Citation Nr: 21007676 Decision Date: 02/10/21 Archive Date: 02/10/21 DOCKET NO. 18-02 055 DATE: February 10, 2021 ORDER Service connection for sleep apnea is denied. Service connection for a lung disability claimed as atelectasis is denied. Service connection for a liver cyst is denied. An initial compensable evaluation for bilateral hearing loss is denied. REMANDED Entitlement to service connection for an eye disability, to include loss of vision, claimed as retinal scarring. Entitlement to service connection for degenerative disc disease and arthritis of the cervical spine. Entitlement to service connection for hypertension. Entitlement to service connection for renal cell carcinoma, status post left nephrectomy with chronic kidney disease. Entitlement to service connection for tooth extraction due to fungal infection. FINDINGS OF FACT 1. Sleep apnea is not related to service or to exposure to herbicide agents. 2. The Veteran does not have a current disability of the lungs. 3. A liver cyst is not related to service or to exposure to herbicide agents. 4. The Veteran has exhibited no worse than Level I hearing loss in his left ear and Level II hearing loss in his right ear. CONCLUSIONS OF LAW 1. The criteria for service connection for sleep apnea are not met. 38 U.S.C. §§ 1101, 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2019). 2. The criteria for service connection for a lung disability claimed as atelectasis are not met. 38 U.S.C. §§ 1101, 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2019). 3. The criteria for service connection for a liver cyst are not met. 38 U.S.C. §§ 1101, 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2019). 4. The criteria for an initial compensable evaluation for bilateral hearing loss are not met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.85, 4.86, Diagnostic Code 6100 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1964 to October 1967, from November 1967 to October 1972, and from April 1978 to September 1980. This appeal is before the Board of Veterans’ Appeals (Board) from a February 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Des Moines, Iowa. In September 2020, the Veteran testified during a Board hearing before the undersigned Veterans Law Judge via videoconference. A transcript is included in the claims file. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection requires: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection may also be granted for any disease diagnosed after discharge when the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection is also warranted for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Such secondary service connection is warranted for any increase in severity of a nonservice-connected disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(b). In the case of a veteran who engaged in combat with the enemy in a period of war, lay evidence of in-service incurrence or aggravation of a disease or injury shall be accepted if consistent with the circumstances, conditions, or hardships of such service, notwithstanding the lack of official record of such incurrence or aggravation. The incurrence or aggravation may be rebutted by clear and convincing evidence to the contrary. See 38 U.S.C. § 1154(b); 38 C.F.R. § 3.304(d); Libertine v. Brown, 9 Vet. App. 521, 524 (1996); Collette v. Brown, 82 F.3d 389, 392-94 (Fed. Cir. 1996). The standard used to determine whether a veteran engaged in combat with the enemy is reasonable doubt, which is to be resolved in a veteran’s favor. See VAOPGCPREC 12-99. The provisions of 38 U.S.C. § 1154(b), however, can be used only to provide a factual basis upon which a determination could be made that a particular disease or injury was incurred or aggravated in service, not to link the claimed disorder etiologically to a current disorder. See Libertine, 9 Vet. App. at 522-23. The provisions of 38 U.S.C. § 1154(b) do not establish service connection for a combat veteran; it aids him by relaxing the adjudicative evidentiary requirements for determining what happened in service. Clyburn v. West, 12 Vet. App. 296, 303 (1999). For certain chronic diseases, such as arthritis and hypertension, a presumption of service connection arises if the disease is manifested to a degree of 10 percent within one year following discharge from service. 38 C.F.R. §§ 3.307(a)(3), 3.309(a). When a chronic disease is not shown to have manifested to a compensable degree within one year after service, under 38 C.F.R. § 3.303(b) for the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. When the fact of chronicity in service is not adequately supported, a showing of continuity after discharge is required to support a claim for such diseases; however, such continuity of symptomatology may only support a claim for those chronic diseases listed under 38 C.F.R. § 3.309(a). 38 C.F.R. § 3.303(b); see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). For certain diseases with a relationship to herbicide agent exposure, a presumption of service connection arises if the disease manifests to a degree of 10 percent or more following service in the Republic of Vietnam any time during the period from January 9, 1962 to May 7, 1975. 