Citation Nr: 21026514 Decision Date: 05/03/21 Archive Date: 05/03/21 DOCKET NO. 14-34 160A DATE: May 3, 2021 REMANDED Entitlement to service connection for breast cancer, to include as due to exposure to toxins, is remanded. Entitlement to service connection for diabetes mellitus, type II, is remanded. Entitlement to service connection for glaucoma, to include as secondary to diabetes mellitus, type II, is remanded. REASONS FOR REMAND The Veteran had honorable active duty service with the United States Air Force from March 1988 to August 1997. The instant matter is on appeal from a December 2010 rating decision. The Board previously remanded this issue in November 2018 to afford the Regional Office (RO) an opportunity to readjudicate these issues following submission of new evidence from the Veteran. Although the further delay entailed by remand is regrettable, current adjudication of the Veteran's claims would be premature. Undertaking additional development prior to a Board decision is the only way to ensure compliance with the duty to assist, as required. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. 1. Entitlement to service connection for breast cancer, to include as due to exposure to toxins, is remanded. The Veteran contends that she is entitled to service connection for breast cancer, to include as due to ionizing radiation and exposure to other toxins. Personnel records list the Veteran's military occupation as air transportation journeyman. Performance evaluations, dated March 1988 through October 1992, indicate that the Veteran was responsible for inspecting and preparing cargo and aircraft loads, handling equipment for loading, and maintaining safety and security precautions regarding hazardous, sensitive, and classified shipments. In June 1991, an occupational health examination noted that log air shop personnel were likely exposed to occupational hazards including carbon monoxide, anti-icing agents, and diesel fuel gases. Service treatment records show that the Veteran underwent numerous physical examinations, to include gynecological evaluations. Although normal physical findings were documented at enlistment in June 1987, beginning on or about 1991, the Veteran frequently complained of gynecological symptoms. Specifically, the record confirms that the Veteran was granted a physical profile due to pregnancy from November 1991 through June 1992. Reportedly, she suffered a miscarriage in 1991, followed by a live birth in 1992. In October 2008, the Veteran submitted a radiation risk activity worksheet where she reported exposure to radiation and chemical solvents; aircraft and vehicle maintenance chemicals, fuels, and oils within the scope of performing her official duties. In response to a direct inquiry, the Department of the Air Force submitted a memorandum regarding occupational radiation exposure in April 2010. The findings indicated that a search of the master radiation exposure registry found no evidence that the Veteran's official duties involved working directly with or near nuclear weapons or related components. Therefore, no dosage assessment or estimation was provided. Post-service treatment records show that the Veteran underwent an annual mammography examination in February 2003. Diagnostic imaging revealed the presence of a well-demarcated nodule, measuring at 10 millimeters (mm) in the right upper-outer quadrant of the right breast. A smaller nodule, measuring at 6 by 8 mm was also observed. Further evaluation via ultrasound was recommended. In April 2003, a biopsy of the right breast documented a tumor measuring at 10 by 4.5 by 1.5 centimeters (cm). A diagnosis of infiltration ductal carcinoma, grade III, impacting the right beast was indicated. Thereafter, a lumpectomy and related reconstructive surgery was performed. Subsequent periodic examinations document complaints of residual symptoms in the right breast and new calcifications in the left breast. In June 2009, a diagnosis of endometriosis was suggested. On review of the record, the Board observes that the Veteran has not been afforded a VA examination. In determining whether the duty to assist requires that a VA medical examination be provided, or medical opinion obtained with respect to a veteran's claim for benefits, there are four factors for consideration: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain diseases manifesting during an applicable presumption period; (3) whether there is an indication that the disability or symptoms may be associated with the veteran's service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. See McLendon v. Nicholson, 20 Vet. App. 79 (2006); 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). With respect to the third factor above, the Court of Appeals for Veterans Claims has stated that this element establishes a low threshold and requires only that the evidence "indicates" that there "may" be a nexus between the current disability or symptoms and the veteran's service. In this case, the Board observes that the Veteran reported exposure to multiple toxins in service. Although her exposure to ionizing radiation has not been established, the record confirms likely exposure to toxins including aircraft engine fumes and other chemicals. Considering the above, the Board finds that a VA examination is required. 