Citation Nr: 21071664 Decision Date: 12/01/21 Archive Date: 12/01/21 DOCKET NO. 13-28 363 DATE: December 1, 2021 REMANDED Entitlement to service connection for chronic pancreatitis, to include as secondary to a service-connected disability, is remanded. Entitlement to service connection for internal varices (claimed as gastric and/or esophageal varices), to include as secondary to a service-connected disability, is remanded. Entitlement to special monthly compensation (SMC) based on the need for aid and attendance, is remanded. REASONS FOR REMAND The Veteran had active service from September 1968 to June 1988. He died in August 2012. The appellant is his surviving spouse, who has been substituted into this appeal. These matters come before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). In September 2015, the Board denied the appellant's claims. The appellant appealed that decision to the United States Court of Appeals for Veterans Claims (Court), which in a January 2017 Order and pursuant to a Joint Motion for Remand (JMR), vacated the September 2015 denial and remanded the case to the Board. The Board conducted further development, including obtaining an advisory medical opinion. In June 2018, the Board again denied the matters. The appellant again appealed the denial to the Court, which in a June 2019 Order and pursuant to a JMR vacated the June 2018 denial. All matters are is remanded. In May 2021, the Board remanded the matters to obtain a medical opinion regarding the etiologies of the claimed disabilities. In August 2021, a physician provided an opinion and subsequent addendum opinions. However, the Board finds that the opinions are inadequate for adjudication purposes. In that regard, the physician provided several contradictory opinions with inadequate supporting rationale. Specifically, in the original opinion, the physician found that it was at least as likely as not that the Veteran's pancreatitis and internal varices were related to in-service radiation. However, in a subsequent addendum opinion, he opined that he could not provide an opinion without resorting to speculation. In another addendum opinion, he concluded that it was less likely than not that the claimed disabilities were related to service or a service-connected disability. Based on the varying opinions, the Board finds that a remand is necessary to obtain a medical opinion, with supporting rationale, from a qualified specialist. The appellant contends that the Veteran's pancreatitis and internal varices caused the need for SMC based on aid and attendance. Accordingly, the claims for entitlement to service connection for pancreatitis and internal varices and SMC based on aid and attendance are inextricably intertwined. See Harris v. Derwinski,1 Vet. App. 180 (1991) (two issues are "inextricably intertwined" when they are so closely tied together that a final Board decision on one issue cannot be rendered until the other issue has been considered). Therefore, the claim for a SMC must be remanded pending the development and readjudication of the service connection appeal. The matters are REMANDED for the following action: 1. Obtain a medical opinion from a pancreatologist if readily available on staff, or if not, from a gastroenterologist, regarding the etiologies of the Veteran's pancreatitis and internal varices. The Veteran's electronic claims file, including a copy of this remand, should be made available to and reviewed by the specialist. The medical opinion should, at a minimum, reflect consideration of (i) the documented history; (ii) the lay contentions; (iii) medical evidence of record; and (iv) medical treatise submitted by the appellant. The opinion should identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). (a) Whether it is at least as likely as not (50 percent probability or greater) that the Veteran's pancreatitis and/or internal varices were incurred in or otherwise related to service, to include due to any documented in-service exposures to ionizing radiation. The specialist is requested to specifically address the following: i. The Veteran's use of hepatotoxic prescription medications; and ii. The Veteran's specialty as a dental laboratory assistant in the Navy, including engagement in shift work. (b) Whether it is at least as likely as not (50 percent probability or greater) that the Veteran's pancreatitis and/or internal varices were caused or aggravated by his service-connected hypertension and/or coronary artery disease, to include due to medication used to treat either disability. (c) If aggravation found, provide baseline manifestations and increased manifestations due to the service-connected disabilities. (d) Whether the Veteran developed metabolic syndrome due to interactions with his service-connected disabilities leading to cirrhosis, in turn leading to pancreatitis and internal varices. The specialist is requested to specifically address arguments outlined by the Veteran, appellant and their representatives. See June 2011 Veteran's correspondence; August 2015 Informal Hearing Presentation, June 2020 Appellant's representative argument. A complete rationale, with citation to appropriate medical principles, must be provided. The Board is returning the matter as the previous medical opinions did not address all lay statements and theories of entitlement raised by the record. Further, the most recent medical opinion contained several contradictory opinions. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 2. Thereafter, readjudicate the issues on appeal as noted above. If the determination remains unfavorable to the appellant, she and her attorney should be furnished a supplemental statement of the case (SSOC) which addresses all evidence associated with the claims file since the last statement of the case. The appellant and her attorney should be afforded the applicable time period to respond. Michael A. Pappas Veterans Law Judge Board of Veterans' Appeals Attorney for the Board L. Baskerville 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.