38 U.S.C. § 1116; 38 C.F.R. §§ 3.307, 3.309(e). The Board notes that the Veteran has National Guard duty, but in a November 2014 statement he explicitly denied that any of his claimed disabilities are related to such service. Specifically, he claims that all his disabilities are due to his service in Vietnam except his cervical spine disability and his retinal scarring, which he believes are related to his period of active duty service from April 1978 to September 1980. In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. 1. Entitlement to service connection for sleep apnea The Veteran claims service connection for sleep apnea. Service treatment records do not reflect any symptoms of or treatment for sleep apnea. At the end of his final period of active duty, the Veteran declined a separation examination in August 1980. At an April 1984 Reserve examination, no sleep abnormality was noted. In his October 2013 claim, the Veteran reported sleep apnea due to exposure to Agent Orange in Vietnam. In a November 2014 statement, the Veteran reported that he has had difficulty sleeping on his back for the prior 10 years. He stated that his wife wakes him up when he stops breathing so he will turn over. He reported that he had not been treated for this condition. He stated his belief that his disability was due to his Agent Orange exposure. At his September 2020 hearing, the Veteran reported that his VA physician recommended that he be tested for sleep apnea, but he never felt it was bad enough. His wife testified that he stopped breathing for periods while sleeping. He stated that it never happened during active duty but started later in life, specifically 25-30 years ago. He stated that he believed that it was associated with exposure to Agent Orange. The Board finds that the evidence weighs against a finding that sleep apnea is related to service or to exposure to herbicide agents. There is no evidence that sleep apnea arose in service, and the Veteran does not contend so. Rather, he states his belief that sleep apnea was caused by exposure to herbicide agents. He served in Vietnam and was therefore presumptively exposed to herbicide agents. Sleep apnea, however, is not among the disabilities for which VA recognizes a presumptive relationship to exposure to herbicide agents. 38 C.F.R. § 3.309(e). The Veteran has not explained his basis of knowledge for believing that sleep apnea could be related to Agent Orange exposure. There is no medical evidence of such a relationship; indeed, there is no medical evidence at all, as the Veteran has never been formally diagnosed with sleep apnea. The only evidence of such a condition are the episodes witnessed and described by his wife. For these reasons, the Board finds that the evidence weighs against a finding that sleep apnea is related to service or to exposure to herbicide agents. Service connection is therefore denied. 2. Entitlement to service connection for a lung disability claimed as atelectasis The Veteran claims service connection for a lung disability. Service treatment records do not reflect any symptoms of or treatment for a lung disability. At the end of his final period of active duty, the Veteran declined a separation examination in August 1980. At an April 1984 Reserve examination, no respiratory abnormality was noted, and in his accompanying report of medical history he explicitly denied having ever experienced asthma, shortness of breath, or chronic cough. VA treatment records reflect that an August 2013 CT scan of the abdomen showed mild bronchiectases in the lung bases. In his October 2013 claim, the Veteran reported atelectasis in both lungs due to exposure to Agent Orange in Vietnam. In a November 2014 statement, the Veteran stated that this disability was noted in an August 2013 CT scan. He stated his belief that his disability was due to his Agent Orange exposure. The Veteran underwent a VA examination in December 2014. He reported the incidental finding of bibasilar dependent atelectasis at his August 2013 CT scan. He denied current symptoms. The examiner diagnosed no current lung disability, explaining that the radiological findings were significant but unto themselves did not constitute a diagnosis. At his September 2020 hearing, the Veteran reported his belief that Agent Orange was the cause of his lung disability. He stated that he did not know of anything else that could have caused it. He also stated that he was treated for pleurisy several times in service. The Board finds that the evidence weighs against a finding of a current lung disability. The December 2014 VA examiner explained that the atelectasis noted at the August 2013 CT scan was an incidental finding that did not in and of itself constitute a disability. This analysis is consistent with record evidence, which is devoid of any treatment or symptoms. There is no medical evidence in the record contradicting the VA examination report. Where the evidence does not support a finding of current disability upon which to predicate a grant of service connection, there can be no valid claim for that benefit. