Citation Nr: 21009450 Decision Date: 02/22/21 Archive Date: 02/22/21 DOCKET NO. 18-39 611 DATE: February 22, 2021 REMANDED Entitlement to service connection for the Veteran’s cause of death is remanded. REASONS FOR REMAND The Veteran had active service from June 1960 to January 1977. He died in July 2013. The Appellant is his surviving spouse. She has appealed a July 2015 rating decision that denied her claim of entitlement to service connection for the Veteran's cause of death. The Appellant and her daughter appeared at a hearing before the undersigned in January 2021. Entitlement to service connection for the Veteran's cause of death is remanded. VA has a duty to ensure any medical examination or opinion it provides is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (overruled on other grounds, Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013)). A medical opinion is adequate where it is based upon consideration of the full medical history and describes a disability in sufficient detail so that the Board’s evaluation will be fully informed. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). Esophageal cancer is among the causes of death listed on the Veteran’s death certificate. During the January 2021 hearing, the Appellant raised three theories of entitlement to service connection for the Veteran’s cause of death. First, she asserts Veteran’s esophageal cancer is causally related to in-service treatment for hiatal hernia, digestive pain, esophageal reflux, and heartburn. Second, she contends the esophageal cancer is due to the Veteran’s exposure to contaminated water at Camp Lejeune. Finally, she contends that the esophageal cancer is related to the Veteran use alcohol and tobacco and the use of these substances was due to his service-connected PTSD. In addition to her January 2021 testimony, the Appellant has submitted multiple written statements and medical literature to support her contentions (July 2014, November 2014, December 2014, January 2015, March 2016, May2016 , August 2018, and July 2019.) January 2014 and July 2015 VA examiners opined the Veteran’s esophageal cancer was less likely than not associated with his in-service treatment for hiatal hernia, heartburn, and digestive problems. These opinions were based, in part, on the examiners’ findings that there was no medical evidence of chronic digestive problems between January 1977, when the Veteran separated from active service, and October 2012, when he was diagnosed with esophageal cancer. However, the Appellant and her daughter testified that after the Veteran separated from active service, he continued to experience heartburn and used over the counter medications (Maalox, Tums, and Rolaids) to treat the condition. As laypeople, the appellant and her daughter are competent to describe their observation of the Veteran using medications and his observable symptomatology. The January 2014 and July 2015 VA examiners did not consider this evidence of continuing digestive symptoms. The opinions are not based on consideration of the full medical history and they are inadequate to evaluate the claim. See Stefl, supra. January 2014 and April 2018 VA examiners opined the Veteran’s esophageal cancer was less likely than not associated with his exposure to contaminated water at Camp Lejeune. In support of these opinions, the examiners stated the Veteran was exposed to contaminated water at Camp Lejeune for 10 months, or less. Under VA regulations regarding contaminated water at Camp Lejeune, “service at Camp Lejeune means any service within the borders of the entirety of the United States Marine Corps Base Camp Lejeune and Marine Corps Air Station New River, North Carolina.” See 38 C.F.R. § 3.307(a)(7)(iii). The Veteran’s Record of Service shows he was stationed at Camp Lejeune from September 1960 to January 1961 and from March 1961 to May 1961. Additionally, the records show he was stationed at the Marine Corps Air Station, New River from April 1965 to July 1965 and from September 1972 to August 1974. Other military personnel records (reenlistment paperwork, life insurance forms, good conduct award) show the Veteran continued his assignment to the Marine Corps Air Station, New River in 1975 and 1976. In addition, the Appellant testified that the Veteran was stationed at Camp Lejeune for many years. During that time, she and the Veteran met, dated, and eventually married in 1976. Thus, the Veteran’s exposure to contaminated water at Camp Lejeune was longer than the six- and 10-month periods considered by the VA examiners. Their opinions are inadequate to evaluate the claim. