Citation Nr: 21023606 Decision Date: 04/21/21 Archive Date: 04/21/21 DOCKET NO. 13-13 606 DATE: April 21, 2021 REMANDED Entitlement to service connection for nephrolithiasis to include as due to herbicide agent exposure is remanded. Entitlement to service connection for neutropenia to include as due to herbicide agent exposure is remanded. Entitlement to service connection for total disability due to individual unemployability for the period prior to May 1, 2014 is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1969 to July 1971. These matters come before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). An informal hearing conference with a Decision Review Officer (DRO) was conducted in March 2015. In April 2015, the Veteran and the appellant testified during a hearing before a DRO at the RO. A transcript of the hearing is included in the record. In December 2016, the Veteran and the appellant testified during a Board videoconference hearing before a Veterans Law Judge (VLJ). A transcript of the hearing is included in the record. The Veteran died in January 2018. The Appellant is the Veteran’s surviving spouse. An April 2018 memorandum issued by the AOJ recognized that the appellant as the properly substituted party in this claim. 38 U.S.C. § 5121A. In February 2020 the Veteran’s surviving spouse testified at a second Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is included in the record. The Board notes that the VLJ whom the Veteran testified before in December 2016 is no longer employed with the Board. In May 2020 the Appellant waived her right to appear at an additional hearing before the Board. A January 2019 Board decision remanded the claim for entitlement to service connection for nephrolithiasis, entitlement to service connection for neutropenia, entitlement to service connection for anxiety disorder and entitlement to total disability due to individual unemployability prior to June 6, 2014 for further development. Following the January 2019 Board remand, a July 2020 rating decision granted the claims for entitlement to service connection for anxiety disorder and entitlement to TDIU beginning May 1, 2014. Thus, the issues remaining before the Board are entitlement to service connection for nephrolithiasis to include as due to herbicide agent exposure; entitlement to service connection for neutropenia to include as due to herbicide agent exposure and entitlement to TDIU prior to May 1, 2014. For the reasons discussed below, remand is again required. 1. Entitlement to service connection for nephrolithiasis to include as due to herbicide agent exposure is remanded. 2. Entitlement to service connection for neutropenia to include as due to herbicide agent exposure is remanded. The VA examinations of record are inadequate. Specifically, while the January 2019 Board remand directed that the VA opinions consider all evidence of record and provide etiology opinions for the Veteran’s nephrolithiasis and neutropenia the examiner failed to do consider all evidence of record. Etiology opinions regarding the Veteran’s nephrolithiasis and the Veteran’s neutropenia were provided by the same examiner. In both opinions the examiner relied on the January 2018 Georgia Postmortem Examination Report. With regards to the Veteran’s nephrolithiasis the examiner indicated that the Veteran’s renal calculi initially occurred in 2011, 40 years post service. The examiner failed to address and consider evidence as remotely as December 2005 which shows as diagnosis of nephrolithiasis and subsequent evidence of nephrolithiasis in September 2007, July 2008, August 2008, November 2008, prior to the 2011 notation of renal calculi. Regarding the Veteran’s neutropenia, the examiner noted a postmortem diagnosis of leukemia with findings that are inconsistent with neutropenia. The examiner failed to consider evidence dated September 2005, March 2006, March 2008, August 2008, and January 2009 which shows ongoing symptoms and diagnosis of neutropenia. Remand is required to obtain adequate etiological opinions. Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). A medical opinion based upon an inaccurate factual premise has no probative value. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). Remand is warranted for opinions based on all evidence of record and supported by adequate rationale. Entitlement to service connection for total disability due to individual unemployability for the period prior to May 1, 2014 is remanded. The TDIU claim must be remanded as it is inextricably intertwined with the remaining issues on appeal. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that issues are inextricably intertwined and must be considered together when a decision concerning one could have a significant impact on the other). The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding whether it is at least as likely as not(i.e., a 50 percent or greater possibility) that the Veteran’s nephrolithiasis had its onset during service or is otherwise medically related to service—to specifically include as a result of kidney problems experienced during service (e.g., kidney infections and upper pole infundibulum as well as a mildly deformed middle pole calyx affecting the right kidney). In addressing the above, the physician must consider and discuss all relevant medical and lay evidence, to include assertions made by the Veteran and the appellant as well as treatment records (including but not limited to records dated in December 2005, September 2007, July 2008, August 2008, November 2008) that note diagnosis and symptoms of nephrolithiasis. Complete, clearly stated rationale for the conclusions reached, must be provided. 4.After all records and/or responses received are associated with the claims file, arrange to have an appropriate VA medical professional comprehensively review the record and provide an etiology opinion as to the Veteran’s diagnosed neutropenia. The examiner should render an opinion, consistent with sound medical principles, as to whether it is at least as likely as not (i.e., a 50 percent or greater possibility) the Veteran’s neutropenia had its onset during service or is otherwise medically related to service. In addressing the above, the physician must consider and discuss evidence of immunological issues during the Veteran’s service, to include evidence showing that white blood cell counts were taken on multiple occasions. The physician must additionally consider all relevant medical and lay evidence, to include assertions made by the Veteran and the appellant and treatment records (including but not limited to records dated September 2005, March 2006, March 2008, August 2008 and January 2009) which shows ongoing symptoms and diagnosis of neutropenia. The physician is advised that the Veteran was competent to report his symptoms and history, and that the appellant is competent to report her observations; hence, the lay assertions in this regard must be considered in formulating the requested opinions. If lay assertions in any regard are discounted, the physician should clearly so state, and explain why. Complete, clearly stated rationale for the conclusions reached, must be provided. 5. After completing the requested actions, and any additional notification and/or development deemed warranted, adjudicate the service connection and TDIU claims remaining on appeal considering all pertinent evidence (to include all evidence added to the electronic claims file since the last adjudication) and legal authority. MICHAEL MARTIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Wimbish, 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.