to be nonmalignant. The Veteran continues to be monitored for reoccurrence of the tumor. An April 2020 VA medical opinion confirmed that a gastrointestinal stromal tumor is a mesenchymal neoplasm. The Board notes that while malignant mesenchymoma is a type of soft-tissue sarcoma presumptively associated with exposure to herbicide agents, nonmalignant mesenchymoma is not. See 38 C.F.R. § 3.309(e). Therefore, because the Veteran’s gastrointestinal stromal tumor was nonmalignant, he is not entitled to presumptive service connection pursuant to 38 C.F.R. § 3.307(a)(6). See id. However, when a veteran is not entitled to a regulatory presumption for a given disability, the claim must nevertheless be reviewed to determine whether service connection can be established on a direct basis. Combee v. Brown, 34 F.3d 1039, 1043-1044 (Fed. Cir. 1994). The Board notes that a VA medical opinion has not yet been obtained that addresses the nature and etiology of the Veteran’s gastrointestinal stromal tumor, to include whether the disease was caused by in-service exposure to herbicide agents. As such, remand is warranted to obtain a VA medical opinion on the Veteran’s behalf before the Board can make an informed decision on the claim. See 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79 (2006); Douglas v. Shinseki, 23 Vet. App. 19, 26 (2009). The matter is REMANDED for the following action: Forward the Veteran’s claims file to a VA physician (M.D.) of appropriate expertise (preferably an oncologist if available) to obtain a medical opinion that assesses the nature and etiology of the Veteran’s gastrointestinal stromal tumor. The examiner must review the Veteran’s entire claims file, to include a copy of this REMAND, and that review must be noted in the report. If the examiner determines that an opinion cannot be provided without an examination, then the Veteran should be scheduled for one. Following a thorough review of the Veteran’s entire medical history, the examiner is asked to provide a fully-articulated medical opinion addressing the following: (a) Is it at least as likely as not (50 percent probability or greater) that the Veteran’s gastrointestinal stromal tumor was incurred in or otherwise caused by any in-service disease, event, or injury, to include presumed exposure to herbicide agents? In responding to the above, the examiner must opine as to whether the condition is directly related to the Veteran’s presumed herbicide agent exposure during service. A medical opinion that concludes that a disease is not related to herbicide exposure solely because there is no presumption of service connection is inadequate. In addition, the examiner should address whether this is a type of malignant tumor, a soft tissue sarcoma, or a small cell carcinoma, as asserted by the Veteran and his representative during the Board hearing. The examiner should note that the term “at least as likely as not” does not mean “within the realm of possibility.” Rather, it means that the weight of the medical evidence both for and against the claim is so evenly divided that it is as medically sound to find in favor of the claim as it is to find against it. The examiner must provide a complete rationale for any opinion expressed, citing to the examiner’s clinical experience, medical expertise, and established medical principles, as necessary. If the examiner is unable to provide an opinion without resorting to speculation, he or she should explain why this is so and what, if any, additional evidence would be necessary before an opinion could be rendered. LESLEY A. REIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Melissa Barbee, 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.