Citation Nr: 21063630 Decision Date: 10/15/21 Archive Date: 10/15/21 DOCKET NO. 16-21 566 DATE: October 15, 2021 REMANDED Entitlement to service connection for a brain tumor (claimed as olfactory groove meningioma), and residuals thereof, including as due to exposure to herbicide agents, is remanded. Entitlement to service connection for vision loss, including as secondary to a brain tumor, is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1964 to August 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2012 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a September 2018 Board hearing before the undersigned Veterans Law Judge (VLJ). A transcript of the hearing is associated with the claims file. This matter was remanded most recently in December 2020 to ensure substantial compliance with prior remand directives. Specifically, the Board directed the RO to obtain an addendum medical opinion as to the etiology of the Veteran's brain tumor and residuals based on consideration of his pre-service, in-service, and post-service complaints of dizziness and headaches, May 1981 treatment records discussing his major motor seizure, and his testimony regarding what doctors had told him about his brain tumor. The RO obtained two addendum medical opinions in May 2021 and July 2021; however, these opinions, taken together, lack sufficient rationale and supporting data as to their conclusions. As such, the Board finds that the remand directives were not substantially complied with, and further remand is necessary. See Stegall v. West, 11 Vet. App. 268. Per the December 2020 remand directives, the Board directed, in part, that "[a]ll opinions must be accompanied by a rationale consistent with the evidence of record" and further specified that "[t]he medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two." The May 2021 examiner did not comply with these remand directives. In the May 2021 opinion, the examiner summarized both the Veteran's pre-existing and in-service history of dizziness, fainting spells, and palpitations, but did not specifically discuss these symptoms and why neither history served as early manifestations of his later diagnosed brain tumor. In the subsequent July 2021 opinion, the examiner determined that the Veteran's May 1981 grand mal seizure was the sentinel manifestation of his brain tumor without discussion as to why this seizure, and not the Veteran's reported 15-year history of micropsia and/or history of dizziness, fainting spells, and palpitations, were sentinel manifestations of the brain tumor. Based on the examiner's lack of rationale and analysis supporting her opinion, the Board finds that both the May 2021 and July 2021 opinions are inadequate due to their conclusory nature and do not substantially comply with the Board's December 2020 remand directives. The Board would like to clarify that aggravation is not an issue in this case. The VA examiner indicated that the Veteran's brain tumor may have pre-existed service, noting that meningiomas are benign tumors that grow slowly and can have a latency period of 20 to 30 years or more, meaning the onset of the Veteran's tumor growth could have begun between 1952 to 1962, which would have been prior to military service. However, every veteran is presumed to be in sound condition when examined, accepted, and enrolled for service, except as to defect, infirmities, or disorders noted at the time of examination, acceptance, and enrollment. 38 U.S.C. § 1111. Although the Veteran reported a pre-service history of dizziness, fainting spells, and heart palpitations at his entrance examination and during service, his entrance examination revealed no abnormalities; therefore, the Veteran is presumed to have been in sound condition upon entry into active service absent clear and unmistakable evidence to the contrary. The examiner's comment that it may have began prior to service does not even remotely approach the clear and unmistakable evidence standard needed to rebut the presumption of soundness. As the Veteran's claim of service connection for vision loss is inextricably intertwined with the claim of service connection for a brain tumor, it must also be remanded. The matters are REMANDED for the following action: Return the claims file to the May 2021 VA examiner, or another examiner if she is not available, to obtain an addendum medical opinion. After a review of the claims file, including this remand, the examiner should respond to the following: Was the brain tumor at least as likely as not related to service? The examiner should explicitly consider the Veteran's April 1965 in-service report that his current symptoms were not the same as those prior to service and his May 1981 report of periodic right-sided headaches for many years and a 15-year history of micropsias. If the examiner determines that the Veteran's in-service symptoms of dizziness, fainting, heart palpitations, and micropsias, as well as his history of periodic headaches, were not early manifestations of his brain tumor, he or she should clearly explain why with full supporting rationale. The examiner is reminded that the standard "at least as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. All opinions must be accompanied by a rationale reflecting full consideration of the evidence of record. A discussion and analysis of the pertinent evidence, relevant medical treatises, and generally accepted medical principles is required. MICHELLE L. KANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Tierno 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.