Citation Nr: 21025234 Decision Date: 04/27/21 Archive Date: 04/27/21 DOCKET NO. 18-10 793 DATE: April 27, 2021 REMANDED Entitlement to service connection for prostate cancer is remanded. Entitlement to service connection for hypertrophy of the breast, to include as secondary to treatment for prostate cancer, is remanded. Entitlement to service connection for high blood pressure is remanded. Entitlement to service connection for residuals from paralysis of the fourth cranial nerve is remanded. Entitlement to service connection for human immunodeficiency virus (HIV) is remanded. Entitlement to service connection for a heart disability, to include as secondary to prostate cancer, is remanded. Entitlement to service connection for a sleep disorder, to include as secondary to any service-connected disability, is remanded. Entitlement to service connection for arthritis of the shoulders, elbows, hips, knees, ankles, feet, and lumbar spine, to include as secondary to any service-connected disability and/or medications, is remanded. Entitlement to service connection for a bone and cartilage disability, to include as secondary to any service-connected disability and/or medications, is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Air Force from June 1962 to March 1966. In August 2018, the Board denied the issue of a higher initial rating for service-connected hearing loss in the right ear, denied the issues of service connection for hearing loss in the left ear, high cholesterol, and recurrent urinary tract infections, and remanded the remaining issues on appeal for additional evidentiary development. The case has been returned to the Board for appellate review. 1. Entitlement to service connection for prostate cancer In an October 2019 VA medical opinion, the VA examiner concluded that “due to high polymorphism, common sequences, and ubiquitous presence, short tandem repeats (STRs) may enhance genomic typing to determine prostate carcinoma (CaP) predisposition” and that it is “most likely STR lead to prostate cancer.” In an additional October 2019 VA medical opinion, the same VA examiner also addressed a nexus between the Veteran’s prostate cancer and reported in-service asbestos exposure but provided a speculative rationale. Medical evidence that is speculative, general, or inconclusive in nature cannot support a claim. See Obert v. Brown, 5 Vet. App. 30, 33 (1993); see Warren v. Brown, 6 Vet. App. 4, 6 (1993). Additionally, the Board notes that malignant neoplasm of the genitourinary system, which contemplates prostate cancer, is listed among the chronic diseases listed under 38 C.F.R. § 3.309(a). During the course of this appeal, the Veteran asserted in the November 2014 VA Form 21-4138 to having continuous symptoms of pain related to his claim for prostate cancer since service. When VA undertakes to provide a VA medical opinion, it must ensure that the opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). As such, the Board finds that an additional VA medical opinion on direct and chronic disease presumption bases is needed to clarify the etiology of the Veteran’s prostate cancer. 2. Entitlement to service connection for hypertrophy of the breast, to include as secondary to treatment for prostate cancer While the Board remands the issue of entitlement to service connection for prostate cancer for additional evidentiary development, as discussed above, that decision may impact this claim for hypertrophy of the breast on a secondary basis. As such, these issues are inextricably intertwined. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). 3. Entitlement to service connection for high blood pressure 4. Entitlement to service connection for residuals from paralysis of the fourth cranial nerve 5. Entitlement to service connection for HIV 6. Entitlement to service connection for a heart disability, to include as secondary to prostate cancer 7. Entitlement to service connection for a sleep disorder, to include as secondary to any service-connected disability 8. Entitlement to service connection for arthritis of the shoulders, elbows, hips, knees, ankles, feet, and lumbar spine, to include as secondary to any service-connected disability and/or medications 9. Entitlement to service connection for a bone and cartilage disability, to include as secondary to any service-connected disability and/or medications Due to the similar dispositions for these claims on appeal, the Board will address them in a common discussion below. Pursuant to the August 2018 remand directives, a request was made in September 2019 for the Veteran to undergo VA examinations for hypertension, cranial nerves, HIV-related illness, heart conditions, sleep apnea, and back conditions in connection with these claims on appeal. In October 2019, these examination requests were cancelled due to the Veteran’s failure to proceed with the scheduling and to report. Nevertheless, in an August 2020 correspondence, the Veteran reported he has never refused any scheduled VA examination. In this case and in the light most favorable to the Veteran, the Board finds that an additional attempt should be made to schedule him for these identified VA examinations. The Veteran is hereby notified that it is his responsibility to report for the scheduled examinations and to cooperate in the development of his claims. Under VA regulations, when a claimant fails to report for a VA examination or re-examination that is scheduled in conjunction with an original claim, and fails to provide good cause for this failure to report, the claim shall be decided based on the evidence of record. See 38 C.F.R. § 3.655 (2020). 10. Entitlement to a TDIU While the Board remands the issues of entitlement to service connection for the disorders listed above for additional evidentiary development, those decisions may impact this claim for TDIU. As such, these issues are inextricably intertwined. See Harris, 1 Vet. App. at 183. The matters are REMANDED for the following actions: 1. The Veteran is hereby notified that it is his responsibility to report for the scheduled examinations and to cooperate in the development of his claims. The consequence for failure to report for any VA examination without good cause for an original claim may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2020). 2. Return the Veteran’s claims file to the examiner who provided the October 2019 VA medical opinions for prostate cancer so a supplemental opinion may be provided. If that examiner is no longer available, provide the Veteran’s claims file to a similarly qualified clinician. The entire claims file and a copy of this remand must be made available to the examiner for review. A new examination is only required if deemed necessary by the examiner. The examiner must provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s prostate cancer (a) began during active service, (b) is related to an incident of service, to include reported asbestos exposure, or (c) began within one year after discharge from active service, to include consideration of the Veteran’s reported continuous symptoms of pain since service (noted in the November 2014 VA Form 21-4138). The examiner must provide all findings, along with a complete rationale for his or her opinions 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 conclusion. 