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (indicating an opinion based on an incorrect factual premise has no probative value). January 2014 , July 2015, and April 2018 VA examiners all noted that alcohol use and tobacco use were risk factors for developing esophageal cancer. A March 2013 VA primary care note states the Veteran, prior to quitting in 1984, had a 30-40 pack year history of smoking. February 2006 VA treatment notes confirm the Veteran’s diagnosis of PTSD, his report of drinking two alcoholic beverages each evening, and counseling from his physician about alcohol and PTSD. The Appellant testified that the Veteran was generally a social drinker but added that alcohol had a calming influence on him. She noted that following nightmares or other sleep disturbances, the Veteran would have a can of beer of glass of wine to calm down. A potential causal link between the Veteran’s PTSD and his esophageal cancer is indicated; however, no VA examiner has provided an opinion as to whether the Veteran’s esophageal cancer is secondary to the Veteran’s PTSD, to include any use of alcohol or nicotine to self-treat his PTSD symptoms. The Board finds a medical opinion is necessary to evaluate this connection. See 38 U.S.C. § 5103A(a); Wood v. Peake, 520 F.3d 1345, 1347-48 (Fed. Cir. 2008) (explaining VA is required to assist a claimant in obtaining a medical opinion or examination regarding a claim for service connection for cause of death whenever such an opinion is necessary to substantiate the claim). Finally, the Board notes there appear to be outstanding medical records. In a July 2014 statement, the Appellant asserted VA treatment records from the Durham VAMC and Hampton VAMC would document the Veteran’s continuous treatment for acid reflux and GERD. While some treatment records from these VA facilities are associated with the claims file, it is not clear that complete records have been obtained. In addition, the record reflects the Veteran received treatment for esophageal cancer from private medical providers, including Duke University Hospital. Complete private treatment records are not included in the claims file. Thus, any outstanding VA treatment records must be associated with the claims file and reasonable efforts should be made to ensure all available, relevant private treatment records have been obtained and associated with the claims file. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c); see also Sullivan v. McDonald, 815 F.3d 786 (Fed. Cir. 2016). The matters are REMANDED for the following action: 1. Obtain all outstanding VA treatment records for the Veteran. 2. Contact the Appellant and attempt to identify and obtain outstanding private treatment records, including treatment records from Duke University Hospital, relevant to the Veteran’s treatment for esophageal cancer, chronic digestive problems, and/or PTSD. 3. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s esophageal cancer was at least as likely as not related to in-service hiatal hernia, gastroesophageal reflux, or heartburn. The examiner should fully review the claims file, including the transcript of the January 2021 hearing, written statements from the Appellant, medical literature submitted by the appellant, and all medical records associated with the claims file. The examiner should discuss all evidence that the Veteran experienced hiatal hernia, gastroesophageal reflux, or other digestive symptoms between his active service and his diagnosis of esophageal cancer. The examiner is advised that lay people are competent to report their observance of the Veteran use of medications or his observable symptomatology. If the examiner dismisses any such report a complete rationale for doing so must be provided. The examiner should also opine as to whether the Veteran’s esophageal cancer was at least as likely as not related to his exposure to contaminated water during his service at Camp Lejeune, including his service at the Marine Corps Air Station, New River. The examiner should review this decision and all military personnel records in determining the extent of the Veteran’s exposure to this contaminated water. The examiner should also explain the current scientific and medical studies applicable to this issue. The examiner should also opine as to whether the Veteran’s esophageal cancer was proximately due to his PTSD, including use of alcohol or tobacco due to PTSD or aggravated beyond its natural progression by PTSD, including use of alcohol or tobacco due to PTSD. In providing each opinion, the examiner should fully review the transcript of the January 2021 and statements and supporting literature submitted by the Appellant in July 2014, November 2014, December 2014, January 2015, March 2016, May 2016, August 2018, and July 2019. The examiner must provide a complete rationale for each of the requested opinions. M. HYLAND Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Jeanne Celtnieks 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.