Citation Nr: 21021437 Decision Date: 04/13/21 Archive Date: 04/13/21 DOCKET NO. 16-04 402 DATE: April 13, 2021 REMANDED Entitlement to service connection for a cardiac condition, to include as due to herbicide exposure and/or exposure to contaminated water at Camp Lejeune and/or secondary to a thyroid condition, is remanded. Entitlement to service connection for a skin condition, to include as due to herbicide exposure and/or exposure to contaminated water at Camp Lejeune, is remanded. Entitlement to service connection for a respiratory condition, to include as due to herbicide exposure and/or exposure to contaminated water at Camp Lejeune, is remanded. Entitlement to service connection for a thyroid condition, to include as due to herbicide exposure and/or exposure to contaminated water at Camp Lejeune, is remanded. Entitlement to service connection for bilateral hearing loss is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1966 to January 1968, including service in the Republic of Vietnam and at Camp Lejeune. The Veteran testified before the undersigned Veterans Law Judge in May 2018. The Board of Veterans’ Appeals (Board) remanded the matters for further development in July 2018. 1. Entitlement to service connection for a cardiac condition, to include as due to herbicide exposure and/or exposure to contaminated water at Camp Lejeune and/or secondary to a thyroid condition is remanded. In August 2020, the Veteran was provided a Camp Lejeune water medical opinion. Of note, the examiner provided a negative nexus opinion and determined the Veteran’s heart condition was related to the Veteran’s thyroid disorders. Accordingly, the heart condition is inextricably intertwined with the remanded service connection claim for a thyroid condition. The Veteran was provided a direct service connection medical opinion in October 2020. The examiner provided a negative nexus opinion; however, the examiner did not explain why the heart condition was not related to the Veteran’s active service. A conclusory opinion without supporting rationale is inadequate. The examiner also found the Veteran’s heart condition was not related to herbicide exposure because the disease is not listed as a presumptive condition under VA regulations. This basis for a negative nexus opinion is inadequate. The Board is well aware of disabilities for which VA has presumptively associated with herbicide exposure, and no professional medical opinion would be necessary for said disabilities. However, under Combee, the Veteran can still meet the requirements for service connection on a direct basis based upon the specific facts of the Veteran’s claims file. See Combee v. Brown, 34 F.3d 1039, 1043-44 (Fed. Cir. 1994). Therefore, a professional medical opinion is necessary to determine if the Veteran’s specific disabilities are due to herbicide exposure, and an addendum opinion is required as to the nature and etiology of the Veteran’s heart condition. 2. Entitlement to service connection for a skin condition, to include as due to herbicide exposure and/or exposure to contaminated water at Camp Lejeune is remanded. The Veteran provided a June 2018 skin diseases disabilities and benefits questionnaire (DBQ). The Veteran was diagnosed with verruca vulgaris, actinic keratoses (AK), hemangioma, and lipomas. No medical opinion was provided. The Veteran was provided a Camp Lejeune water medical opinion in August 2020. The examiner provided a negative opinion for the diagnosed AK. The examiner did not discuss any other conditions diagnosed during the appellate period as required by the previous remand directives. The Board finds the examination inadequate for adjudication purposes and not in compliance with the prior remand directives, and another remand is required. Stegall v. West, 11 Vet. App. 268 (1998). The Veteran was provided a direct service connection medical examination and opinion in October 2020. The examiner listed 2018 as the date of diagnosis for AK in Section I, and then listed 1969 as the date of diagnosis in Section II. The correct date of diagnosis needs to be resolved because 1969 could mean AK began within one year of separation from active duty. Additionally, the examiner only provided opinions for currently diagnosed AK and lipoma, without addressing the other disorders diagnosed in the June 2018 DBQ. Id. The examiner also provided a conclusory negative nexus opinion for AK and lipoma without providing adequate rationale by basing the opinion upon VA regulations for presumptive service connection. Combee, supra. Therefore, a professional medical opinion is necessary to determine if the Veteran’s specific disabilities are due to herbicide exposure, and an addendum opinion is required as to the nature and etiology of the Veteran’s skin condition. 3. Entitlement to service connection for respiratory and thyroid conditions, to include as due to herbicide exposure and/or exposure to contaminated water at Camp Lejeune is remanded. The Veteran was provided direct service connection medical opinions for the respiratory and thyroid conditions in October 2020. The examiner provided negative nexus opinions; however, the examiner did not explain why the respiratory and thyroid conditions were not related to the Veteran’s active service. A conclusory opinion without supporting rationale is inadequate. The examiner also found the Veteran’s respiratory and thyroid conditions were not related to herbicide exposure because the diseases were not listed as a presumptive condition under VA regulations. This basis for a negative nexus opinion is inadequate. Id. Therefore, a professional medical opinion is necessary to determine if the Veteran’s specific disabilities are due to herbicide exposure, and addendum opinions are required as to the nature and etiology of the Veteran’s respiratory and thyroid conditions. 