2. Entitlement to service connection for diabetes mellitus, type II, is remanded. The Veteran contends that she is entitled to service connection for diabetes mellitus, type II, as either directly related to service, or secondarily related to her service-connected acquired psychiatric disorder. Service treatment records confirm normal physical findings at enlistment in June 1987. Urinalysis findings were negative for the presence of sugar. Periodic physical fitness and weight evaluation records indicate that the Veteran met military weight requirements from June 1989 through January 1991. During that period, her weight ranged from 146 pounds (lbs.) to 160 lbs. However, after giving birth in late 1991 early 1992, the Veteran's weight was recorded as 199 lbs. in June 1993. Thereafter, her weight ranged between 190-200 lbs. Despite referral to a weight management program, the Veteran continued to struggle with her weight. Multiple official reprimands were issued due to her failure to maintain weight-related standards. In January 1996, the Veteran was evaluated for irregular menstrual cycles. During the clinical interview, she reported increasing work-related stressors, a recent death in the family and concern regarding her husband's deployment overseas. Her treating physician advised her to avoid forms of contraception that were likely cause hormonal fluctuations. Other medical records document a body mass index consistent with obesity. A field medical record indicates that the Veteran was assessed for a possible eating disorder in August 1996. During the clinical interview, the Veteran reported weight management struggles, purging, binging, and use of laxatives. In June 1997, a family practice clinical record notes an evaluation for extreme distress due to unsatisfactory progress with a required weight management program. The Veteran reported current symptoms including depression, suicidal thoughts, and an unstable mood. Possible diagnoses were listed as adjustment disorder with a depressed mood and a personality disorder not otherwise specified. Post-service treatment records list diagnoses of diabetes mellitus, type II, and pre-glaucoma around August 2004. In multiple lay statements, the Veteran asserted that bloodwork suggested that she was pre-diabetic during her period of active service. In analyzing the Veteran's claim, the Board observes that she was described as "obese" in service treatment records. Occupational stress, depression, and anxiety due to her failure to meet military weight requirements were suggested as additional factors in the Veteran's struggles with weight. Considering the above, the Board recognizes that service connection may be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. See 38 C.F.R. § 3.310 (a); Harder v. Brown, 5 Vet. App. 183, 187 (1993). Additional disability resulting from the aggravation of a nonservice-connected condition by a service-connected condition is also compensable under 38 C.F.R. § 3.310 (b). See Allen v. Brown, 7 Vet. App. 439, 448 (1995). The Board notes that obesity is not a disease for which service connection can be granted; however, obesity can be considered an "intermediate step" in determining whether secondary service connection is warranted. See VAOPGCPREC 1-2017. In order for obesity or weight gain to qualify as that intermediate step, it must be determined whether: (1) the service-connected disability caused or aggravated the Veteran's obesity; (2) the obesity as a result of the service-connected disability, or, the aggravation of the obesity gain as a result of the service-connected disability was a substantial factor in causing the claimed disability; and (3) the claimed disability would not have occurred but for the obesity caused or aggravated by the service-connected disability. See VAOPCGPREC 1-2017 (Jan. 6, 2017); Walsh v. Wilkie, No. 18-0495 (Vet. App. Feb. 24, 2020). Review of the record indicates that the Veteran was granted service-connection for depression. As the record suggests interplay between the Veteran's weight struggles, obesity, depression, and diabetes mellitus, type II, the Board finds that a VA examination is required. 3. Entitlement to service connection for glaucoma, to include as secondary to diabetes mellitus is remanded. The Veteran contends that she is entitled to service connection for glaucoma, to include as secondary to diabetes mellitus, type II. Review of service treatment records show that the Veteran suffered from defective visual acuity at enlistment. Due to correction of the observed refractive error with use of contact lenses or glasses, she was deemed qualified for active service. However, during subsequent optometry evaluations, the Veteran reported blurred vision. In December 1988, a color vision medical review revealed normal findings. One year later, in December 1989, an optometry examination revealed evidence of myopia and astigmatism, bilaterally. The Veteran's prescribed corrective lenses were changed. Antibiotic eye-drops were also noted. In September 1992, the Veteran's bilateral myopia and astigmatism were described as stable. Post-service treatment records listed pre-glaucoma as a current condition in 2004. In January 2015, an optometry note acknowledged a prior history of treatment for bilateral glaucoma, refractive error, and hyperpigmentation. Subsequent treatment records reflect a diagnosis of, and treatment for, glaucoma, as well as a family history of the disability. Review of the record indicates that the Veteran was afforded a VA examination in July 2010. Although the examiner acknowledged a suggestion of glaucoma during service, the condition was not formally diagnosed at the time of the examination. The Veteran has since been diagnosed with glaucoma. Evidence of record also suggests a correlation between the Veteran's diabetes mellitus, type II, and her glaucoma. Thus, remand is necessary in order to obtain a more thorough VA examination addressing the etiology of her glaucoma. