Citation Nr: A21018682 Decision Date: 11/23/21 Archive Date: 11/23/21 DOCKET NO. 190904-29374 DATE: November 23, 2021 REMANDED Entitlement to service connection for multiple myeloma as secondary to left femur fracture is remanded. Entitlement to service connection for left femur fracture is remanded. Entitlement to service connection for right groin hernia is remanded. Entitlement to service connection for peripheral neuropathy, claimed as left leg nerve damage is remanded. REASONS FOR REMAND On August 23, 2017, the President signed into law the Veterans Appeals Improvement and Modernization Act, Pub. L. No. 115-55 (to be codified as amended in scattered sections of 38 U.S.C.), 131 Stat. 1105 (2017), also known as the Appeals Modernization Act (AMA). This law creates a new framework for Veterans dissatisfied with VA's decision on their claim to seek review. This decision has been written consistent with the new AMA framework. The Veteran had honorable active-duty service with the United States Air Force from November 1974 to February 1977. The Veteran selected the Supplemental claim review lane when he submitted the RAMP election form, dated August 2018. Accordingly, January 2019 RAMP rating decision considered the evidence of record as of the date VA received the RAMP election form. The Veteran timely appealed this RAMP rating decision to the Board via VA Form 10182 Notice of Disagreement and requested evidence submitted with to be considered by the Board of Veterans Appeals. A request to submit additional evidence within 90 days was also indicated. On review of the record, the Board finds that a remand is necessary in this case to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's claim so that he is afforded every possible consideration. 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159 (2020). 1. Entitlement to service connection for multiple myeloma as secondary to left femur fracture is remanded. Although the further delay entailed by remand is regrettable, current adjudication of the Appellant's claims would be premature. Undertaking additional development prior to a Board decision is the only way to ensure compliance with the duty to assist, as required. 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159 (2020). According to military personnel records, the Veteran's official military occupation was listed as a Fire Protection Specialist and Fire Fighter. During active service, the Veteran was stationed at Vandenberg Airforce Base in California, where he worked in the Fire Department Section of the 4392 Civil Engineering Squadron. Review of service treatment records indicates that no disqualifying abnormalities were documented during a physical examination at enlistment in February 1974. In a comments section, a prior medical history included a left hernia repair with an undescended testicle. No medical conditions were reported in a corresponding report of medical history. In February 1975, the Veteran was evaluated for tenderness in the genital region. A physical examination revealed tenderness along the prostate region. A urinalysis revealed normal findings. A diagnosis of mild prostatitis was indicated. A surgical record, dated July 1975, noted the appearance of marked edema and a fibrous lesion suggested that it prevented removal of the undescended testicle. In December 1976, the Veteran filed a request for voluntary separation. Approval was recommended in February 1977. No physical examination was conducted. Post-service treatment records show that the Veteran has a current diagnosis of multiple myeloma. In February 2017, he was evaluated in the emergency room at a VA hospital in Dallas, following a fall in his home. Acute left leg pain was reported. Skeletal imaging revealed an impending fracture of the left femur. On the same day, the Veteran was transferred to a private hospital where he underwent open reduction and internal fixation (ORIF). A computerized tomography (CT) scan showed lytic lesions in multiple bones. A pathology report from a bone marrow biopsy listed a current diagnosis of plasmacytoma consistent with multiple myeloma. The Veteran was referred to an orthopedic oncologist for field irradiation. Two cycles of radiation were conducted in March and April 2017. The treatment involved the left femur, left scapula, and right humerus. Also, in March 2017, a radiation and oncology consultation record noted a history of right inguinal hernia and hematuria. Other treatment records show that primary chemotherapy treatments were performed from February 2017 through June 2017. A second cycle of 6 treatments followed field irradiation. In August 2017, the Veteran was diagnosed for idiopathic peripheral neuropathy. Morphine was prescribed to treat pain, at 15 milligrams twice per day. Two months later, an oncology consultation referenced low testosterone with a recent history of multiple myeloma, cellulitis of the right ankle, and microscopic hematuria. One of the most common causes of microscopic hematuria are urinary tract infection, benign prostatic hyperplasia, and urinary calculi. In June 2017, a hematologic and lymphatic conditions disability benefits questionnaire was associated with the record. The previous diagnosis of multiple myeloma was confirmed. Current symptoms include mild weakness, easy fatigability, bone pain. Prescribed treatments include