Citation Nr: 21025452 Decision Date: 04/28/21 Archive Date: 04/28/21 DOCKET NO. 17-39 710A DATE: April 28, 2021 ORDER Entitlement to service connection for the Veteran’s cause of death is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Air Force from May 1963 to November 1966, June 1982 to December 1982, and February 2003 to December 2003. This matter returns to the Board of Veterans’ Appeals (Board) after a Mach 2020 Board decision remanded the matter of service connection for the Veteran’s cause of death for further development. The Board finds that the March 2020 remand directives were not substantially complied with and the matters must be remanded again. See Stegall v. West, 11 Vet. App. 268 (1998). The Appellant contends that the Veteran’s cause of death was due to disorders incurred in active service or, in the alternative, caused or aggravated by his service-connected skin cancer. Specifically, the Appellant contends that the Veteran’s clival chordoma began during service, and that had proper imaging been conducted in 2003 the mass could have been found. The Appellant also contends that the treatment for the Veteran’s service-connected chronic, aggressive skin cancer affected his immune system and impaired his body’s ability to fight off infections, such as meningitis. She contends that the Veteran developed meningitis due to multiple surgeries around his head and neck that he had undergone, most of which were for skin cancer. In March 2020, the Board remanded the claim to obtain a VA opinion to address the Appellant’s contentions. A May 2020 VA examination report provided an opinion regarding the Veteran’s clival chordoma. The May 2020 VA examiner opined that clival chordoma is a type of bone cancer and is not in any way etiologically related to a brain tumor or the nervous system. Therefore, the examiner determined that the disorder is not an organic disease of the nervous system. The examiner further opined that the clival chordoma, which was found in February 2005, less likely than not had its onset during the Veteran’s service from February 2003 to December 2003, or within one year of separation from that service. After providing an explanation regarding how clival chordoma develops and its origins, the examiner highlighted that the Veteran’s tumor was large at the time of the diagnosis in 2005. The examiner opined that because chordoma is a relatively slow growing tumor, and considering the size at diagnosis 2005, it was more likely than not present long before his 2003 deployment. The Board finds that May 2020 VA opinion inadequate to decide this matter because it based on contradictory conclusions, does not adequately address all aspects of the contentions raised, and is not supported by sufficient rationale. Specifically, the Board notes that the Veteran’s service records do not reflect a diagnosis or findings of clival chordoma prior to his 2003. Thus, the Veteran is presumed to have been sound at the time of his active service in 2003. The May 2020 opinion, however, does not adequately address whether there is clear and unmistakable evidence to rebut this presumption (the correct legal standard when assessing claims involving preexisting conditions) or address whether the Veteran’s clival chordoma may have been present during an even earlier period of active service. Moreover, the examiner’s discussion opens the possibility the clival chordoma could have its onset during the Veteran’s earlier periods of service. Although the examiner noted that the condition is a relatively slow growing tumor, the examiner did not specify how slowly the condition develops or if such a rate of growth could be used to bookend the earliest onset date. As such, the examiner has raised the question of whether the tumor preexisted service of could have had its onset date during one of the Veteran’s earlier periods of active service. Therefore, an addendum opinion must be obtained to address these shortfalls. The matters are REMANDED for the following action: 1. Obtain an expert medical opinion from an oncologist to address the cause of the Veteran’s death. The examiner is to be provided access to the Veteran’s entire electronic claims file and should specify in the report that these records have been reviewed. The examiner must then address: (a.) Is there clear and unmistakable evidence that the Veteran’s clival chordoma preexisted any period of active duty service, specifically from May 1963 to November 1966, June 1982 to December 1982, and February 2003 to December 2003? In addressing the onset of the condition, the examiner is asked to consider and discuss the May 2020 examiner’s comments that clival chordoma is a slow growing tumor and, if possible, discuss the growth rate of the disease, as applicable to the facts of the present claim. In other words, the examiner must address if the rate of growth of the Veteran’s clival chordoma can be used to determine the approximate onset date. (b.) If clival chordoma preexisted any period of active service, the examiner is asked to opine whether there is clear and unmistakable evidence that the preexisting disease did not permanently increase in severity as a result of any subsequent period of active service. The examiner must identify the medical facts and principles used to determine whether the increase (if there is one) is due to service or the natural progression of the condition. (c.) If the Veteran’s clival chordoma is not found to have clearly and unmistakably had its onset prior to a period of active service, is it as likely as not (a fifty percent probability or greater) that the Veteran’s clival chordoma had its onset during any of the Veteran’s periods of active service, including from May 1963 to 1966, June 1982 to December 1982, or February 2003 to December 2003, or within one year of separation of any of these periods? (d.) In providing the requested the opinions, the examiner must consider and discuss any conflicting medical evidence or opinions of record A complete and fully explanatory rationale must be provided for any opinion offered. If any opinion cannot be rendered without resorting to speculation, the examiner must provide an explanation why one cannot be provided. In this case, the examiner must clearly state that (1) the examiner considered all procurable and assembled data before stating that an opinion cannot be reached and (2) the examiner must explain the basis for his or her conclusion that a non-speculative opinion cannot be offered. The statement that an opinion cannot be provided without resort to speculation must be based on a lack of knowledge among the “medical community at large” and not a limitation of the individual examiner, be it based on lack of expertise, insufficient information, or unprocured testing. DELYVONNE M. WHITEHEAD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Boushehri, Darjush M. 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.