Citation Nr: 21026402 Decision Date: 05/03/21 Archive Date: 05/03/21 DOCKET NO. 16-27 292 DATE: May 3, 2021 REMANDED Entitlement to service connection for an intestine condition, to include as due to exposure to herbicide agents and/or exposure to contaminated water at Camp Lejeune, is remanded. Entitlement to service connection for internal bleeding, to include as due to exposure to herbicides and/or exposure to contaminated water at Camp Lejeune, is remanded. Entitlement to service connection for blood in stool, to include as due to exposure to herbicides and/or exposure to contaminated water at Camp Lejeune, is remanded. Entitlement to service connection for acid reflux (claimed as stomach condition), to include as due to exposure to herbicides and/or exposure to contaminated water at Camp Lejeune, is remanded. Entitlement to service connection for bone disease, to include as due to exposure to herbicides and/or exposure to contaminated water at Camp Lejeune, is remanded. REASONS FOR REMAND The Veteran served on active duty in the Marine Corps from July 1969 to July 1971. This case comes before the Board of Veterans' Appeals (Board) on appeal from the February 2015 and August 2015 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO). These matters were previously before the Board in October 2018, where they were remanded for additional development. The Board notes that there was substantial compliance with its October 2018 remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998); D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). However, regrettably, the Board finds that another remand is necessary prior to readjudication of the claims. As an initial matter, the Board notes that the VA has conceded to the Veteran's exposures to contaminated water at Camp Lejeune and the herbicide agent, Agent Orange, based on the Veteran's military personnel records reflecting verified service at Camp Lejeune and in the vicinity of the Republic of Vietnam during the applicable periods. See SOC, May 2016; see also BVA Decision, October 2018. 1. Entitlement to service connection for an intestine condition, to include as due to exposure to herbicide agents and/or exposure to contaminated water at Camp Lejeune, is remanded. 2. Entitlement to service connection for internal bleeding, to include as due to exposure to herbicides and/or exposure to contaminated water at Camp Lejeune, is remanded. 3. Entitlement to service connection for blood in stool, to include as due to exposure to herbicides and/or exposure to contaminated water at Camp Lejeune, is remanded. 4. Entitlement to service connection for acid reflux (claimed as stomach condition), to include as due to exposure to herbicides and/or exposure to contaminated water at Camp Lejeune, is remanded. The Veteran contends that his overall stomach and intestine conditions are directly related to his active duty service, to include his conceded exposures to herbicides and/or contaminated water at Camp Lejeune. After review of the record, the Board finds that further development of the medical evidence is necessary before adjudicating the claims, in accordance with VA's duty to assist. In September 2019, the Veteran was afforded VA examinations to assess the current nature and etiology of his claimed conditions. The examiner diagnosed the Veteran with the following stomach and intestinal conditions: gastric ulcer, duodenal ulcer, gastrointestinal reflux disease (GERD), internal hemorrhoids, and constipation. The examiner then provided an unfavorable nexus opinion as to all of these conditions being etiologically related to the Veteran's active duty service, to include exposure to contaminated water at Camp Lejeune. The examiner rationalized that the Veteran's service treatment records (STRs) do not support any diagnoses, visits, signs or symptoms for these conditions; as well as, there being no established relationship based on presumptive service connection between water contamination at Camp Lejeune and the Veteran's conditions. See C&P Exam, September 2019. Nevertheless, the Board finds the September 2019 VA medical opinion to be inadequate for adjudicative purposes, as the examiner improperly relied on the lack of specific medical evidence corroborating complaints, treatments, symptoms, or diagnoses of the conditions as the primary basis for providing the unfavorable opinion. Additionally, while the examiner partially relied on the lack of established relationship between the Veteran's conditions and his exposure to contaminated water at Camp Lejeune to warrant service connection on a presumptive basis, the examiner failed to consider and/or discuss the possible relationship on a direct basis. The examiner also failed to provide any opinion and/or discussion of a possible relationship between the Veteran's conditions and his conceded exposure to herbicides. Furthermore, the Veteran indicated that his stomach and/or intestinal conditions could be related an in-service injury in which he was punched, kicked, and hit with the butt of a M-14 and M-16 rifle and was not allowed to go to sick call for treatment (see Form 9, June 2016). The VA examiner also failed to address this contention in his opinion. Therefore, based on the above, the Board finds that the Veteran should be provided an addendum VA medical opinion that adequately addresses the Veteran's contentions, prior to re-adjudication of the claims. Accordingly, a remand is necessary to address the matters discussed above. 