Citation Nr: 21067603 Decision Date: 11/04/21 Archive Date: 11/04/21 DOCKET NO. 16-30 578 DATE: November 4, 2021 REMANDED Entitlement to service connection for microscopic hematuria is remanded. Entitlement to service connection for actinic keratosis is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Marine Corps from February 1969 to February 1973. This matter comes before the Board of Veterans Appeals (Board) on appeal from an April 2015 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). This matter was previously remanded by the Board in November 2018 and June 2021 to obtain examinations regarding the etiology of the Veteran's claimed conditions. While the Board regrets additional delay, unfortunately, a third remand is necessary. When a case is remanded, a veteran is entitled to substantial compliance with all remand instructions. Stegall v. West, 11 Vet. App. 268, 271 (1998). If the RO does not substantially comply with the Board's remand instructions, the Board is legally bound to continue remanding until the mistake is corrected. See id. Additionally, VA has a duty to ensure that any medical examination or opinion it provides is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). A medical opinion is adequate where it is based upon consideration of the full medical history and describes a disability in sufficient detail so that the Board's evaluation will be fully informed. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). The Board finds that the June 2021 VA examination, conducted pursuant to the June 2021 remand, was inadequate. The June 2021 VA examiner gave brief, identical opinions on the etiology of both claimed conditions: [The service treatment records (STRs) are] silent for any evidence of [hematuria or actinic keratosis]. Records indicate the condition developed many years post military. Thus, neither chronicity of an in-service condition, nor continuity of symptoms between service and today is established. Therefore, it is less likely than not the [microscopic hematuria / actinic keratosis] was incurred while on active duty. ... It is less likely than not the microscopic hematuria was caused by exposure to "agent orange". Medical literature search is silent to support exposures to chemicals "agent orange" would later cause the microscopic hematuria to develop. It is less likely than not the actinic keratosis was caused by exposure to "agent orange". Medical literature search is silent to support exposures to chemicals "agent orange" would later cause actinic keratosis to develop. This opinion is far too vague for the Board to properly evaluate. The examiner says nothing about the etiology of the Veteran's claimed conditions, or about the etiology of microscopic hematuria and actinic keratosis generally. The examiner's reasoning that the Veteran's conditions did not have their onset in service because they were not noted in his STRs is inadequate without information about how these conditions typically progress, to include whether these conditions typically have a sudden, obvious onset, or if they are conditions with a slow, subtle progression, that could have reasonably gone unnoticed for years. The opinion goes on to state that the medical literature is "silent to support" a link between herbicide agent exposure and the Veteran's claimed conditions, but again, does not explain what is more likely to have caused the claimed conditions. Furthermore, it is unclear exactly how the medical literature fails to support a link between herbicide agent exposure and the claimed conditions. The June 2021 examination also did not address whether the Veteran's claimed conditions were caused or aggravated by any of his service-connected disabilities, such as diabetes mellitus and hypertension. Due to the deficiencies in the June 2021 opinion, the Board finds that a new medical examination is warranted. The matters are REMANDED for the following action: 1. Obtain an opinion from an appropriate clinician, who has not already provided an opinion in this case, if possible, regarding the nature and etiology of the Veteran's microscopic hematuria. If the clinician believes an in-person or telehealth examination is necessary, one should be scheduled. After reviewing the entire claims file, the examiner should answer the following: (a) Is it at least as likely as not (50 percent or greater probability) that the Veteran's microscopic hematuria had its onset during service? (b) Is it at least as likely as not that the Veteran's microscopic hematuria is related to an in-service injury, disease, or event? The examiner should specifically address the Veteran's conceded exposure to herbicide agents during service. (c) Is it at least as likely as not that the Veteran's microscopic hematuria was caused or aggravated by any service-connected condition, to include hypertension and diabetes mellitus? (d) If the Veteran's microscopic hematuria is unrelated to his military service, what is its likely etiology? The opinion must reflect consideration of the Veteran's full medical history and the record as a whole. If the examiner is unable to reach a conclusion without resorting to mere speculation, the examiner must explain why. 2. Obtain an opinion from an appropriate clinician, who has not already provided an opinion in this case, if possible, regarding the nature and etiology of the Veteran's actinic keratosis. If the clinician believes an in-person or telehealth examination is necessary, one should be scheduled. After reviewing the entire claims file, the examiner should answer the following: (e) Is it at least as likely as not (50 percent or greater probability) that the Veteran's actinic keratosis had its onset during service? (f) Is it at least as likely as not that the Veteran's actinic keratosis is related to an in-service injury, disease, or event? The examiner should specifically address the Veteran's conceded exposure to herbicide agents during service. (g) Is it at least as likely as not that the Veteran's actinic keratosis was caused or aggravated by any service-connected condition, to include hypertension and diabetes mellitus? (h) If the Veteran's actinic keratosis is unrelated to his military service, what is its likely etiology? The opinion must reflect consideration of the Veteran's full medical history and the record as a whole. If the examiner is unable to reach a conclusion without resorting to mere speculation, the examiner must explain why. JENNIFER HWA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Shermila Sundquist 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.