Citation Nr: 21076524 Decision Date: 12/27/21 Archive Date: 12/27/21 DOCKET NO. 17-15 126 DATE: December 27, 2021 REMANDED Entitlement to service connection for a left shoulder disability, to include as secondary to service-connected back disability is remanded. Entitlement to service connection for ulcerative colitis with bowel and incontinence disorder, to include as due to exposure to hazardous and toxic substances, including those identified with his service in Southwest Asia is remanded. Entitlement to service connection for a liver disorder with allergies, to include as due to exposure to hazardous and toxic substances, including those identified with his service in Southwest Asia and/or as secondary to ulcerative colitis is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1980 to June 1992, with additional service in the U.S Air Force Reserves. This case has been before the Board multiple times, most recently in August 2021 when it was remanded for additional developments. There has not been substantial compliance with the remand directives and the claim must be remanded again. Stegall v. West, 11 Vet. App. 268 (1998). Entitlement to service connection for a left shoulder disability, to include as secondary to service-connected back disability is remanded. The September 2021 VA opinion on the Veteran's left shoulder disability inadequate because the examiner used the wrong standard for aggravation; the examiner addressed beyond natural progression, rather than the correct "any increase" in disability. 38 C.F.R. § 3.310 (b); Allen v. Brown, 7 Vet. App. 439 (1995). Accordingly, a new opinion is necessary. Entitlement to service connection for ulcerative colitis with bowel and incontinence disorder, to include as due to exposure to hazardous and toxic substances, including those identified with his service in Southwest Asia is remanded. Entitlement to service connection for a liver disorder with allergies, to include as due to exposure to hazardous and toxic substances, including those identified with his service in Southwest Asia and/or as secondary to ulcerative colitis is remanded. The September 2021 VA opinion on the Veteran's ulcerative colitis and liver disorder are inadequate. The Veteran has asserted several theories of entitlement as to how both his ulcerative colitis and liver disorder are related to his active duty service. He has asserted that his ulcerative colitis is related to a diagnosis of gastroenteritis during his active duty Air Force service, due to exposure to contaminated water, and due to exposures to toxic chemicals, asbestos, and uranium during his service in Southwest Asia. He also asserted that his liver disorder is due to exposure to contaminated water, and due to exposures to toxic chemicals, asbestos, and uranium during his service in Southwest Asia, and related to his ulcerative colitis. In the August 2021 remand, the Board specifically directed the examiner to consider these assertions for both disabilities. However, the September 2021 VA examiner provided negative nexus opinions for both ulcerative colitis and liver disorder based on the lack of a continuity of symptoms from his separation from active duty in 1992 until an October 2001 reserve physical. The examiner did not discuss the Veteran's exposure to chemicals, asbestos, and uranium during his service in Southwest Asia, which was after October 2001. Accordingly, new opinions are necessary. Additionally, the Board also notes that the September 2021 VA examiner used the wrong standard for aggravation to address whether his liver disorder was aggravated by his ulcerative colitis; the examiner addressed beyond natural progression, rather than the correct "any increase" in disability. 38 C.F.R. § 3.310 (b); Allen v. Brown, 7 Vet. App. 439 (1995). On remand, updated treatment records should be obtained. See 38 C.F.R. § 3.159. See also Bell v. Derwinski, 2 Vet. App. 611 (1992). The matters are REMANDED for the following action: 1. Obtain the names and addresses of all medical care providers who treated the Veteran for any left shoulder, gastrointestinal, or liver complaints since service not already associated with the record. After securing the necessary release, take all appropriate action to obtain these records, including any VA treatment records since March 2016. 2. After the completion of the above, obtain an addendum opinion from the VA examiner who provided September 2021 VA opinion, (or another appropriate provider if the September 2021 examiner is unavailable) to determine the nature and etiology of the Veteran's left shoulder disability. Copies of all pertinent records, including this remand, must be made available to the examiner for review. Based on the review of the record (and examination if needed), the examiner should answer the following: Is it at least as likely as not that the Veteran's left shoulder disability is (i) caused by or (ii) aggravated by (defined as any increase in disability) the Veteran's service-connected back disability? Why or why not? The examiner should specifically consider and discuss as necessary the Veteran's lay statement that he aggravates his left shoulder by using it for additional support to hold his posture when sitting of driving due to his back pain. The examiner must explain the rationale for all opinions in detail, citing to supporting clinical data and/or medical literature, as appropriate. If an opinion cannot be provided, the examiner should indicate why. 3. After the completion of (1), obtain an addendum opinion from the VA examiner who provided September 2021 VA opinion, (or another appropriate provider if the September 2021 examiner is unavailable) to determine the nature and etiology of the Veteran's ulcerative colitis. Copies of all pertinent records, including this remand, must be made available to the examiner for review. Based on the review of the record (and examination if needed), the examiner should answer the following: Is it at least as likely as not that the Veteran's diagnosed ulcerative colitis is related to an in-service injury, event, or disease, to include exposure to jet fuel, asbestos, perfluro-octane sulfate (PFOS) in groundwater at Eielson Air Force Base, depleted uranium, explosives at Eielson Air Force Base and Hill Air Force Base, and hazardous and toxic materials during his service in Southwest Asia? Why or why not? The examiner must explain the rationale for all opinions in detail, citing to supporting clinical data and/or medical literature, as appropriate. If an opinion cannot be provided, the examiner should indicate why. 4. After the completion of (1) and (3), obtain an addendum opinion from the VA examiner who provided September 2021 VA opinion, (or another appropriate provider if the September 2021 examiner is unavailable) to determine the nature and etiology of the Veteran's liver disorder with allergies. Copies of all pertinent records, including this remand, must be made available to the examiner for review. Based on the review of the record (and examination if needed), the examiner should answer the following: (a.) Is it at least as likely as not that the Veteran's diagnosed liver disorder is related to an in-service injury, event, or disease, to include exposure to jet fuel, asbestos, perfluro-octane sulfate (PFOS) in groundwater at Eielson Air Force Base, depleted uranium, explosives at Eielson Air Force Base and Hill Air Force Base, and hazardous and toxic materials during his service in Southwest Asia? Why or why not? (b.) If the answer to (a) is no, is it at least as likely as not that the Veteran's liver disorder is caused or aggravated (defined as any increase in disability) by his ulcerative colitis? Why or why not? The examiner must explain the rationale for all opinions in detail, citing to supporting clinical data and/or medical literature, as appropriate. If an opinion cannot be provided, the examiner should indicate why. (Continued on the next page) 5. Confirm that the VA medical opinion provided comports with this remand, specifically that the standard for the secondary aggravation opinion is any increase in disability, not the standard of beyond the natural progression as noted on the examination form itself. If not, get an addendum. Z. SAHRAIE Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Eric Struening 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.