Citation Nr: 21067061 Decision Date: 11/03/21 Archive Date: 11/03/21 DOCKET NO. 15-33 381A DATE: November 3, 2021 REMANDED Entitlement to service connection for squamous cell carcinoma is remanded. Entitlement to service connection for basal cell carcinoma with scarring is remanded. REASONS FOR REMAND The Veteran served on active duty from November 1966 to August 1969, to include service in the Republic of Vietnam. The Veteran was awarded the Purple Heart Medal for his honorable service. He died in November 2019. These matters come before the Board of Veterans' Appeals (Board) on appeal from an August 2015 rating decision issued by a Regional Office (RO) of the United States Department of Veterans Affairs (VA). In November 2020, the Veteran's surviving spouse was substituted as the Appellant. As to the matters on appeal, the late Veteran and the Appellant presented sworn testimony before the undersigned Veterans Law Judge at an October 2018 Board hearing. A transcript of the proceeding has been associated with the claims file. These matters were previously denied by the Board in July 2019. However, as submitted evidence had not been considered in the decision, it was vacated in April 2020. The Board thereafter remanded the claims for further evidentiary development in April 2021. Although regretting the additional delay, the Board finds that remand is again needed to ensure compliance with the prior remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). 1. Entitlement to service connection for squamous cell carcinoma is remanded. 2. Entitlement to service connection for basal cell carcinoma with scarring is remanded. The Appellant has contended that the Veteran's squamous cell carcinoma and basil cell carcinoma were the result of his active service, to include his presumed exposure to herbicide agents in Vietnam and/or as secondary to his use of immunosuppressive therapy to treat his service-connected Crohn's disease. The April 2021 remand directed the RO to obtain a medical opinion that specifically considered April 2019, August 2019, and June 2019 private medical opinions and a medical article discussing the use of azathioprine and the increased risk of developing nonmelanoma skin carcinomas The Board instructed the examiner to address whether it was at least as likely as not that the Veteran's squamous cell and basal cell carcinomas were proximately due to or the result of the long-term immunosuppressive therapy used to treat his service-connected Crohn's disease. The examiner was also instructed to address whether it was at least as likely as not that his squamous cell and basal cell carcinomas underwent any incremental increase in disability, regardless of its permanence, due to or the result of the long-term immunosuppressive therapy used to treat the Veteran's service-connected Crohn's disease. A VA examiner undertook the required review in August 2021. Unfortunately, the Board finds the reports inadequate. None of the reports address the private opinions or article specifically highlighted in the remand order. See Stegall v. West, 11 Vet. App. at 271 (holding that a remand by the Board confers upon the Veteran, as a matter of law, the right to compliance with its remand instructions, and imposes upon VA a concomitant duty to ensure compliance with the terms of the remand). Moreover, while listing possible risk factors for squamous cell and basal cell carcinomas, the examiner did not then apply them to the Veteran's circumstances. Finally, the opinions appear to offer no rationale in support of their conclusions. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 300-301 (2008) (holding that to have probative value, the opinion provider must be fully informed of the pertinent factual premises, provide a fully articulated opinion, and provide a supportive reasoned analysis); see also Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007) (holding that once VA undertakes the effort to provide an examination when developing a claim, even if not statutorily obligated to do so, VA must ensure that the examination provided is adequate). In addition, the Board observes that the report repeatedly refers to the Veteran's contention in January 2012 that his skin disabilities were related to his "tropical sun exposure and sunburn during military service." The Board has been unable to find this statement, or one similar to it, in the claims file. However, in correspondence in November 2016, the private physician GW opined that the Veteran's exposure to ultraviolet light while on active duty in Vietnam "contributed to the development of numerous skin carcinomas." Though, as with several other of his opinions, he offered no rationale for his conclusion, he nevertheless has raised the contention that the Veteran's squamous cell and basal cell carcinomas were proximately due to or the result of his exposure to ultraviolet light while on active duty in Vietnam. This theory echoes a similar theory expressed in VA examiners' opinions from other cases filed by the Veteran over the course of presenting his claim. None of the examiners' opinions prior to August 2021, nor the Board's vacated decision or remand orders, have addressed this theory of service connection. See Robinson v. Shinseki, 557 F.3d 1355, 1361 (Fed. Cir. 2009); Szemraj v. Principi, 357 F.3d 1370, 1373 (Fed. Cir. 2004) (all theories of entitlement must be considered). Accordingly, a new VA medical opinion should also consider this theory of entitlement. The matters are REMANDED for the following action: 1. Obtain a VA medical opinion from an appropriate VA examiner regarding the etiology of the Veteran's squamous cell and basal cell carcinomas. Following a complete review of the electronic claims file, including a copy of this REMAND, the VA examiner is requested to address the following inquiries: a. Is it at least as likely as not that the Veteran's squamous cell and basal cell carcinomas were proximately due to or the result of the long-term immunosuppressive therapy used to treat his service-connected Crohn's disease? b. Is it at least as likely as not that the Veteran's squamous cell and basal cell carcinomas underwent any incremental increase in disability, regardless of its permanence, due to the long-term immunosuppressive therapy used to treat his service-connected Crohn's disease? See Ward v. Wilkie, 31 Vet. App. 233 (2019). (i) The term "incremental increase in disability" means additional impairment of earning capacity. Objective measurement, or numerical quantification, is not required to ascertain an increase in disability. Moreover, any "incremental increase in disability" need not be permanent. c. Is it at least as likely as not that the Veteran's squamous cell and basal cell carcinomas were proximately due to or the result of exposure to ultraviolet light while on active service? d. The VA examiner is specifically requested to consider and address the April 2019, August 2019, and June 2019 private medical opinions, as well as the medical article discussing azathioprine and the increased risk of developing nonmelanoma skin carcinomas in addressing the first two issues. The examiner is also requested to consider and address the November 2016 opinion and any other relevant documents in addressing the third issue. e. The VA examiner must provide a complete rationale for any opinion expressed that is based on the examiner's clinical experience and medical expertise; established medical principles; and citation to the evidence of record, as appropriate. 2. After the above development, and any additionally indicated development, has been completed, readjudicate the claim. MICHAEL A. PAPPAS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Wilkinson, Edward L. 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.