Citation Nr: 21009388 Decision Date: 02/22/21 Archive Date: 02/22/21 DOCKET NO. 16-46 814 DATE: February 22, 2021 REMANDED Service connection for a thyroid condition, to include thyroid nodular disease and hyperparathyroidism. Service connection for residuals of skin cancer. Service connection for gastroesophageal reflux disease (GERD). A total disability rating based on unemployability (TDIU).   REASONS FOR REMAND The Veteran served on active duty from February 1961 to October 1981. The case is on appeal from a December 2015 rating decision and a January 2016 rating decision. Most recently, in September 2020, the Board denied claims of service connection for a left shoulder disability, a left knee disability, a right knee disability, a left hip disability, a right hip disability, and a cervical spine disorder; denied an effective date prior to May 29, 2014 for the assigment for a 30 percent disability rating for an unspecified anxiety disorder, and a rating in excess of 30 percent for an unspecified anxiety disorder. The Board also reopened a claim of service connection for GERD and remanded that claim and claims of service connection for thyroid nodular disease, residuals of skin cancer, and a TDIU for additional development. 1. Service connection for a thyroid condition to include thyroid nodular disease and hyperparathyroidism. The Veteran is seeking service connection for a thyroid condition. He asserts he has thyroid condition related to radiation exposure from his 20 years of service as a nuclear weapons specialist. In correspondence received from the Veteran in June 2014, the Veteran specifically asserts further that he was exposed to liquid tritium in his duties calibrating urinalysis machines. The Board notes that the RO developed the claim per directives pertaining to claimed radiation exposure, determining that although the Veteran had some exposure to nuclear weaponry, the Veteran’s claimed exposure was insufficient to constitute a “radiation risk activity.” Pursuant to the Board’s February 2018 remand, the Veteran underwent a VA examination in June 2018. The examiner reported diagnoses including hyperparathyroidism and benign thyroid nodules. The examiner provided a negative etiology opinion regarding thyroid nodular disease. She based her opinion of the absence of a thyroid condition in the Veteran’s service treatment records (STRs) and the fact that post service treatment records document a repeated history by the Veteran of radiation treatment as a teenager for acne. Pursuant to the Board’s September 2020 remand, an additional VA opinion was obtained in October 2020. At that time, the examiner reported diagnoses including hyperparathyroidism and benign neoplasm of the thyroid. The examiner provided a negative etiology opinion regarding the Veteran’s thyroid nodules. The examiner based her opinion on a review the Veteran’s medical history. She noted the common causes of thyroid nodular disease, which are unrelated to the Veteran’s service, and also found significant the duration of time between the Veteran’s separation from service diagnosis of thyroid nodular disease. In this case, the Board finds that the opinions of record are not entirely sufficient to decide the claim. Although the June 2018 opinion and October 2020 opinion include a diagnosis of hyperparathyroidism, neither opinion includes an etiology opinion concerning this diagnosis, or adequately address notations in the Veteran’s private medical records indicating symptoms of this condition appeared relatively shortly after the Veteran’s separation from service in 1981. Private medical records reflect that that the Veteran underwent a surgical exploration of a parathyroid adenoma in 1987, and that in 2006 a private treatment reflects that the Veteran’s treating physician told him he likely had this condition for 20 years. In addition, neither opinion addresses the Veteran’s contention that he has a thyroid condition that is related to exposure to chemicals he used to remove paint including trichloroethylene and toluene. Accordingly, a new examination and opinion are warranted on remand. In light of the remand, updated VA treatment records should be obtained. 2. Service connection for residuals of skin cancer. Similarly, the Veteran is seeking service connection for residuals of skin cancer. He asserts he has skin cancer that is due to radiation exposure from his 20 years of service as a nuclear weapons specialist. In correspondence received from the Veteran in June 2014, the Veteran asserts further he was exposed to liquid tritium in his duties calibrating urinalysis machines. In addition, in his August 2016 substantive appeal, the Veteran contends his skin cancer is due to chemicals he used during service including trichloroethylene and toluene to remove paint. The Board notes the RO developed the claim per directives pertaining to claimed radiation exposure, determining that although the Veteran had some exposure to nuclear weaponry, the Veteran’s claimed exposure was insufficient to constitute a “radiation risk activity.” The Veteran underwent a VA examination in June 2018. The examiner reported a diagnosis of basal cell carcinoma. The opinion stated it is less likely than not that the Veteran’s basal cell carcinoma is related to benign moles removed from the Veteran’s back in 1991 as reflected in his STRs. The examiner also stated that it is less likely than not that the Veteran’s basal cell carcinoma is related to in-service radiation exposure based on the evidence of record and the weight of medical literature. The Board remanded the claim in September 2020 in order to obtain a VA examination and opinion addressing whether the Veteran’s skin cancer was related to his exposure to tritium. However, it appears the RO did not obtain an additional examination or VA opinion regarding this theory of entitlement. Accordingly, there was not substantial compliance with the Board’s remand directives, and another examination and opinion warranted. See Stegall v. West, 11 Vet. App. 268 (1998); see also D’Aries v. Peake, 22 Vet. App. 97, 104-05 (2008). In addition, the Board notes that June 2018 VA opinion does not address the Veteran’s contention that his skin cancer is related to his exposure to chemicals he used to remove paint including trichloroethylene and toluene. As such, an opinion addressing this theory of entitlement is warranted on remand. 