Citation Nr: 21014555 Decision Date: 03/15/21 Archive Date: 03/15/21 DOCKET NO. 15-41 447 DATE: March 15, 2021 REMANDED The issue of entitlement to service connection for a renal disability, to include kidney stones and renal cysts, is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1975 to September 1979 and September 1980 to September 1982. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a January 2015 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran submitted a notice of disagreement in February 2015. The RO issued a statement of the case in September 2015, and the Veteran submitted his substantive appeal (VA Form 9) in October 2015. The Board remanded the appeal in September 2018 in order to obtain a VA examination considering whether the Veteran’s renal disability is related to his service at Camp LeJeune. The RO issued a supplemental statement of the case in October 2020. The appeal has now been returned to the Board for further appellate review. The Board notes that the Veteran opted into the Rapid Appeals Modernization Program (RAMP) in June 2018. However, by a letter of November 2018, the Veteran was advised that the appeal regarding his renal disability was excluded from RAMP because the appeal had been activated by the Board and no longer qualified for processing under RAMP. As such, the appeal remains under the Legacy appeals process. The Veteran contends that his renal disability was caused by his exposure to contaminated water while stationed at Camp LeJeune. He also contends, in the alternative, that his renal disability was caused by or aggravated by his continued use of medications for his service-connected conditions. The use of acetaminophens and Amoxicillin are specifically noted by the Veteran and his representative. The Veteran’s representative also cited to a Healthline article, indicating potential risks of kidney and liver function damage with use of Amoxicillin. The issue of entitlement to service connection for a renal disability, to include kidney stones and renal cysts, is remanded While the Board regrets the additional delay, due to the VA’s failure to assist, the Veteran’s claim of entitlement to service connection for a renal disability must be remanded. The VA has the duty to make reasonable efforts to assist a claimant in securing evidence necessary to substantiate their claim for VA benefits. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). Additionally, a remand confers on the claimant, as a matter of law, the right to compliance with the remand order and imposes upon the VA a concomitant duty to ensure compliance with the remand. See Stegall v. West, 11 Vet. App. 268 (1998). As mentioned above, in September 2018, the Board remanded the issue of entitlement to service connection for a renal disability specifically for the purpose of determining whether there is a connection between the Veteran’s renal disability and his exposure to contaminated water at Camp LeJeune. In October 2020, the Veteran was afforded a VA kidney conditions examination. The examiner opined that the renal disability was less likely than not incurred in or caused by the clamed in-service injury, event, or illness. However, the rationale for the examiner’s opinion did not include any discussion as to whether the Veteran’s renal disability is at least as likely as not related to his exposure to contaminated water at Camp LeJeune. Therefore, the opinion did not comply with the dictates of Stegall. Furthermore, the rationale for the opinion was primarily based upon a lack of documentation showing continuity of care since the Veteran’s military service. A lack of evidence cannot be corroborating to conclude that there is no relationship between the Veteran’s current disability and his military service. See Dalton v. Nicholson, 21 Vet. App. 23 (2007). Also, by not addressing the issue of whether the Veteran’s exposure to contaminated water at Camp LeJeune caused the renal disability the examiner omitted an essential fact that was necessary to address in order to fully apply valid medical analysis to the particular case. It is the factually accurate, fully articulated, and sound reasoning for the conclusion that contributes probative value to a medical opinion. The Board must be able to conclude that a medical expert has applied valid medical analysis to the significant facts of the particular case in order to reach the conclusion submitted in the medical opinion.” See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); see also Stefl v. Nicholson, 21 Vet. App. 120, 125 (2007) (holding that “a mere conclusion by a medical doctor is insufficient to allow the Board to make an informed decision as to what weight to assign to a doctor’s opinion”). Moreover, the Veteran has contended that his renal disability is secondary to his use of medications for his service-connected conditions. However, the October 2020 examiner did not consider whether the Veteran’s renal disability was caused by, or has been aggravated by, the use of medications for the Veteran’s service-connected conditions. A medical opinion is inadequate when it does not consider all raised theories of entitlement. See Stefl, 21 Vet. App. 120 (2007). Based on the foregoing reasons, the October 2020 VA examination opinion is inadequate, and remand is warranted. The matters are REMANDED for the following action: 1. Obtain any outstanding VA treatment records and associate them with the case file. 2. After the development directed in paragraph one has been completed to the extent possible, provide the Veteran’s claim file to a qualified clinician so that an addendum opinion may be obtained addressing the etiology of the Veteran’s renal disabilities. The entire claims file and a copy of this remand must be made available to the examiner for review. A physical examination of the Veteran or telehealth examination is only required if deemed necessary by the clinician. The examiner must review the claims file giving particular attention to the Veteran’s VA treatment records, lay assertions, and the pertinent medical evidence. The examiner must provide an opinion as to: a. Whether it is at least as likely as not (i.e. a 50 percent probability or greater) that any of the Veteran’s diagnosed renal disabilities had their clinical onset during active service, to include conceded exposure to contaminated water at Camp LeJeune. b. Whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s diagnosed renal disabilities are proximately due to or the result of his service-connected disabilities, to include the use of medications for his service-connected disabilities. c. Whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s kidney disabilities are aggravated beyond its natural progression by his service-connected disabilities, to include the use of medications for his service-connected disabilities. It is insufficient for the examiner to provide a negative opinion merely because kidney stones/renal cysts are not on the list of conditions and diseases presumptively associated with Camp Lejeune contaminated water exposure. In addressing the issue of whether the renal disability is secondary to, or aggravated by, the Veteran’s service-connected conditions, the examiner must address the following article provided by the Veteran’s representative in the June 2018 Appellant’s Brief: “Amoxicillin: Side Effects, Dosage, Uses, and More,” Healthline, Healthline Media, www.healthline.com/health/amoxicillin-oral-tablet#take-as-directed The examiner is advised that the term “aggravation” is defined for legal purposes as a chronic worsening of the underlying condition beyond its natural progression versus a temporary flare-up of symptoms. The examiner is advised that the Veteran is competent to report symptoms and treatment and that his reports, including his reports as to the onset and chronic nature of his symptoms, must be considered, along with the other evidence of record, in formulating the requested opinions. The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above-requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such a conclusion. (Continued on the next page)   3. After completing the requested actions, and any additional action deemed warranted, readjudicate the claim on appeal. If the benefit sought on appeal remains denied, provide a supplemental statement of the case to the Veteran and his representative and afford them an opportunity to respond. Then, return the case to the Board. N. Stevens Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. Temple, 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.