Citation Nr: 21071261 Decision Date: 11/30/21 Archive Date: 11/30/21 DOCKET NO. 17-24 281 DATE: November 30, 2021 REMANDED Entitlement to service connection for irritable bowel syndrome (IBS) and Crohn's disease, to include as secondary to service-connected diabetes mellitus type II, is remanded. Entitlement to service connection for clear cell renal carcinoma (claimed as kidney cancer) is remanded. REASONS FOR REMAND The Veteran served in the United States Air Force from November 1967 to November 1971. These matters come before the Board of Veterans' Appeals (Board) on appeal from an October 2016 rating decision concerning IBS and Crohn's disease and an August 2017 rating decision concerning a kidney condition, both from a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge at a videoconference hearing in August 2021, and a transcript of this hearing is associated with the claims file. 1. Entitlement to service connection for irritable bowel syndrome (IBS) and Crohn's disease, to include as secondary to service-connected diabetes mellitus type II, is remanded. The Veteran contends that his IBS and Crohn's disease are due to his exposure to herbicide agents during service or is secondary to his service-connected diabetes. The Board notes the Veteran has current diagnoses of IBS and Crohn's disease. The Board also notes that the Veteran is currently service connected for diabetes. Additionally, the Board concedes that the Veteran had in-country service in the Republic of Vietnam during the Vietnam era, and therefore is presumed to have been exposed to herbicide agents during service. The Veteran has not received a VA examination for his IBS or Crohn's disease. The Board has considered whether it can remand to schedule an examination. When determining whether VA is required to provide a VA medical examination or a medical opinion, the following factors should be considered: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in-service, or evidence establishing certain chronic diseases were manifested during an applicable post-service presumptive period; (3) whether there is an indication that the disability or symptoms may be associated with the Veteran's service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). The third factor has a low threshold and requires only that the evidence "indicates" that there "may" be a nexus between the current disability or symptoms and a veteran's service. McLendon v. Nicholson, 20 Vet. App. 79 (2006). In the present case, the Veteran has provided diagnoses of IBS and Crohn's disease, and thus meets the first McLendon element. VA has conceded that the Veteran was in the Republic of Vietnam during the Vietnam era and meets the requirements for presumed herbicide exposure. Additionally, the Veteran is service connected for diabetes and has alleged that his IBS and Crohn's are due to his diabetes. Therefore, the second element of McClendon is met. With respect to the third McLendon element, the Board finds that while the Veteran's IBS and Crohn's diagnoses are not presumed conditions under 38 C.F.R. § 3.309(e), the evidence is sufficient enough to raise the question of whether the Veteran's condition is due to his in-service herbicide exposure. Thus, the Board finds that the third McLendon element has been met. Lastly, the Board requires additional evidence before it can make a determination as to whether the Veteran's IBS and Crohn's disease are related to service. Therefore, the Board finds a VA examination is necessary to address this question, and thus the claim must be remanded. 2. Entitlement to service connection for clear cell renal carcinoma (claimed as kidney cancer) is remanded. The Veteran contends that his kidney condition is due to his in-service herbicide exposure. Conversely, he alleges that his kidney condition is due to his service-connected diabetes. The Veteran was afforded a VA examination in August 2017. The examiner noted the Veteran had a diagnosis of clear cell renal carcinoma. The examiner also noted the Veteran was service connected for diabetes but found that there was no evidence of persistent microalbuminuria, which the examiner noted is a pre-requisite for any diabetes-related kidney disorder. Thus, the examiner opined that the Veteran's clear cell renal carcinoma was less likely than not proximately due to his service-connected diabetes. The examiner also listed risk factors for clear cell renal carcinoma, to include older age, smoking, obesity, treatment for kidney failure, certain inherited syndromes, and family history. The Veteran is of an older age and obese, although he does not have any family history of kidney issues and although he smoked tobacco products, he reported quitting in his early 20's, over 40 years prior to his diagnosis. However, although the August 2017 examiner addressed whether the Veteran's kidney condition was proximately due to his service-connected diabetes, the examiner failed to address whether his diabetes aggravated his kidney condition. El-Amin v. Shinseki, 26 Vet. App. 136, 140 (2013). Additionally, the Veteran contends that his kidney condition is due to his in-service herbicide exposure, but the August 2017 examiner failed to address if there is a nexus between the Veteran's kidney condition and his herbicide exposure. For the reasons above, the Board finds the August 2017 examination to be inadequate, and remand is necessary in order to obtain a new VA medical opinion addressing the issues of direct service connection and aggravation. Accordingly, these matters are REMANDED for the following action: 1. Obtain a VA medical opinion from a qualified examiner to determine the nature and etiology of the Veteran's IBS and Crohn's disease. If an in-person or telehealth examination is deemed necessary, such must be arranged. The examiner must thoroughly review the Veteran's claims file and must address the following: (a.) Whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran's IBS or Chron's disease, or any other diagnosed gastrointestinal disability, is due to or otherwise related to his service, to include as due to herbicide exposure. (b.) Whether it is at least as likely as not that the Veteran's IBS or Chron's disease, or any other diagnosed gastrointestinal disability, is proximately due to his service-connected diabetes. (c.) Whether it is at least as likely as not the Veteran's IBS or Chron's disease, or any other diagnosed gastrointestinal disability, has been aggravated by his service-connected diabetes. The examiner is to note that absence of the Veteran's condition on the list of conditions eligible for presumptive service connection due to herbicide exposure is not an acceptable rationale to deny service connection. 2. Obtain an addendum opinion from a qualified medical professional to determine the nature and etiology of the Veteran's clear cell renal carcinoma. The examiner must thoroughly review the Veteran's claims file and must address the following: (a.) Whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran's clear cell renal carcinoma is due to or otherwise related to his service, to include as due to herbicide exposure. (b.) Whether it is at least as likely as not that the Veteran's clear cell renal carcinoma is proximately due to or otherwise related to his service-connected diabetes. (c.) Whether it is at least as likely as not that the Veteran's clear cell renal carcinoma has been aggravated by his service-connected diabetes. The examiner is to note that absence of the Veteran's condition on the list of conditions eligible for presumptive service connection due to herbicide exposure is not an acceptable rationale to deny service connection. Caroline B. Fleming Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Gabrielle Ongies, 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.