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). As such, the Board finds that the evidence weighs against a finding of a current disability and service connection must therefore be denied. 3. Entitlement to service connection for a liver cyst The Veteran claims service connection for a liver cyst. Service treatment records do not reflect any symptoms of or treatment for a liver cyst. At the end of his final period of active duty, the Veteran declined a separation examination in August 1980. At an April 1984 Reserve examination, no liver abnormality was noted, and in his accompanying report of medical history he explicitly denied having ever experienced hepatitis, jaundice, or liver trouble. VA treatment records reflect that the abovementioned August 2013 CT scan which revealed a left renal mass also revealed a small liver cyst. In his October 2013 claim, the Veteran reported a cyst on his liver due to exposure to Agent Orange in Vietnam. In a November 2014 statement, the Veteran reported that a cyst on his liver was discovered in an August 2013 CT scan. He stated that he felt that this was due to his exposure to Agent Orange. At his September 2020 hearing, the Veteran reported his belief that Agent Orange was the cause of his liver cyst. He stated that he did not know of anything else that could have caused it. He also stated that he was hospitalized for jaundice while serving in France in 1966. The Board finds that the evidence weighs against a finding that a liver cyst is related to service or to exposure to herbicide agents. At his September 2020 hearing, he stated for the first time that he had jaundice in service in 1966. There is no record of jaundice in his service treatment records, and as late as his Reserve examination in April 1984 he explicitly denied having ever experienced jaundice. The evidence therefore weighs against such an in-service diagnosis. Initially, he stated his belief that the liver cyst was caused by exposure to herbicide agents. He served in Vietnam and was therefore presumptively exposed to herbicide agents. A liver cyst, however, is not among the disabilities for which VA recognizes a presumptive relationship to exposure to herbicide agents. 38 C.F.R. § 3.309(e). The Veteran has not explained his basis of knowledge for believing that a liver cyst could be related to Agent Orange exposure. There is no competent evidence of such a relationship. For these reasons, the Board finds that the evidence weighs against a finding that a liver cyst is related to service or to exposure to herbicide agents. Service connection is therefore denied. 4. Entitlement to an initial compensable evaluation for bilateral hearing loss The Veteran claims an increased rating for hearing loss. Disability evaluations are determined by application of the criteria set forth in the VA’s Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. An evaluation of the level of disability present must also include consideration of the functional impairment of the Veteran’s ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran’s entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). In evaluating service-connected hearing loss, disability ratings are derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are performed. Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). An examination for hearing impairment for VA purposes must be conducted by a state-licensed audiologist and must include a controlled speech discrimination test (Maryland CNC) and a pure tone audiometry test. 38 C.F.R. § 4.85. Evaluations of bilateral hearing loss range from noncompensable to 100 percent based on an organic impairment of hearing acuity, as measured by controlled speech discrimination tests in conjunction with the average hearing threshold, as measured by pure tone audiometric tests in the frequencies of 1000, 2000, 3000 and 4000 cycles per second. The rating schedule establishes 11 auditory acuity Levels designated from Level I for essentially normal hearing acuity through Level XI for profound deafness. VA audiological evaluations are conducted using a controlled speech discrimination test together with the results of pure tone audiometry tests. The vertical line in Table VI (printed in 38 C.F.R. § 4.85) represents nine categories of the percentage of discrimination based on a controlled speech discrimination test. The horizontal columns in Table VI represent 9 categories of decibel loss based on the pure tone audiometry test. The numeric designation of impaired hearing (Levels I through XI) is determined for each ear by intersecting the vertical row appropriate for the percentage of discrimination and the horizontal column appropriate to the pure tone decibel loss. The percentage evaluation is found from Table VII in 38 C.F.R. § 4.85 by intersecting the vertical column appropriate for the numeric designation for the ear having the better hearing acuity and the horizontal row appropriate for the numeric designation for the level for the ear having the poorer hearing acuity. For example, if the better ear had a numeric designation of Level V and the poorer ear had a numeric designation of Level VII the percentage evaluation is 30 percent. See 38 C.F.R. § 4.85. Regulations also provide that in cases of exceptional hearing loss, i.e., when the pure tone threshold at each of the four specified frequencies (1000, 2000, 3000 and 4000 hertz) is 55 decibels or more, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral. Each ear will be evaluated separately. 