4. Entitlement to service connection for bilateral hearing loss is remanded The Veteran’s entrance examination occurred in January 1966. Prior to January 1967, service departments used American Standards Association (ASA) units when recording auditory thresholds. Audiometric data originally recorded using ASA units should be converted to International Standards Organization-American National Standards Institute (ISO-ANSI) units for VA purposes to determine hearing loss under 38 C.F.R. § 3.385. Once converted to ISO-ANSI units, the January 1966 entrance examination showed left ear hearing loss for VA purposes due to a 40 dB auditory threshold at 500 Hz. Impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the above frequencies are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. The Veteran was provided with VA nexus opinions in October 2017 and September 2020. In both opinions, the examiners provided negative nexus opinions; and in part, noted normal hearing upon entrance. The rationale provided in the examinations show the examiners did not convert the auditory thresholds from ASA to ISO-ANSI. Although the right ear did not show hearing loss for VA purposes, an addendum opinion where the rationale is based upon properly converted auditory thresholds is necessary to determine the nature and etiology of the right ear hearing loss. The Veteran’s left ear hearing loss upon entrance showed the Veteran’s left ear hearing loss preexisted active duty service. Because the hearing loss preexisted active duty service, an addendum opinion is necessary to determine if the pre-existing left ear hearing loss was aggravated by active duty service. The matters are REMANDED for the following action: 1. Forward the Veteran’s claim file to a qualified medical professional in order to obtain an addendum opinion as to the nature and etiology of the Veteran’s heart condition. The claims file, to include a copy of this Remand, must be made available to and be reviewed by the examiner. Specifically, the examiner must address the following: (a.) Identify all heart conditions demonstrated during the appeal period (since July 2014) or in proximity to the claim, even if currently resolved; (b.) Provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that any heart disorder identified is related to service, to include due to exposure to Agent Orange and contaminated water at Camp Lejeune; and (c.) Provide an opinion as to whether it is at least as likely as not that any heart disorder identified is caused or aggravated (increased in severity beyond the natural progress of the disorder) by the thyroid condition. A complete rationale for all opinions expressed should be provided. The examiner must explain the relevance or significance, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching his or her conclusions, by detailing how such medical knowledge applies to the Veteran specifically. Recitation of VA regulations is not an adequate rationale for Board purposes. 2. Forward the Veteran’s claim file to a qualified medical professional in order to obtain an addendum opinion as to the nature and etiology of the Veteran’s skin condition. The claims file, to include a copy of this Remand, must be made available to and be reviewed by the examiner. Specifically, the examiner must address the following: (a.) Identify all skin conditions (to include the June 2018 DBQ) demonstrated during the appeal period (since September 2017) or in proximity to the claim, even if currently resolved; and (b.) Provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that any skin disorder identified is related to service, to include due to exposure to Agent Orange and contaminated water at Camp Lejeune. A complete rationale for all opinions expressed should be provided. The examiner must explain the relevance or significance, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching his or her conclusions, by detailing how such medical knowledge applies to the Veteran specifically. Recitation of VA regulations is not an adequate rationale for Board purposes. 3. Forward the Veteran’s claim file to a qualified medical professional in order to obtain an addendum opinion as to the nature and etiology of the Veteran’s respiratory condition. The claims file, to include a copy of this Remand, must be made available to and be reviewed by the examiner. Specifically, the examiner must address the following: (a.) Identify all respiratory conditions (to include the June 2018 DBQ) demonstrated during the appeal period (since September 2017) or in proximity to the claim, even if currently resolved; and (b.) Provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that any respiratory disorder identified is related to service, to include due to exposure to Agent Orange and contaminated water at Camp Lejeune. A complete rationale for all opinions expressed should be provided. The examiner must explain the relevance or significance, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching his or her conclusions, by detailing how such medical knowledge applies to the Veteran specifically. Recitation of VA regulations is not an adequate rationale for Board purposes. 4. Forward the Veteran’s claim file to a qualified medical professional in order to obtain an addendum opinion as to the nature and etiology of the Veteran’s thyroid condition. The claims file, to include a copy of this Remand, must be made available to and be reviewed by the examiner. Specifically, the examiner must address the following: (a.) Identify all thyroid conditions (to include the June 2018 DBQ) demonstrated during the appeal period (since July 2014) or in proximity to the claim, even if currently resolved; and (b.) Provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that any thyroid disorder identified is related to service, to include due to exposure to Agent Orange and contaminated water at Camp Lejeune. A complete rationale for all opinions expressed should be provided. The examiner must explain the relevance or significance, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching his or her conclusions, by detailing how such medical knowledge applies to the Veteran specifically. Recitation of VA regulations is not an adequate rationale for Board purposes. 5. Forward the Veteran’s claim file to a qualified medical professional in order to obtain an addendum opinion as to the nature and etiology of the Veteran’s hearing loss. The claims file, to include a copy of this Remand, must be made available to and be reviewed by the examiner. Specifically, the examiner must address the following: (a.) The examiner should make any necessary conversions from ASA to ISO-ANSI standards. Any conversions should be documented. (b.) Provide an opinion as to whether right ear hearing loss is at least as likely as not (a 50 percent or greater probability) related to service; and (c.) Provide an opinion as to whether left ear hearing loss, which preexisted active duty per entrance examination, was clearly and unmistakably NOT aggravated by service. A complete rationale for all opinions expressed should be provided. The examiner must explain the relevance or significance, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching his or her conclusions, by detailing how such medical knowledge applies to the Veteran specifically. A. C. MACKENZIE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. N. Quarles, 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.