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination with an appropriate clinician to determine the nature and etiology of the Veteran's breast cancer. The examination may be conducted via telehealth, if practicable. The entire claims file and a copy of this remand should be made available to the examiner for review, and such review should be noted in the examination report. Following a review of the medical and lay evidence of record, the examiner should provide an opinion as to the following: (a.) Is it at least as likely as not (50 percent or greater probability) that the Veteran's breast cancer began during active service, within one year of discharge, or is otherwise related to active duty service? (b.) Specifically discuss the Veteran's assertion of exposure to radiation, engine fuel, solvents, and other toxins during service. Any opinion offered must be accompanied by a thorough rationale, which should reflect consideration of the STRs, medical evidence of record, and lay statements. If any requested opinion cannot be offered without resorting to speculation, the examiner should indicate such in the examination report and explain why a non-speculative opinion cannot be offered. The examiner should also identify what, if any, additional information, or evidence would allow for a more definitive opinion. 2. Schedule the Veteran for a VA examination with an appropriate clinician to determine the nature and etiology of her diabetes mellitus, type II. The examination may be conducted via telehealth, if practicable. The entire claims file and a copy of this remand should be made available to the examiner for review, and such review should be noted in the examination report. Following a review of the medical and lay evidence of record, the examiner should provide an opinion as to the following: (a.) Is it at least as likely as not (50 percent or greater probability) that the Veteran's diabetes mellitus, type II, began during active service, within one year of discharge, or is otherwise related to active duty service? The examiner should discuss the Veteran's post-pregnancy obesity and report of prediabetes during service. (b.) If not, did the Veteran's service-connected acquired psychiatric disorder cause her to become obese? (c.) If so, is the Veteran's obesity a substantial factor in causing or aggravating her diabetes mellitus, type II? (d.) Would the Veteran's diabetes mellitus, type II, have not occurred but for the obesity caused or aggravated by her service-connected acquired psychiatric disorder? In providing the requested opinions, the examiner must consider and discuss all lay assertions of record. The examiner must provide a thorough rationale for all proffered opinions. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 3. Schedule the Veteran for a VA examination with an appropriate clinician to determine the nature and etiology of her claimed eye disability, to include glaucoma. The examination may be conducted via telehealth, if practicable. The entire claims file and a copy of this remand should be made available to the examiner for review, and such review should be noted in the examination report. Following a review of the medical and lay evidence of record, the examiner should provide an opinion as to the following: (a.) Identify any and all disabilities of the eye with which the Veteran is presently diagnosed. (b.) For each identified disability, is it at least as likely as not (50 percent or greater probability) that the identified eye disability began during active service, within one year of discharge, or is otherwise related to active duty service? (c.) If not, is it at least as likely as not (50 percent or greater probability) that the identified eye disability was caused by the Veteran's diabetes mellitus, type II? (d.) If not, is it at least as likely as not (50 percent or greater probability) that the identified eye disability was aggravated by the Veteran's diabetes mellitus, type II? In providing the requested opinions, the examiner must consider and discuss all lay assertions of record. The examiner must provide a thorough rationale for all proffered opinions. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. (Continued on the next page) 4. After completing all indicated development, the Veteran's claim should be readjudicated based on the entirety of the evidence. If the benefit sought on appeal is not granted, the Veteran and her representative should be provided a Supplemental Statement of the Case (SSOC) and afforded the requisite opportunity to respond before the case is returned to the Board. Hannah Fisher Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Whitaker, 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.