38 C.F.R. § 4.86(a). The provisions of 38 C.F.R. § 4.86(b) further provide that when the pure tone threshold is 30 decibels or less at 1000 hertz and 70 decibels or more at 2000, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or VIa, whichever results in the higher numeral. That numeral will then be evaluated to the next higher Roman numeral. The Veteran underwent a VA examination in December 2014. He reported difficulty hearing or understanding, especially in a group or in a crowd. Pure tone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 Average RIGHT 55 25 15 65 40 LEFT 20 15 20 60 28.75 Speech audiometry revealed speech recognition ability of 88 percent in the right ear and 94 percent in the left ear. He was diagnosed with mixed hearing loss in the right ear and sensorineural hearing loss in the left ear. VA treatment records reflect that in February 2017 the Veteran reported worsening hearing. His audiologist noted that his hearing had worsened since it was last tested in September 2012, but specific pure tone thresholds were not provided in the record. In April 2017, his hearing was tested again. Pure tone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 Average RIGHT 60 30 35 65 47.5 LEFT 30 10 30 55 31.25 Speech audiometry revealed speech recognition ability of 100 percent in both ears. At his September 2020 hearing, the Veteran reported that his hearing had worsened since his December 2014 VA examination. The Board finds that an initial compensable evaluation for hearing loss is not warranted. While his hearing has worsened since his December 2014 VA examination, the April 2017 audiogram is sufficient to establish his worsened level of hearing without remand for a new examination. Taking the highest pure tone frequencies match with the lowest speech recognition scores, the Veteran has no worse than Level I hearing loss in his left ear and Level II hearing loss in his right ear. Compensable ratings are not available without hearing loss at Level IV or worse in at least one ear. Furthermore, none of the record audiological findings qualify as an exceptional pattern of hearing under 38 C.F.R. § 4.86. For these reasons, the Board finds that a compensable evaluation for hearing loss is not warranted. REASONS FOR REMAND 1. Entitlement to service connection for an eye disability, to include loss of vision, claimed as retinal scarring The Veteran claims service connection for an eye disability. Service treatment records do not reflect any symptoms of or treatment for an eye disability. At the end of his final period of active duty, the Veteran declined a separation examination in August 1980. At an April 1984 Reserve examination, no eye abnormality was noted, and in his accompanying report of medical history he explicitly denied having ever experienced eye trouble. Service personnel records confirm the Veteran’s reports, described below, that during his final period of active duty service he worked with lasers. VA treatment records reflect that the Veteran had a vision consultation in May 2013. He was diagnosed with refractive error, immature cataracts, and presumed ocular histoplasmosis syndrome (POHS) versus possible laser exposure. Subsequent treatment records do not reference either diagnosis. In his November 2013 claim, the Veteran claimed service connection for retinal scarring. In a November 2014 statement, the Veteran stated that during his third period of service, he used lasers, including involvement in a project to determine the maximum safe exposure for distance, laser color, and beam diameter. He stated that his VA treating ophthalmologist concluded that his retinal scarring was due to accidental laser exposure. In a March 2015 statement associated with his notice of disagreement, the Veteran repeated his contention that he worked with lasers during his period of service from 1978 to 1980. He stated that he used safety goggles, but they were sometimes difficult to manage. He stated that when his VA treating ophthalmologist noted his scarring, he was asked if he had worked with lasers in the past. At his September 2020 hearing, the Veteran reported that during his final period of active duty he was a test engineer who conducted laser experiments to show thermal impact to tissue and damage to the inner optics of the eye. He reported that his VA ophthalmologist told him that it could have caused his current scarring. The Board finds that remand is necessary to provide the Veteran with a VA examination. VA has a duty to provide a medical examination where there is (1) competent evidence of a current disability or symptoms thereof; (2) evidence establishing that an event, injury, or disease occurred in service; (3) an indication that the disability is associated with service; and (4) insufficient competent medical evidence to decide the claim. McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006); see 38 U.S.C. