Citation Nr: 21071366 Decision Date: 11/30/21 Archive Date: 11/30/21 DOCKET NO. 18-39 943 DATE: November 30, 2021 REMANDED Entitlement to service connection for a lung disorder, to include thrush, chronic obstructive pulmonary disease (COPD), and emphysema is remanded. REASONS FOR REMAND The Veteran had active service from June 1957 to April 1959. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2016 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO or AOJ). Procedurally, and as pertinent to this appeal, the Veteran initially filed a claim for service connection for a lung disorder and for thrush in March 2016. In the September 2016 rating decision on appeal, the RO denied service connection for a lung disorder also claimed as thrush. This case was previously before the Board in June 2020 when it was remanded for additional development. The evidence of record includes a May 2014 private treatment record noting a diagnosis of oral thrush. After additional development, which included a VA examination in December 2020, the Veteran was also diagnosed with COPD and emphysema. Accordingly, the Veteran's claim has been recharacterized as one for entitlement to service connection for a lung disorder, to include thrush, COPD, and emphysema to better reflect the assertions and medical findings of record. Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). Here, the Veteran contends that he developed thrush as an allergic reaction to antibiotics that he was administered in service. He contends that he has experienced ongoing flare-ups of thrush for more than 60 years. See November 2014 notice of disagreement and July 2018 correspondence. The Veteran also contends that he was exposed to unknown gases during chamber tests while in active service. See June 2016, August 2016, and January 2021 correspondence. The Board previously remanded the matter for an opinion specifically addressing the Veteran's credible report that his lung disorder, to include thrush, began during service and has continued since service. Additionally, the opinion was to specifically address that the Veteran's confirmed allergic reaction to penicillin is thrush and that he was prescribed penicillin during active service. On VA examination in December 2020, the examiner noted the Veteran's report of shortness of breath and thrush that had started many years ago. In a December 2020 VA medical opinion, the examiner provided a negative nexus opinion based on a lack of evidence in the Veteran's service treatment records for complaints of thrush or shortness of breath. In an August 2021 addendum VA medical opinion, the examiner added that thrush is not an allergic reaction and that COPD and emphysema are separate diagnoses and do not have any direct medical relationship with penicillin. The Board finds the August 2021 addendum VA medical opinion to be less than fully responsive to the remand instructions and, therefore, inadequate. There is still a conflict in the medical evidence regarding whether the Veteran's oral thrush is an allergic reaction to penicillin. Of note, the Veteran's private treatment records indicate the Veteran's allergies include penicillin from which "he gets tongue thrush." See March 2016 private treatment record. Such was not adequately reconciled by the VA examiner. The examiner also did not adequately explain the premise behind the conclusion that the Veteran's oral thrush is not etiologically related to his service in light of the credible report of in-service complaints of thrush which has continued to date. See September 2017 private treatment record noting ritual mouth cleaning for history of thrush. Additionally, the VA medical opinions of record fail to adequately address whether the Veteran's diagnosed COPD and emphysema is etiologically related to his service in light of the Veteran's report of experiencing shortness of breath and in-service exposure to an unknown gas during chamber tests. Accordingly, a remand is needed to ensure substantial compliance with the June 2020 remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). The matters are REMANDED for the following action: 1. Attempt to verify the Veteran's alleged in-service exposure to gas during chamber tests to include determining whether such gas was mustard gas. Associate any attempts with the record. 2. Arrange for the Veteran's record to be forwarded to an appropriate clinician for review and an addendum medical opinion regarding the likely etiology of his lung disorder, to include thrush, COPD, and emphysema. As it pertains to the Veteran's diagnosed oral thrush, the examiner should state: (a) is it at least as likely as not (i.e. approximate balance of evidence) that the Veteran's diagnosed oral thrush was either incurred in, or is otherwise related to, the Veteran's active duty service. In this regard, the examiner should specifically address whether the Veteran's allergic reaction to penicillin is oral thrush. (b) If not, the consulting clinician should reconcile that conclusion with the evidence in the record, to include the March 2016 private treatment record indicating the Veteran's allergic reaction to penicillin is oral thrush. (c) If so, is it at least as likely as not (an approximate balance of evidence) that the Veteran's oral thrush is etiologically related to the in-service prescription for penicillin? As it pertains to the Veteran's diagnosed COPD and emphysema, the examiner should state: (d) is it at least as likely as not (i.e. an approximate balance of evidence) that the Veteran's diagnosed COPD and emphysema was either incurred in, or is otherwise related to, the Veteran's active duty service, to include in-service exposure to gas during chamber tests. The consulting provider should note that the Veteran's statements are credible for the limited purpose of providing the requested medical opinions; and the examiner should not rely on the absence of evidence of in-service treatment or injury in rendering an opinion. A complete rationale for all opinions must be provided. If the examiner cannot provide the requested opinion without resorting to speculation, it must be so stated, and he/she must provide the reasons why an opinion would require speculation. The examiner must indicate whether there is any further need for information or testing necessary to make a determination. Additionally, the examiner must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. Marissa Caylor Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Smith, 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.