Citation Nr: 21009572 Decision Date: 02/22/21 Archive Date: 02/22/21 DOCKET NO. 20-00 395 DATE: February 22, 2021 REMANDED Entitlement to service connection for multiple endocrine neoplasia, type 1 (MEN-Type 1), to include as due to exposure to herbicide agents, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from October 1965 to September 1967, from August 1969 to September 1969, and from October 1969 to May 1972. The Veteran served in the Republic of Vietnam and is in receipt of the Bronze Star medal. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a September 2018 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In March 2020, the Veteran testified before the undersigned Veterans Law Judge at a videoconference hearing. The Board remanded this matter in May 2020 for further development. While the Board regrets further delay, the Veteran’s appeal must once again be remanded as the Board is not satisfied that there has been substantial compliance with its prior remand directives. Stegall v. West, 11 Vet. App. 268 (1998) (a remand by the Board confers on the Veteran, as a matter of law, the right to compliance with the remand). Entitlement to service connection for MEN-Type 1, to include as due to exposure to herbicide agents, is remanded. Pursuant to the Board’s May 2020 remand, the appeal was returned to the RO for additional development, to include obtaining a VA opinion regarding the Veteran’s MEN-Type 1. In the remand directives, the Board requested that, in providing an opinion, the examiner consider a March 2018 treatment note detailing that genetic testing did not detect a pathogenic variant in the MEN-1 gene, letters from private physicians stating that there may be a link between Agent Orange exposure and MEN-1, the Veteran’s testimony that he has suffered a variety of endocrine disorders since service, and medical literature on the subject of exposure to herbicide agents and MEN-1. While the examiner addressed the May and June 2018 letters, and medical literature in his rationale, he did not specifically address the Veteran’s negative test for the MEN-1 gene, nor the Veteran’s testimony regarding the endocrine disorders he has suffered since service, In light of the above deficiencies, the Board finds the October 2020 examination to be inadequate. Because the examiner did not comply with the Board’s May 2020 remand directives, this matter must once again by remanded. Stegall v. West, 11 Vet. App. 268, 271 (1998). Under 38 U.S.C. § 5109 (a), VA may obtain an advisory medical opinion from an independent medical expert from outside the Department based upon the medical complexity or controversy of a particular case. The Board finds that an independent expert medical opinion will be useful in this case given the complexity of the medical issue. Accordingly, the matter is REMANDED for the following actions: 1. Arrange for an independent medical expert opinion by an appropriate expert under 38 U.S.C. § 5109 (an M.D. who specializes in endocrinology) to obtain a medical opinion that assesses the nature and etiology of the Veteran’s MEN-Type 1. The examiner must review the Veteran’s entire claims file, to include a copy of this REMAND, and that review must be noted in the report. (a.) Is it at least as likely as not (50 percent probability or greater) that the Veteran’s MEN-Type 1 is etiologically related to his active duty service, to include exposure to herbicide agents? This opinion must specifically consider the physician’s opinion that the Veteran’s MEN-Type 1 is not genetic. In responding to the above, the examiner must opine as to whether the condition is directly related to the Veteran’s presumed herbicide agent exposure during his service in Vietnam. A medical opinion that concludes that a disease is not related to herbicide exposure solely because there is no presumption of service connection is inadequate. The requested opinion MUST adequately consider, and specifically address the pertinent evidence of record, to include: • VA treatment note, February 2018 (signed March 3, 2018), detailing that genetic testing did not detect a pathogenic variant in the MEN-1 gene/the Veteran does not have the MEN-1 gene. o Please reconcile the Veteran’s diagnosis of MEN-1 despite testing negative for the MEN-1 gene. Please explain if this is affirmative evidence that in this Veteran’s case, that this is not a genetic disorder? • Letter from Dr. M.N., May 2018 • Letter from Dr. L.B., June 2018 • Testimony from the Veteran that he has suffered with a variety of endocrine disorders since discharge from service, including his service-connected basal cell carcinoma which the Veteran testified could be linked to MEN-1, hypothyroidism, and a pituitary tumor • The Veteran’s December 2020 statement that his service-connected basal cell carcinoma is a skin disease associated with MEN-1, that MEN-1 predisposes patients to angio-fibromas, lipomas, and melanomas which combined with the Veteran’s high numbers of 35 malignancies serve as evidence of Agent Orange causation • Medical Literature/Research: o “Agent Orange Exposure Increases Likelihood of Endocrine Complications,” Jeannette Y. Wick, July 2014, found at: https://www.mdmag.com/journals/internal-medicine-world-report/2014/july-2014/agent-orange-exposure-increases-likelihood-of-endocrine-complications o “Agent Orange Exposure and Disease Prevalence in Korean Vietnam Veterans: The Korean Veterans Health Study,” Sang-Wook Yi, et al, August 2014, found at: https://www.sciencedirect.com/science/article/abs/pii/S0013935114001194?via%3Dihub  Please address the abstract conclusion that, “Agent Orange exposure increased the prevalence of endocrine disorders, especially in the thyroid and pituitary gland [.]” (b) If there is another likely etiology for the Veteran’s MEN-Type 1 please so indicate. The examiner should note that the term “at least as likely as not” does not mean “within the realm of possibility.” Rather, it means that the weight of the medical evidence both for and against the claim is so evenly divided that it is as medically sound to find in favor of the claim as it is to find against it. The examiner must provide a complete rationale for any opinion expressed, citing to the examiner’s clinical experience, medical expertise, and established medical principles, as necessary. If the examiner is unable to provide an opinion without resorting to speculation, he or she should explain why this is so and what, if any, additional evidence would be necessary before an opinion could be rendered. LESLEY A. REIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Gates 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.