Dexamethasone, Bortezomib, Lenalidomide, and chemotherapy. No recurrent infections were attributable to the Veteran's condition. There was no evidence of polycythemia vera, sickle cell anemia, nor any other pertinent physical findings. Due to his current diagnosis, the Veteran has a limited ability to exert himself. His current course of treatment requires 4 visits to the doctor every 3 weeks. No etiological opinion was indicated. A hematology outpatient record, dated December 2018, described the Veteran's multiple myeloma as in remission. Maintenance medications included Revlimid. During the clinical interview, the Veteran stated that the baseline of his neuropathy was stable. In September 2019, a favorable private medical opinion was provided by a physician with 40 years of experience in pharmacology and toxicology. Over 20 years of experience in providing researched based expert opinions was also reported. Following a review of the record, to include a lay statement from the Veteran, the examiner opined that it is at least as likely as not that the Veteran developed multiple myeloma due to his exposure due to JP-4 jet fuel, fire retardant spray foam, and diesel fumes. Use of protective gear, which shielded his face, lungs and skin was not reported. In support of the stated conclusion, the examiner noted that the Veteran's service-related duties as a fire fighter involved extinguishing fires and frequent exposure to JP-4 jet fuel (once per month), diesel fumes (daily), and other toxic mechanisms, to include aqueous film forming foams (AFFF) (foam retardant). The development of cancer can be triggered by genetic or chemical disruption in the in the body. Some individuals with monoclonal gammopathy of undetermined significance (MGUS) are at risk for multiple myeloma. Approximately 1 percent of people with MGUS develop multiple myeloma. Review of VA treatment records found no evidence of MGUS. Other causes of multiple myeloma include genetic abnormalities and environmental exposures. Considering the absence of MGUS in the Veteran's medical history, the only trigger for the development of multiple myeloma is his exposure to JP-4 jet fuel, diesel fumes and AFFF during active service. No history of tobacco use, nor any other exposure to mutagens/carcinogens during his lifetime, except for during his military service. The Veteran also denied any family history of cancer. In an appellant's brief, dated September 2019, the Veteran's counsel called attention to his current diagnosis of multiple myeloma and medical evidence suggesting a correlation between that diagnosis and other conditions, to include his left femur fracture and left leg nerve damage. These conditions were also listed as possible secondary complications of multiple myeloma or related treatment for the condition. Considering the above, the Board finds that a pre-decisional duty-to-assist error had been committed as the agency of original jurisdiction (AOJ) failed to obtain a VA etiological opinion regarding a possible causal linkage between the Veteran's diagnosis of multiple myeloma and his in-service exposure to JP-4 jet engine fuel, diesel fumes and AFFF. Similarly, no consideration has been given to whether the Veteran's other conditions, left femur fracture and peripheral neuropathy (also claimed as left leg nerve damage), are secondary to multiple myeloma. This failure constituted an additional error. Accordingly, the Board finds that a remand is required to correct the pre-decisional duty-to-assist errors noted above. 2. Entitlement to service connection for left femur fracture is remanded. The Board incorporates by reference the procedural arguments, findings, and conclusions articulated in Section 1. 3. Entitlement to service connection for peripheral neuropathy, claimed as left leg nerve damage is remanded. The Board incorporates by reference the procedural arguments, findings, and conclusions articulated in Section 1. 4. Entitlement to service connection for right groin hernia is remanded. The Veteran contends that he is entitled to service connection for a right groin hernia. As noted above, service treatment records indicate that the Veteran reported a prior history of treatment for left groin hernia prior to enlistment. Nevertheless, no disqualifying abnormalities were identified. Other treatment records indicate that the Veteran was treated for tenderness along the prostate region. A diagnosis of mild prostatitis. A separate notation referenced the appearance of marked edema and a fibrous lesion prevented removal of the left testicle. It was described as undescended. Post-service treatment records note treatment for low testosterone, a history of inguinal hernia and microscopic hematuria. The Veteran's left teste was described as undescended. A preventive health nursing record referenced a history of hernia to right groin without surgical intervention. Considering the above, the Board finds that a pre-decisional duty to assist has occurred. Specifically, the medical evidence shows that there is inconsistent information regarding whether the Veteran was treated for an inguinal hernia to the left or right side. While a prior history of treatment was noted at enlistment, the Veteran underwent a surgical evaluation to address an undescended teste as well as treatment for prostatitis. Post-service treatment records show complaints of low testosterone, a