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4)(i). The Veteran’s service personnel records corroborate his description of his in-service work with lasers, and the May 2013 VA treatment record gives a possible diagnosis of retinal scars due to lasers. The record, however, indicates a level of uncertainty that was never clarified. An examination is therefore necessary to determine if any current eye disability can be linked to the Veteran’s in-service work with lasers. 2. Entitlement to service connection for degenerative disc disease and arthritis of the cervical spine The Veteran claims service connection for a cervical spine disability. Service treatment records do not reflect any symptoms of or treatment for a cervical spine disability. At the end of his final period of active duty, the Veteran declined a separation examination in August 1980. At an April 1984 Reserve examination, no cervical abnormality was noted, and he did not report any cervical disability in his accompanying report of medical history. Service personnel records confirm the Veteran’s reports, described below, that during his final period of active duty service he worked in impact testing. A November 1979 order indicates that he was granted hazardous duty pay incentives. VA treatment records reflect that in June 2012 the Veteran reported that while in service in 1980 he failed an examination because of disc disease in his neck. He reported that it did not bother him for several years but now he has pain. He was diagnosed with possible degenerative disc disease. X-rays confirmed muscular spasm and spondylosis/degenerative disc disease. In his November 2013 claim, the Veteran claimed service connection for collapsed neck vertebrae. In a November 2014 statement, the Veteran reported that during his third period of service he was a test engineer in the human impact studies branch which designed, conducted, and analyzed impact metrics from human experiments on the vertical drop tower, centrifuge, and high-velocity acceleration track. He reported that in the summer of 1980 he had a physical for the experiments, at which time x-rays showed two collapsed vertebrae in his neck. He reported that this disability was confirmed to be current by VA x-rays the prior year. The Veteran underwent a VA examination in December 2014. He reported an onset of neck symptoms in June 1980, at which time he was told he had degenerative disc disease. He reported that symptoms had worsened since then. The examiner diagnosed degenerative disc disease and degenerative arthritis of the cervical spine. No etiological opinion is in the record. In a March 2015 statement associated with his notice of disagreement, the Veteran repeated the contentions of his November 2014 statement. At his September 2020 hearing, the Veteran reported that during his final period of active duty he was a test engineer on the track that did vertical drops with rocket sled impacts. He stated that he was allowed to participate in several tests, but after three months he was not permitted to participate because of protruding vertebrae on an x-ray. Private treatment records include an October 2020 MRI showing chronic cervical spondylosis with evidence of multilevel degenerative disc disease and degenerative neural foraminal stenosis. The Board finds that remand is necessary to provide the Veteran with a VA medical opinion. VA has a duty to provide an opinion where there is (1) competent evidence of a current disability or symptoms thereof; (2) evidence establishing that an event, injury, or disease occurred in service; (3) an indication that the disability is associated with service; and (4) insufficient competent medical evidence to decide the claim. McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006); see 38 U.S.C. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4)(i). While the Veteran’s reported 1980 x-rays are absent from his service treatment records, service personnel records corroborate his description of his in-service hazardous impact testing. He underwent a December 2014 VA examination, but no opinion is evident in the record. An opinion is therefore necessary to determine if his current degenerative arthritis is related to the in-service injury he describes which was consistent with the circumstances of his service. 