Citation Nr: 21064191 Decision Date: 10/19/21 Archive Date: 10/19/21 DOCKET NO. 16-53 622A DATE: October 19, 2021 REMANDED Entitlement to service connection for a skin condition, to include Fournier's gangrene (also claimed as fungus of the testicles), as a result of presumed herbicide agent exposure in the Republic of Vietnam or as secondary to service-connected B-cell chronic lymphocytic leukemia, is remanded. Entitlement to service connection for loss of left and right testicles, to include as a result of presumed herbicide agent exposure in the Republic of Vietnam or as secondary to service-connected B-cell chronic lymphocytic leukemia, is remanded. REFERRAL TO THE AGENCY OF ORIGINAL JURISDICTION In a June 2014 Notice of Disagreement, the Veteran appealed an April 2014 rating decision and noted that he disagreed with decisions regarding service connection for "impotent, no sex drive, no sexual erection" and low back pain. These claimed disabilities, however, had not been adjudicated in the April 2014 rating decision as they had not been raised previously and they have not been adjudicated since then. The Agency of Original Jurisdiction (AOJ) should ask the Veteran whether he intended to file a claim of service connection for these disabilities and, if so, provide him with the appropriate application form to file such a claim. REASONS FOR REMAND The Veteran served on active duty in the United States Army from April 1971 to April 1973, to include service in the Republic of Vietnam. His decorations include the Vietnam Service Medal with one Bronze star and the Republic of Vietnam Campaign Medal with 1960 Device. This matter comes before the Board of Veterans' Appeals (Board) from an April 2014 rating decision by a Department of Veterans Affairs (VA) AOJ. In a November 2016 VA Form 9, the Veteran requested a Board hearing in this matter and a hearing was scheduled in October 2019. In a September 2019 Statement in Support of Claim, the Veteran's representative stated that the Veteran requested the Board hearing to be cancelled. In the same document, the representative also stated that the Veteran "has decided not to pursue his appeal any further." The Board reads this last statement as part of the Veteran's request to cancel the hearing and not as a request to withdraw the appeal, as the Veteran's representative has filed two Informal Hearing Presentations (IHP) since September 2019, demonstrating that the Veteran wishes his appeal to be adjudicated. In December 2019, the Board remanded this matter to obtain VA examinations and medical opinions, which were obtained in December 2019. The examiner opined that the Veteran's claimed disabilities are less likely than not secondary to his service-connected leukemia. Unfortunately, remand is warranted again as the December 2019 medical opinions are inadequate. In this regard, the examiner's opinions do not include a discussion of a medical article cited in the November 2019 IHP. The August 2021 IHP also cited two additional medical articles which have not yet been considered by an examiner, including a research study published on August 30, 2021. In addition, the examiner's opinions only addressed secondary service connection and not direct service connection as a result of presumed exposure to herbicide agents. Furthermore, the examiner provided a negative opinion regarding gangrene on the basis that the condition has resolved; however, the examiner did not indicate when the condition had resolved or whether any residuals have persisted. Lastly, the examiner's rationale regarding secondary proximate causation and aggravation theories for both claimed disabilities is inadequate as the examiner merely repeated that there is no connection between leukemia and the claimed disabilities. Without additional explanation, authority, or details to support this contention, the Board is unable to weigh the probative value of the opinions and is unable to render a fully-informed decision. For these reasons, remand is necessary to obtain addendum opinions. Updated VA and private treatment records should also be secured. The matters are REMANDED for the following action: 1. Obtain any outstanding VA treatment records. 2. With any necessary assistance from the Veteran, obtain any outstanding pertinent private treatment records. 