reference to a right inguinal hernia, and treatment for hematuria. Military personnel records also confirm exposure to various toxins. To date, a VA etiological opinion has not been obtained to determine whether the Veteran's pre-existing hernia was aggravated by active service, to include as manifested by service-related treatment for prostatitis, and post-service treatment for hematuria and low testosterone. Accordingly, the Board finds that a remand is required to correct the pre-decisional duty-to-assist errors noted above. The matters are REMANDED for the following action: 1. Schedule the Veteran for an appropriate VA examination to determine the nature and etiology of the Veteran's multiple myeloma, to include as secondary to in-service exposure to JP-4 jet engine fuel, diesel fumes and in-service exposure to JP-4 jet engine fuel, diesel fumes and aqueous film forming foams (AFFF). The entire claims file and a copy of this remand should be made available to the examiner for review, and such review should be noted in the examination report. All necessary tests and studies should be conducted. (b) Then, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability), that Veteran's multiple myeloma was caused by or is otherwise related to in-service exposure to JP-4 jet engine fuel, diesel fumes and aqueous film forming foams (AFFF). As a part of the examination and/or opinion, the examiner must consider all prior diagnoses in the record and nexus opinions and explain or distinguish any variations in findings and conclusions. The examining physician/specialist should provide information to demonstrate that he or she is qualified to offer the above requested opinion (such as a curriculum vitae or similar demonstrable documentation). This information is to be associated with the Veteran's claims file. See Francway v. Wilkie, 940 F.3d 1304 (Fed. Cir. 2019). Any opinion offered must be accompanied by a complete rationale, which should reflect consideration of the STRs, medical evidence of record, and lay statements. If any requested opinion cannot be offered without resorting to speculation, the examiner should indicate such in the examination report and explain why a non-speculative opinion cannot be offered. The examiner should also identify what, if any, additional information or evidence would allow for a more definitive opinion. 2. Upon completion of the directive listed in item #1 and if a favorable etiological finding is reached, the examiner is also requested to provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability), that Veteran's left femur fracture and idiopathic peripheral neuropathy (also called left leg nerve damage) are secondarily related to his multiple myeloma. Any opinion offered must be accompanied by a complete rationale, which should reflect consideration of the STRs, medical evidence of record, and lay statements. If any requested opinion cannot be offered without resorting to speculation, the examiner should indicate such in the examination report and explain why a non-speculative opinion cannot be offered. The examiner should also identify what, if any, additional information or evidence would allow for a more definitive opinion. 3. Schedule the Veteran for an appropriate VA examination to determine the nature and etiology of the Veteran's inguinal hernia. The entire claims file and a copy of this remand should be made available to the examiner for review, and such review should be noted in the examination report. All necessary tests and studies should be conducted. (a) The examiner should identify whether a diagnosis for a left or right inguinal hernia is found and note the evidence in support thereof. (b) Then, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's pre-existing hernia was aggravated beyond its natural progression by active service, to include as manifested by service-related treatment for prostatitis, and post-service treatment for hematuria and low testosterone. As a part of the examination and/or opinion, the examiner must consider all prior diagnoses in the record and nexus opinions and explain or distinguish any variations in findings and conclusions. The examining physician/specialist should provide information to demonstrate that he or she is qualified to offer the above requested opinion (such as a curriculum vitae or similar demonstrable documentation). This information is to be associated with the Veteran's claims file. See Francway v. Wilkie, 940 F.3d 1304 (Fed. Cir. 2019). Any opinion offered must be accompanied by a complete rationale, which should reflect consideration of the STRs, medical evidence of record, and lay statements. If any requested opinion cannot be offered without resorting to speculation, the examiner should indicate such in the examination report and explain why a non-speculative opinion cannot be offered. The examiner should also identify what, if any, additional information or evidence would allow for a more definitive opinion. 4. Thereafter, re-adjudicate the Appellant's claims. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires all claims remanded by the Board or by the United States Court of Appeals for Veterans Claims to be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112. B. MULLINS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Whitaker, 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.