3. Entitlement to service connection for hypertension The Veteran claims service connection for hypertension. VA regulations require that hypertension or isolated systolic hypertension be confirmed by readings taken two or more times on at least three different days. For compensation purposes, hypertension means that the diastolic blood pressure is predominantly 90mm or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160mm or greater with a diastolic blood pressure of less than 90mm. 38 C.F.R. § 4.104, Diagnostic Code 7101. Service treatment records do not reflect any symptoms of or treatment for hypertension. At the end of his final period of active duty, the Veteran declined a separation examination in August 1980. At an April 1984 Reserve examination, no hypertension abnormality was noted, and in his accompanying report of medical history he explicitly denied having ever experienced high blood pressure. VA treatment records reflect that at his May 2010 initial consultation the Veteran was diagnosed with hypertension. In his October 2013 claim, the Veteran reported hypertension due to exposure to Agent Orange in Vietnam. Private treatment records reflect that in December 2013 the Veteran reported a 10-year history of hypertension to his treating nephrologist. In a November 2014 statement, the Veteran reported that he had been treated for high blood pressure for the prior 10 years. He stated his belief that hypertension was due to his exposure to Agent Orange. At his September 2020 hearing, the Veteran reported that he did not have hypertension until it was detected by his doctor about 25 years ago. He reported that he did not drink or smoke and exercised often and always had. He stated that he was in good physical shape and therefore felt that Agent Orange was the cause of his hypertension. In addition, the relevant National Academy of Sciences (NAS) 2006 report regarding a relationship was discussed. The Board finds that a VA examination should be provided in light of the National Academy of Sciences (NAS) 2006 report regarding the relationship between hypertension and herbicide exposure. McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). The Secretary has acknowledged that in an Update 2006 NAS concluded that there is suggestive evidence of a link between exposure to herbicide agents in Vietnam and hypertension. See 75 Fed. Reg. 32540, 32549 (June 8, 2010). In light of studies identifying a potential link between herbicide exposure and hypertension, the Veteran’s claim should be remanded in order to provided him with a VA examination. 4. Entitlement to service connection for renal cell carcinoma, status post left nephrectomy with chronic kidney disease The Veteran claims service connection for kidney cancer and its residuals. Service treatment records do not reflect any symptoms of or treatment for any kidney disability. At the end of his final period of active duty, the Veteran declined a separation examination in August 1980. At an April 1984 Reserve examination, no current kidney abnormality was noted, but the examination report and the accompanying report of medical history reflected a history of kidney stones in 1975 with no problems or sequelae since. VA treatment records reflect that at his May 2010 initial consultation the Veteran reported a history of kidney stones. In June 2010 he was diagnosed with mild renal insufficiency. In July 2013 he reported abdominal pain. An August 2013 CT scan revealed a large left renal mass. Private treatment records reflect that in August 2013 the Veteran’s urologist noted his history of 20 years of smoking, gross hematuria from kidney stones, prostatitis, and slow hesitant stream. He was diagnosed with a right renal stone and left renal mass. His stone was treated, and in September 2013 his urologist recommended a partial nephrectomy. In October 2013 he underwent an open left radical nephrectomy that demonstrated renal cell carcinoma. In his October 2013 claim, the Veteran reported kidney cancer due to exposure to Agent Orange in Vietnam. Private treatment records reflect that in January 2014 he was treated for stage-3 chronic kidney disease with acute exacerbation due to nephrectomy. Records indicate ongoing treatment for kidney stones. His nephrologist opined that the etiology for his kidney disease was likely his hypertension. In a November 2014 statement, the Veteran described his treatment for his carcinoma and stated his belief that the disability was due to his exposure to Agent Orange. The Veteran underwent a VA examination in December 2014. He was diagnosed with status post left nephrectomy for renal carcinoma with residual scarring. The examiner opined that the disability was less likely than not related to service. This opinion was based on the rationale that while military examinations reference kidney stones and blood in urine, there is no mention in his treatment records of such conditions between 1984 and 2014, which does not establish a longitudinal trend. At his September 2020 hearing, the Veteran reported that he had his first kidney stone in 1974 after serving in Vietnam. He reported that he has had a total of 20 kidney stones since that time. He reported that one of the kidney stones was passed during his final year of active duty in 1980. He reported that his private urologist told him that his exposure to herbicide agents was the probable cause of his cancer. A February 2015 