Citation Nr: 21005395 Decision Date: 02/01/21 Archive Date: 02/01/21 DOCKET NO. 17-62 828 DATE: February 1, 2021 REMANDED Entitlement to service connection for Parkinson’s disease of the right hand is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1956 to December 1959. This matter is before the Board of Veterans’ Appeals (Board) on appeal from an April 2016 rating decision. In September 2017, an informal conference was held before a Decision Review Officer (DRO) at the Regional Office (RO); a summary is in the record. In April 2019, a videoconference hearing was held before the undersigned; a transcript of the hearing is in the Veteran’s record. In May 2019, the case was remanded for additional development. Unfortunately, the Veteran died in March 2020, during the pendency of this appeal. The RO has recognized his widow as the substitute claimant for the purpose of processing this claim to completion. See July 1, 2020 VA correspondence. Entitlement to service connection for Parkinson's disease of the right hand The Board is aware that this matter has been remanded before (and regrets the delay inherent with another remand); but because there was not substantial compliance with previous remand instructions, another remand is necessary. See Stegall v. West, 11 Vet. App. 268, 271 (1998). In May 2019, the Board remanded the claim for additional development, including to obtain records of private treatment, for a dose estimate (regarding exposure to ionizing radiation), and for a medical opinion to determine the likely etiology of the Veteran’s diagnosed Parkinson’s disease of the right hand (which specifically acknowledges his exposures to benzene and ionizing radiation inservice). Private records were obtained/submitted (or determined to be unavailable), and in March 2020, the Department of the Navy Dosimetry Center provided a service radiation exposure estimate of 0.720 REM. In September 2020, a VA internal medicine physician reviewed the record and provided a negative nexus (to service) opinion. He wrote, “While there has been association of benzene and Parkinson’s disease, this is not an established primary etiology of Parkinson’s in the medical literature.” [He cited to a medical journal article which states, “The causes of PD remain poorly understood, although environmental toxicants may play etiologic roles.” An anecdotal study regarding toluene (methylbenzene) was included, but benzene was not otherwise discussed.] He also wrote, “There is no association between ionizing radiation and Parkinson’s,” but did not include rationale with the statement. He opined that the more likely etiology was genetic/age-related. He cited an article which explains that “Age is the biggest risk factor for PD,” but also states that “PD is a multifactorial disease, with both genetic and environmental factors playing a role.” The Board finds the opinion inadequate for rating purposes. First, the rationale employs an improper (not “at least as likely as not”) standard to judge causative relationships, as it acknowledges a relationship between benzene exposure and Parkinson’s disease but states such is “not an established primary [emphasis added] etiology” (i.e. does not fully address such causative relationship). Additionally, the opinion regarding ionizing radiation is conclusory, as it does not include rationale. [Notably, the Board remanded this appeal, in part, based on a finding that prior (VA and private) opinions lacked sufficient rationale (and were based on an incomplete evidentiary record).] Remand for another, fully adequate, medical opinion is necessary. The matter is REMANDED for the following: Arrange for the Veteran’s claims file to be forwarded to an appropriate clinician (one with subject matter experience/expertise, other than the September 2020 VA provider) for review and an advisory medical opinion regarding the likely etiology of his Parkinson’s disease of the right hand. The entire record (to include this remand, the Board’s May 2019 remand, and the September 2020 VA advisory medical opinion) must be reviewed by the provider. The consulting provider should respond to the following: (a) Identify the likely etiology for the Veteran’s Parkinson’s disease of the right hand. Specifically, is it at least as likely as not (a 50% or greater probability) that the disability is etiologically related to his service/events therein, to specifically include his acknowledged exposures to benzene and/or ionizing radiation in service? [The rationale for the opinion must acknowledge and discuss his exposure to both, including the March 2020 Naval dosimetry service radiation exposure estimate of 0.720 REM.] (b) If the Parkinson’s disease is found to not be related to service, identify the etiology that is considered more likely (and explain why that is so). The examiner should explain the rationale for all opinions, citing to supporting factual data and medical literature/treatise, as deemed appropriate. GEORGE R. SENYK Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Dupont, 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.