Citation Nr: 21012312 Decision Date: 03/04/21 Archive Date: 03/04/21 DOCKET NO. 17-66 031 DATE: March 4, 2021 ORDER Entitlement to service connection for prostate cancer is granted. REMANDED Entitlement to service connection for leukopenia and chronic neutropenia is remanded. Entitlement to service connection for a left knee injury is remanded. FINDINGS OF FACT 1. The Veteran has a current diagnosis of prostate cancer. 2. Granting the Veteran the benefit of reasonable doubt, he was exposed to herbicide agents during active service. CONCLUSION OF LAW The criteria for service connection for prostate cancer have been met. 38 U.S.C. §§ 1110, 1112, 1116, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran served on active duty from January 1971 to December 1974. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a November 2014 rating decision. The Veteran testified before the undersigned during an October 2020 hearing. Entitlement to service connection for prostate cancer Generally, service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the current disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also 38 C.F.R. § 3.303, Hickson v. West, 12 Vet. App. 247, 252-53 (1999). Additionally, service connection may be established on a presumptive basis for diseases enumerated in section 3.309(e) for veterans who were exposed to certain herbicide agents during active military, naval, or air service. 38 C.F.R. § 3.307(a)(6). VA has determined that there was significant use of herbicide agents on the fenced-in perimeters of certain military bases in Thailand intended to eliminate vegetation and ground cover for base security purposes. Therefore, VA has applied the presumptive provisions regarding herbicide agent exposure to veterans who served with the U.S. Air Force in Thailand during the Vietnam Era on Royal Thai Air Force Bases, including U-Tapao, Ubon, Nakhon Phanom, Udorn, Takhli, Korat, and Don Muang, when the evidence establishes their duties placed them on or near the perimeters of the base. When there is an approximate balance of positive and negative evidence as to any issue material to the determination of a matter, VA will resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Here, the record establishes that the Veteran has prostate cancer, which is listed in 38 C.F.R. § 3.309(e) as a disease presumed to be associated with herbicide agent exposure. The Veteran served at Royal Thai Air Force Base Udorn during the Vietnam Era. The Veteran has submitted credible evidence that the nature of his duties at Udorn Air Base likely resulted in exposure to herbicide agents along the base flight line and perimeter. Resolving reasonable doubt in favor of the Veteran, the Board concludes that herbicide exposure should be conceded in this case. As a result, the criteria for service connection for prostate cancer have been met. REASONS FOR REMAND 1. Entitlement to service connection for leukopenia and chronic neutropenia is remanded. The Veteran’s private medical records contain clear evidence that he has been diagnosed with idiopathic chronic neutropenia, a form a leukopenia or low white blood cell count, since at least 2008. The record also contains two letters from a private physician familiar with the Veteran’s medical history who have provided opinions in support of the Veteran’s claim. The first such letter was submitted in February 2014 and contained an opinion from a private physician, A.T., that the Veteran’s idiopathic chronic neutropenia could be related to Agent Orange exposure. A.T. provided no rationale for this opinion, and the statement that the Veteran’s current disability could be caused by exposure to herbicide agents during service does not address whether this was at least as likely as not the cause of the Veteran’s current disability. For these reasons, the Board finds this opinion is inadequate to support finding a nexus between the Veteran’s current disability and his now conceded exposure to herbicide agents. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (“[A] medical opinion...must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions.”). The second letter, which was also written by private physician A.T., was dated September 2017 and provided additional information. In this letter, A.T. indicated that the Veteran’s chronic idiopathic neutropenia/leukopenia has no particular cause based on past evaluations, and exposure to toxic chemicals can cause low white blood cell count. For these reasons, he opines that the Veteran’s leukopenia is very likely related to or caused by exposure to herbicide agents and other toxic chemicals. Despite indicating that toxic chemicals generally may cause leukopenia, A.T. did not state or provide reference to any medical evidence showing that herbicide agents specifically may cause leukopenia. Though this second letter provides more rationale for the opinion provided than the earlier 2014 letter, the Board finds it remains inadequate to support finding a nexus in this case, as the Veteran’s physician has not provided adequate information for the Board to judge the credibility of his conclusion that the Veteran’s neutropenia is likely related to herbicide agent exposure. Id. When VA concludes that a private medical examination is unclear or insufficient in some way, and it reasonably appears that a request for clarification could provide relevant information that is otherwise not in the record and cannot be obtained in some other way, the Board must either seek clarification from the private examiner or the claimant or clearly and adequately explain why such clarification is unreasonable. Savage v. Shinseki, 24 Vet. App. 259, 269 (2011). Therefore, a remand is necessary to allow the Veteran the opportunity to obtain clarification from his physician or provide additional supporting evidence showing his chronic idiopathic neutropenia is related to his concede exposure to herbicide agents during service.   2. Entitlement to service connection for a left knee injury is remanded. VA is required to obtain a medical opinion when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability; the record indicates that the disability or signs and symptoms of disability may be associated with active service; and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79 (2006). In this case, the Veteran asserts that he has left knee arthritis status post total knee replacement related to an injury sustained during active service. The Veteran has testified that he initially hurt his knee when he fell through a damaged floor in a barracks during active service. Though this incident and related treatment are not documented in the Veteran’s service records, his spouse has stated that the Veteran’s knee has frequently been painful and given out since she first met him in 1978, about four years after separation from service. Based on this evidence, the Board finds the Veteran has a current left knee disability and the record contains evidence that this disability may be associated with an injury during active military service. Therefore, a remand is necessary to obtain a medical opinion in this case. The matters are REMANDED for the following action: 1. Seek a clarifying medical opinion from the Veteran’s private physician, A.T., M.D., that includes rationale to support his conclusion that the Veteran’s chronic idiopathic neutropenia/leukopenia is likely related to or caused by exposure to herbicide agents during the Veteran’s military service. All efforts to obtain the requested addendum must be documented in the claims file. If an addendum cannot be obtained from A.T., M.D., a formal finding to this effect must be associated with the claims file. If a clarifying medical opinion cannot be obtained from A.T., M.D., or the obtained opinion is inadequate in some way, obtain a new medical opinion from another clinician regarding the nature and etiology of any neutropenia/leukopenia. The Veteran should only be scheduled for an examination if deemed necessary by the selected examiner. The examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease, including the Veteran’s conceded exposure to herbicide agents during military service. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinion. If the examiner rejects the Veteran’s reports, he or she must provide a reason for doing so. The fact that his report of symptoms is not corroborated by contemporaneous medical treatment records is not, by itself, a sufficient reason to reject the Veteran’s report of symptoms capable of lay observation. The examiner’s report must include a complete rationale for the opinion. 2. Obtain a new medical opinion regarding the nature and etiology of any left knee disability. The Veteran should only be scheduled for a new examination if deemed necessary by the selected examiner. The examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease, including the injury described by the Veteran in his October 2020 Board hearing testimony. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinion. If the examiner rejects the Veteran’s reports, he or she must provide a reason for doing so. The fact that his report of symptoms is not corroborated by contemporaneous medical treatment records is not, by itself, a sufficient reason to reject the Veteran’s report of symptoms capable of lay observation. The examiner must consider the lay evidence of record, to include statements provided by the Veteran and his spouse both during his October 2020 Board hearing and other statements submitted to VA, to include the October 2020 correspondence from the Veteran’s spouse describing his history of knee symptoms. The examiner is further advised that it is not necessary for pain to attributable to a specific diagnosis or pathology to be considered a service-connected disability so long as the pain is productive of functional impairment. The examiner’s report must include a complete rationale for the opinion. M. HYLAND Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Pitman, 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.