3. Obtain an addendum opinion addressing the etiology of the Veteran's claimed skin condition, to include Fournier's gangrene (also claimed as fungus of the testicles), preferably from an oncologist or similar specialist, and someone other than the December 2019 examiner. A new examination is not needed unless the examiner indicates that s/he cannot render a fully-informed opinion without a concurrent examination, in which case the examiner must so state and an examination must be scheduled. The entire claims file must be made available to and reviewed by the examiner. After reviewing the claims file, the examiner is asked to address the following items: (a.) Identify any skin conditions present since December 2013, to include Fournier's gangrene (also claimed as fungus of the testicles), even if resolved. If the examiner indicates that a condition has resolved, the examiner must explain when and why that condition resolved, and whether the Veteran has experienced or manifested any residuals of the condition since December 2013. (b.) If the examiner identifies any skin conditions or residuals of a skin condition present since December 2013, to include Fournier's gangrene, please opine whether it is at least as likely as not (50 percent probability or greater) that the condition was caused by or is otherwise related to the Veteran's active service, to include as a result of presumed herbicide agent exposure. Please note that a negative opinion cannot be based on the fact that the claimed condition is not listed in the regulation of disabilities presumptively caused by herbicide agents; doing so will render the opinion inadequate. The examiner must note that the Veteran is presumed to have been exposed to herbicide agents during his active service in the Republic of Vietnam. (c.) Whether it is at least as likely as not (50 percent probability or greater) that the condition is proximately due to the Veteran's service-connected B-cell chronic lymphocytic leukemia. (d.) Whether it is at least as likely as not (50 percent probability or greater) that the condition has been aggravated (worsened) by the Veteran's service-connected B-cell chronic lymphocytic leukemia. If aggravation is found, the examiner should attempt to identify the baseline level of disability prior to such aggravation. In addressing the questions above in (b.)-(d.), the examiner must consider and discuss the Veteran's arguments raised in the August 2021 and November 2019 Informal Hearing Presentations, as well as the following medical articles: Fournier's Gangrene in Patients with Oncohematological Diseases: A Systemic Review of Published Cases (August 2021), available at https://www.researchgate.net/publication/354229280_Fournier's_Gangrene_in_Patients_with_Oncohematological_Dis-Eases_A_Systematic_Review_of_Published_Cases. Rituximab in B-cell Hematologic Malignancies: A Review of 20 Years of Clinical Experience (October 2017), available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5656728 Fournier's Gangrene Complicating Hematologic Malignancies: a Case Report and Review of Literature (November 2013), available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3867231 4. Obtain an addendum opinion addressing the etiology of the Veteran's loss of left and right testicles, preferably from an oncologist or similar specialist, and someone other than the December 2019 examiner. A new examination is not needed unless the examiner indicates that s/he cannot render a fully-informed opinion without a concurrent examination, in which case the examiner must so state and an examination must be scheduled. The entire claims file must be made available to and reviewed by the examiner. After reviewing the claims file, the examiner is asked to address the following items: (a.) Whether it is at least as likely as not (50 percent probability or greater) that the Veteran's loss of left and/or right testicles was caused by or is otherwise related to the Veteran's active service, to include as a result of presumed herbicide agent exposure. Please note that a negative opinion cannot be based on the fact that the claimed condition is not listed in the regulation of disabilities presumptively caused by herbicide agents; doing so will render the opinion inadequate. The examiner must note that the Veteran is presumed to have been exposed to herbicide agents during his active service in the Republic of Vietnam. (b.) Whether it is at least as likely as not (50 percent probability or greater) that the condition is proximately due to the Veteran's service-connected B-cell chronic lymphocytic leukemia. (c.) Whether it is at least as likely as not (50 percent probability or greater) that the condition has been aggravated (worsened) by the Veteran's service-connected B-cell chronic lymphocytic leukemia. If aggravation is found, the examiner should attempt to identify the baseline level of disability prior to such aggravation. (Continued on the next page) Please provide a robust rationale based on medical principles to support any conclusions reached. If unable to opine without speculation, please support your conclusion in this regard. ERIC S. LEBOFF Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. deBruyn, 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.