letter from the urologist was read into the record, but this letter is not in the claims file. In a November 2020 statement, the Veteran reported that since 1976 he has had an average of one kidney stone removed every 2-3 years, 11 of which required hospitalization. Specifically, he reported kidney stones removed in 1976, 1985, 1987, 1994, 2006, 2010, August 2013, September 2013, October 2013, November 2013, two stones in February 2014, August 2015, October 2019, and June 2020. In a letter received by VA in November 2020, the Veteran’s private urologist opined that the Veteran’s carcinoma could have been caused by his exposure to Agent Orange. The urologist noted that the Veteran had no family history of renal cancer and no known risk factors. The Board finds that remand is necessary for multiple reasons. First, at his September 2020 hearing, the Veteran read into the record a February 2015 letter from his private urologist. While this letter uses language similar to that in the same urologist’s November 2020 letter, the February 2015 letter found that the Veteran’s cancer was “as likely as not” related to herbicide exposure. The Veteran should be contacted and asked to provide a copy of this letter with the more probative language. Second, a new medical opinion is required regarding the potential relationship between renal cell carcinoma and exposure to herbicides. The November 2020 letter states that such a relationship is possible, indicating a potential relationship to service. Other than the February 2015 opinion obtained secondhand through the Veteran’s testimony, there is no opinion explaining whether such a relationship is as likely as not. Such an opinion is necessary. Finally, private treatment records indicate that in January 2014 the Veteran’s nephrologist indicated that his disability was related to his hypertension. As such, this issues is inextricably intertwined with that issue, and an opinion should be obtained regarding such a relationship. 5. Entitlement to service connection for tooth extraction due to fungal infection The Veteran claims service connection for tooth extraction. Under VA law, compensation is only available for certain types of dental and oral conditions, which are rated under 38 C.F.R. § 4.150, Diagnostic Codes 9900-16. Diagnostic Code 9913 applies to dental service connection claims involving teeth. Compensation is only paid for loss of teeth due to loss of substance of body of the maxilla or mandible without loss of continuity (as a result of trauma) or disease such as osteomyelitis. Compensation is not available for loss of the alveolar process (the ridge on the surfaces of the upper (maxilla) and lower (mandible) jaws containing the tooth sockets) as a result of periodontal disease, since such loss is not considered disabling. See Note, 38 C.F.R. § 4.150, Diagnostic Code 9913. VA regulations distinguish between “replaceable missing teeth” or periodontal disease and teeth lost as a result of “loss of substance of body of maxilla or mandible.” Simington v. West, 11 Vet. App. 41 (1998); 38 C.F.R. § 3.381. Replaceable missing teeth may be considered as service connected solely for the purpose of determining entitlement to dental examinations or outpatient dental treatment, but only the loss of teeth involving the loss of substance of body of either the maxilla or mandible (as described in 38 C.F.R. § 3.381) is considered compensable, and may be rated under the appropriate diagnostic codes. Thus, to warrant compensation for a dental disability, as opposed to outpatient dental treatment solely, the evidence must show not only that there was a dental trauma or disease (such as osteomyelitis), but that such trauma or disease caused a loss of substance of body of the maxilla or mandible resulting in a loss of teeth. Service treatment records do not contain record of any dental treatment during initial periods of active duty. Dental records from his final period of active duty from 1978 to 1980 merely note the absence of three upper teeth on the right side of the Veteran’s mouth. In his October 2013 claim, the Veteran reported a fungus on the right side of his face, with removal of 3 teeth and surrounding bone and tissue, due to exposure to Agent Orange in Vietnam. In a November 2014 statement, the Veteran reported that while he was in Vietnam, he went to the dentist in the summer of 1969 with severe pain in the right jaw. He reported that the dentist extracted the back three teeth on his upper right jaw, along with the surrounding bone and tissue. He stated that he was prescribed medicine to cure a fungus that had found its way into the bone area surrounding the teeth. He stated that his current dentist told him that because of the bone and tissue loss, reconstruction is not possible. In a March 2015 statement associated with his notice of disagreement, the Veteran repeated the contentions of his November 2014 statement. At his September 2020 hearing, the Veteran reported that in the summer of 1969 while serving in Vietnam he began having very intense pain on the right side of his