Citation Nr: 21026505 Decision Date: 05/03/21 Archive Date: 05/03/21 DOCKET NO. 13-27 517 DATE: May 3, 2021 REMANDED Entitlement to service connection for a liver disability, to include as due to herbicide exposure and/or secondary to service-connected PTSD, for accrued benefits purposes is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1964 to September 1967; and died in May 2011. The appellant is the Veteran's widow. This case comes before the Board of Veterans' Appeals (Board) on appeal from a December 2016 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania. This matter was previously before the Board in September 2016 and May 2017, where it was remanded for further development; and in September 2017, where the claim was denied. The appellant appealed the September 2017 Board's decision to the United States Court of Appeals for Veterans Claims (CAVC), resulting in an April 2019 Memorandum Decision, which vacated the September 2017 Board decision with respect to only the issue listed above. In August 2019 and in August 2020, the Board remanded this issue for further development. The Board notes that there was not substantial compliance with its August 2020 remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998); D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). Entitlement to service connection for a liver disability, to include as due to herbicide exposure and/or secondary to service-connected PTSD, for accrued benefits purposes is remanded. The appeal has been remanded by the Board on multiple occasions, most recently in August 2020. Unfortunately, a remand is required once again. The Board notes that there was not substantial compliance with its August 2020 remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998); D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). The Board remanded the appellant's claim for further development, requesting that a VA medical opinion be provided to address whether the Veteran's heavy alcohol use/abuse was caused and/or aggravated by his service-connected PTSD, as a possible intermediary step to the Veteran's liver disability. In the requested opinion, the examiner was specifically advised that he "must address both causation and aggravation." See August 2020 remand. The examiner issued an addendum opinion in December 2020, in response to the August 2020 remand, wherein he opined that it is less likely than not that the Veteran's claimed alcohol abuse was caused by and/or aggravated (beyond the natural progression) by his service-connected PTSD. Pertinently, the examiner reasoned that his medical opinion is based upon the review of the claims file including medical records, the Board remand, the Veteran's death certificate which noted that the Veteran was 64 years old at time of death, Metastatic Spindle Cell Cancer as to cause of death, the fact that no other contributory conditions were noted on the certificate, and the fact that the Veteran's death certificate described the Veteran's death as "Natural". The Board agrees with the February 2021 arguments of the Appellant's representative and finds the examiner's rationale to be entirely unresponsive to the remand instructions. To wit, there is not a single reference in the examiner's rationale as to the relationship between PTSD and alcohol abuse, and between alcohol abuse and the Veteran's liver disease. In fact, the examiner copied the November 2016 VA examination and opinion in its entirety which was previously found inadequate for adjudication purposes. The Board underlines that the Veteran's liver disease is not claimed as his cause of death. Rather, the requested opinion was for service connection for accrued purposes claimed on a secondary basis to service-connected PTSD with alcohol abuse as an intermediary step. The addendum opinion must be responsive to this question. In addition, the Board acknowledges the relevant evidence associated to the record by the Appellant, including her own statement of January 2021 testifying as to the Veteran's longstanding and frequent, daily alcohol abuse; as well as medical research indicative of a causal relationship between alcohol abuse disorder and PTSD. These must be considered by the examiner and addressed in the formulation of any etiological opinion. For these reasons, the appeal must be remanded once again. See Stegall v. West, 11 Vet. App. 268 (1998). The matters are REMANDED for the following action: 1. Obtain and associate any outstanding VA and private treatment records relating to the Veteran's liver disability and associate them with the Veteran's claims file. 2. Thereafter, forward the claims file, including a copy of this remand, to an appropriately qualified VA clinician to determine the etiology of the Veteran's liver disability. The entire claims file must be made available to the examiner, and the examiner must note review of the record in the examination report. All material relevant evidence should be discussed. All pertinent medical complaints, symptoms, and clinical findings must be reported in detail. Following complete review of the record, the examiner must: (a) opine whether it is at least as likely as not (50 percent or greater probability) that the Veteran's alcohol abuse was caused by his service-connected PTSD; (b) opine whether it is at least as likely as not (50 percent or greater probability) that the Veteran's alcohol abuse was aggravated (beyond the natural progression) by his service-connected PTSD; (c) and, if so, whether his liver disorder is at least as likely as not (50 percent or greater probability) caused by and/or aggravated (beyond the natural progression) by his alcohol abuse. Please note: the examiner must address both causation and aggravation in providing the opinion(s) requested above. Additionally, the examiner must reconcile and/or clarify whether an objective diagnosis of alcoholic liver disease is needed for there to be a causal relationship between the Veteran's liver disability and his alcohol use/abuse, or whether merely consuming alcohol is enough. 3. Any opinion must include a detailed rationale. The examiner should consider the entire claims file and discuss the Veteran's and appellant's lay statements regarding the nature and onset of symptoms. The examiner is advised that the Veteran and appellant are competent to report symptoms, and that her/his reports must be considered in formulating the requested opinion. The examiner must also address the medical research evidence of record, including articles entitled "The Epidemiology of Post-Traumatic Stress Disorder and Alcohol Use Disorder"; and "Alcohol Alert" from the National Institute on Alcohol Abuse and Alcoholism. 4. If the examiner(s) is unable to offer the requested opinion(s), it is essential that the examiner offer a rationale 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. See Jones v. Shinseki, 23 Vet. App. 382. (2010). T.D. JONES Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Comninos, Georgio 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.