3. Then, reschedule the Veteran for an examination (physical or telehealth) with an appropriate clinician for his high blood pressure. The entire claims file and a copy of this remand must be made available to the examiner for review. The examiner must provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s current diagnosis of hypertension began during active service, is related to an incident of service, or began within one year after discharge from active service. 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 conclusion. 4. Reschedule the Veteran for an examination (physical or telehealth) with an appropriate clinician for his residuals from paralysis of the fourth cranial nerve. The entire claims file and a copy of this remand must be made available to the examiner for review. Although an independent review of the claims file is required, the Board calls the examiner’s attention to the following: Review of medical records in the claims file shows the following diagnoses: right cranial nerve 4 palsy (idiopathic in September 2009 and resolved by July 2017) and myasthenia gravis in September 2010. The examiner must provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s disability (diagnosed as right cranial nerve 4 palsy and myasthenia gravis, even if since resolved) began during active service or is related to an incident of service. 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 conclusion. 5. Reschedule the Veteran for an examination (physical or telehealth) with an appropriate clinician for his HIV. The entire claims file and a copy of this remand must be made available to the examiner for review. The examiner must provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s HIV disability (diagnosed in December 2002) began during active service or is related to an incident of service. 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 conclusion. 6. Reschedule the Veteran for an examination (physical or telehealth) with an appropriate clinician for his heart disability. The entire claims file and a copy of this remand must be made available to the examiner for review. Although an independent review of the claims file is required, the Board calls the examiner’s attention to the following: Review of medical records in the claims file shows the following diagnoses: ischemia, mitral valve prolapse, and mild concentric left ventricle hypertrophy. The examiner must provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s heart disability (diagnosed as ischemia, mitral valve prolapse, and mild concentric left ventricle hypertrophy, even if since resolved) began during active service, is related to an incident of service, or began within one year after discharge from active service. 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 conclusion. 7. Then, reschedule the Veteran for an examination (physical or telehealth) with an appropriate clinician for his sleep disorder. The entire claims file and a copy of this remand must be made available to the examiner for review. The examiner must opine as to the following: (a.) Whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s current diagnosis of a sleep disorder began during active service or is related to an incident of service. (b.) Whether it is at least as likely as not that the Veteran’s current diagnosis of a sleep disorder was proximately due to or the result of any service-connected disability. (c.) Whether it is at least as likely as not that the Veteran’s current diagnosis of a sleep disorder disability was aggravated beyond its natural progression by any service-connected disability. (d.) Note - the Veteran’s service-connected disabilities include bilateral hearing loss and tinnitus. 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 conclusion. 8. Reschedule the Veteran for an examination(s) (physical or telehealth) with an appropriate clinician for arthritis and bone and cartilage disability. The entire claims file and a copy of this remand must be made available to the examiner for review. Although an independent review of the claims file is required, the Board calls the examiner’s attention to the following: Review of medical records in the claims file shows the following diagnoses: metastatic disease in the sacroiliac joint, left inferior pubic ramus on bone scans, and osteopenia The examiner must opine as to the following: (a.) Identify any additional current disability of the following joints: shoulders, elbows, hips, knees, ankles, and feet. (b.) Identify any current disability of the lumbar spine. (c.) Whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s disability of the joints (including metastatic disease in the sacroiliac joint) began during active service, is related to an incident of service, or if symptoms of arthritis began within one year after discharge from active service. (d.) Whether it is at least as likely as not that the Veteran’s disability of the lumbar spine began during active service, is related to an incident of service, or if symptoms of arthritis began within one year after discharge from active service. (e.) Whether it is at least as likely as not that the Veteran’s disability of a bone or cartilage disability (including left inferior pubic ramus on bone scans, and osteopenia) began during active service, is related to an incident of service, or if symptoms of arthritis began within one year after discharge from active service. (f.) Whether it is at least as likely as not that the Veteran’s joint, spine, or bone and cartilage disability was proximately due to or the result of any service-connected disability and/or medications. (g.) Whether it is at least as likely as not that the Veteran’s joint, spine, or bone and cartilage disability was aggravated beyond its natural progression by any service-connected disability and/or medications. (h.) Note – the Veteran’s service-connected disabilities include bilateral hearing loss and tinnitus. 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 conclusion. 9. Then, review all examination reports and medical opinions provided to ensure that the requested information was provided. If any report or opinion is deficient in any manner, the agency of original jurisdiction (AOJ) must implement corrective procedures. (Continued on the next page)   10. Then, readjudicate the claims. If any decision is adverse to the Veteran, issue a Supplemental Statement of the Case and allow the applicable time for response. Then, return the case to the Board. D. Martz Ames Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Carter, 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.