3. Service connection for GERD. The Veteran is seeking service connection for GERD. He asserts that his GERD is related to multiple gastrointestinal related complaints documented in his STRs. In addition, in an August 2018 statement, the Veteran alternatively asserts his GERD is secondary to his service-connected irritable bowel syndrome (IBS). He also contends this GERD is related to his exposure to hazardous chemicals including trichloroethylene and toluene used to remove paint during service. The Veteran underwent a VA examination in November 2015. At that time, the examiner reported a diagnosis of GERD and provided a negative etiology opinion based on the absence of diagnosis or treatment of GERD in the Veteran’s STRs. An additional opinion was obtained in December 2015. The examiner who provided the December 2015 opinion considered several instances of gastrointestinal complaints in the Veteran’s STRs but provided a negative etiology opinion based on the Veteran’s reports of the onset of GERD symptoms occurring in 2012, which is 19 years after service. Pursuant to the Board’s February 2018 remand, an additional VA opinion was obtained in June 2018. The examiner who provided the June 2018 opinion also provided a negative etiology opinion based on the absence of any notations related to GERD in the Veteran’s STRs and the duration of time between the Veteran’s separation from service and documented treatment for GERD, which occurred many years after service in 2006. An additional VA opinion was obtained in October 2018. The examiner addressed whether the Veteran’s GERD was secondary to his service-connected IBS. The examiner concluded that it is less likely than not that the Veteran’s GERD was caused by the Veteran’s service-connected IBS as the documented symptoms of IBS do not include esophageal irritation. The Board remanded the claim in September 2020 as the opinions of record did not adequately explain how the Veteran’s in-service gastrointestinal complaints differed from his GERD or include an opinion regarding secondary aggravation. An additional opinion was obtained in October 2020. The examiner provided a negative etiology opinion. She reviewed each instance of a gastrointestinal complaint noted in the Veteran’s STRs and distinguished each from GERD. Concerning secondary aggravation, the examiner provided information regarding IBS and stated that the Veteran’s GERD was not aggravated by the Veteran’s IBS but did not provide a rationale. In this case, the Board finds that the opinions of record are not entirely sufficient to decide the claim. The opinions of record have not addressed the Veteran’s contention that his GERD is related to exposure to hazardous chemicals during service. In addition, an additional opinion is warranted regarding secondary aggravation as the examiner who provided the October 2020 did not provide a rationale for her opinion that the Veteran’s GERD was less likely than not aggravated by his service-connected IBS. Accordingly, a new examination and opinion are warranted on remand. 4. A TDIU. The Board will remand the TDIU claim as intertwined with the other remanded claims. The matters are REMANDED for the following action: 1. Obtain VA treatment records since June 2018. 2. Schedule the Veteran for a VA examination (or telehealth interview, record review, etc., if an in-person examination is not feasible) by a qualified medical professional for an opinion to determine the nature and etiology of any thyroid condition. The entire claims file should be reviewed by the examiner. The examiner should identify any current thyroid conditions. The examiner is to provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that each thyroid condition identified, including thyroid nodules and hyperparathyroidism, had its onset during service, or is otherwise causally related to service, to include his asserted exposure to tritium and chemicals including trichloroethylene and toluene used to remove paint. The examiner should consider private medical records that reflect that the Veteran underwent a surgical exploration of a parathyroid adenoma in 1987, and that in 2006 a note reflects that the Veteran’s treating physician told him he likely had hyperparathyroidism for 20 years. The examiner should provide rationale for all opinions expressed, including by citing to the record. 3. Also, schedule the Veteran for a VA examination (or telehealth interview, record review, etc., if an in-person examination is not feasible) by a qualified medical professional for an opinion to determine the nature and etiology of the residuals of his skin cancer. The entire claims file should be reviewed by the examiner. The examiner is to provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that any residuals of the Veteran’s skin cancer had its onset during service, within one year of service, or is otherwise causally related to service, to include his asserted exposure to tritium and chemicals including trichloroethylene and toluene used to remove paint. The examiner should provide rationale for all opinions expressed, including by citing to the record. 4. Also, schedule the Veteran for a VA examination (or telehealth interview, record review, etc., if an in-person examination is not feasible) by a qualified medical professional for an opinion to determine the nature and etiology of GERD. The entire claims file should be reviewed by the examiner. The examiner is to provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that GERD had its onset during service, or is otherwise causally related to service, to include his asserted exposure to tritium and chemicals including trichloroethylene and toluene used to remove paint. If not directly related to service, 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 GERD is caused or aggravated by his service-connected IBS. “Aggravation” is an increase in severity beyond the natural progress of the disease. The examiner should provide rationale for all opinions expressed, including by citing to the record. RYAN T. KESSEL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. Gray, Associate 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.