5. Entitlement to service connection for bone disease, to include as due to exposure to herbicides and/or exposure to contaminated water at Camp Lejeune, is remanded. The Veteran contends that his current bone disease is directly related to his active duty service, to include his conceded exposures to herbicides and/or contaminated water at Camp Lejeune. After review of the record, the Board finds that further development of the medical evidence is necessary before adjudicating the claim, in accordance with VA's duty to assist. In September 2019, the Veteran was afforded a VA bone examination to assess the current nature and etiology of his claimed condition. Upon examination, the examiner diagnosed the Veteran with Paget's disease in remission; however, provided an unfavorable opinion as to this condition being etiologically related to the Veteran's active duty service, to include exposure to contaminated water at Camp Lejeune. The examiner rationalized that the Veteran does not have bone cancer (in referencing the diagnosis of enchondroma shown in the record), and noted that there was no established relationship based on presumptive service connection between water contamination at Camp Lejeune and the Veteran's Paget's disease. See C&P Exam, September 2019. The Board finds the September 2019 VA medical opinion to be inadequate for adjudicative purposes, as the examiner relied solely on the lack of established relationship between the Veteran's condition and his exposure to contaminated water at Camp Lejeune to warrant service connection on a presumptive basis, without further consideration and/or discussion of the possible relationship on a direct basis. Additionally, the examiner failed to provide any opinion and/or discussion of a possible relationship between the Veteran's condition and his conceded exposure to herbicides. Furthermore, the Board notes that the examiner provided an extensive overview of Paget's disease and its possible causes, noting in most cases that environmental factors play a role. However, the examiner failed to actually discuss whether the Veteran's specific environmental factors (exposure to contaminated water and/or herbicides during active service) was an etiological cause of the claimed condition. Therefore, based on the above, the Board finds that the Veteran should be provided an addendum VA medical opinion that adequately addresses the Veteran's claim. Accordingly, a remand is necessary. The matters are REMANDED for the following action: 1. Request the Veteran to identify all medical providers (VA and private) from whom he has received treatment for his bone disease, stomach conditions, and intestinal conditions, and obtain any outstanding records and associate them with the Veteran's claims file. 2. After associating all newly acquired records with the claims file, send the claims file back to the September 2019 VA examiner to provide the Veteran with addendum VA medical opinions to determine the nature and etiology of the Veteran's claimed conditions. If the September 2019 VA examiner is not available, obtain the necessary addendum opinions from another appropriate clinician. The entire claims file, including a copy of this remand, must be made available to the examiner, and note review of the record in the examination report. Any indicated tests or studies should be performed, and all material relevant evidence should be discussed. All pertinent medical complaints, symptoms, and clinical findings must be reported in detail. The Veteran should be scheduled for another examination if deemed necessary by the person providing the addendum report to address the following: (a) Opine whether it is at least as likely as not (50 percent or greater probability) that any of the Veteran's claimed stomach and intestinal conditions (diagnosed as gastric ulcer, duodenal ulcer, gastrointestinal reflux disease (GERD), internal hemorrhoids, and constipation) had their onset during any period of active duty service, or are otherwise etiologically related to his active duty service, to include the incident of being punched, kicked, and hit with the butt of a M-14 and M-16 rifle during service and/or the conceded exposures to herbicides and/or contaminated water at Camp Lejeune. Please note: the examiner must provide an opinion as to each diagnosed condition, as it relates to the Veteran's active duty service and each conceded exposure. The examiner cannot rely on the Veteran's diagnoses not being diseases listed for presumptive service connection as a basis for an unfavorable opinion. (b) Opine whether it is at least as likely as not (50 percent or greater probability) that the Veteran's bone disease (diagnosed as Paget's disease and enchondroma) had its onset during any period of active duty service, or is otherwise etiologically related to his active duty service, to include the conceded exposures to herbicides and/or contaminated water at Camp Lejeune. Please note: the examiner must provide an opinion as to each diagnosed condition, as it relates to the Veteran's active duty service and each conceded exposure. The examiner cannot rely on the Veteran's diagnoses not being diseases listed for presumptive service connection as a basis for an unfavorable opinion. (c) Any opinion should include a detailed rationale. The examiner should consider the entire claims file, and discuss the Veteran's lay statements regarding the nature, onset, and chronicity of symptoms. The examiner is advised that the Veteran is competent to report symptoms, and that his reports must be considered in formulating the requested opinion. (d) If the examiner is unable to offer the requested opinion, it is essential that the examiner offer a rational for the conclusion that an opinion could not be provided without resorting to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. Katherine Kiemle Buckley Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Hodges, 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.