face. His dentist pulled three teeth and performed bone surgery due to a fungus in the bone. He reported that he was currently unable to have dental implants because of the missing bone. The Board finds that remand is necessary to obtain a medical opinion. While there is no record of the removal of the Veteran’s teeth while he was in Vietnam, he has consistently reported it and, as a Veteran with combat decorations, his reports of receiving such care are granted credibility, and his dental records from his final period of active duty reflect that the teeth described as removed by the Veteran were indeed missing by that time. What is necessary is a medical evaluation of the Veteran to determine whether jawbone was extracted to render the disability eligible for compensation under VA regulations. As such, a dental VA examination is necessary to describe the nature of the Veteran’s dental disability. The matters are REMANDED for the following action: 1. Obtain and associate with the claims file any additional medical evidence that may have come into existence but has not been associated with the record. 2. Contact the Veteran and request that he provide a printed copy of the February 2015 letter from his private physician which he read at his September 2020 hearing and which describes a relationship between his renal cell carcinoma and exposure to Agent Orange. 3. Schedule the Veteran for a VA examination of his vision. The claims file must be reviewed by the examiner. For each disability diagnosed, the examiner should provide an opinion as to whether it is at least as likely as not (i.e. 50 percent probability or more) that such disability was incurred in or as a result of active duty service, to include the Veteran’s reported work with lasers in service. In so doing, the examiner should discuss the May 2013 VA treatment record which diagnosed POHS versus possible laser exposure. 4. Obtain a VA medical opinion from a qualified examiner regarding the Veteran’s cervical spine arthritis. The claims file must be reviewed by the examiner. A new examination may be ordered if the examiner deems it necessary. The examiner should provide an opinion as to whether it is at least as likely as not (i.e. 50 percent probability or more) that such disability was incurred in or as a result of active duty service, to include the Veteran’s reported described work with impact studies in service. 5. Obtain a VA medical opinion from a qualified examiner regarding the Veteran’s hypertension. The claims file must be reviewed by the examiner. An in-person or virtual examination may be ordered if the examiner deems it necessary. The examiner should provide an opinion as to whether it is at least as likely as not (i.e. 50 percent probability or more) that the Veteran’s hypertension was incurred in or as a result of active duty service, to include his presumptive exposure to herbicide agents. In so doing, the examiner should reference the 2006 NAS study which shows a potential relationship between hypertension and exposure. 6. Obtain a VA medical opinion from a qualified examiner regarding the Veteran’s kidney disabilities. The claims file must be reviewed by the examiner. An in-person or virtual examination may be ordered if the examiner deems it necessary. The examiner should provide an opinion as to whether it is at least as likely as not (i.e. 50 percent probability or more) that the Veteran’s renal cell carcinoma and/or chronic kidney stones were incurred in or as a result of active duty service, to include his presumptive exposure to herbicide. In so doing, the examiner must discuss the November 2020 letter from the Veteran’s private urologist, as well as the February 2015 letter if the Veteran provides it. 7. Provide the Veteran with a VA dental examination. The examiner must review the claims file. Based on the examination’s results, the examiner should describe the Veteran’s disability in terms of the requirements for compensation under VA regulations. Specifically, the examiner should explain whether the Veteran’s tooth extractions in Vietnam involved loss of substance of body of the maxilla or mandible due to systemic disease (such as an alleged in-service fungal infection) and is eligible for service connection, or if such extractions involved merely loss of the alveolar process as a result of periodontal disease, which is not eligible. 8. All opinions are to be accompanied by a rationale consistent with the evidence of record. A discussion of the pertinent evidence, relevant medical treatises, and generally accepted medical principles is requested. If the examiner cannot provide an opinion without resorting to speculation, he or she shall provide complete explanations stating why this is so. In so doing, the examiner shall explain whether any inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. 9. After completing the above, and any other development deemed necessary, readjudicate the appeal. JONATHAN B. KRAMER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Gallagher, 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.