Citation Nr: 21027841 Decision Date: 05/07/21 Archive Date: 05/07/21 DOCKET NO. 16-50 182 DATE: May 7, 2021 REMANDED Entitlement to service connection for a prostate disability, to include hypertrophy of the prostate, is remanded. Entitlement to service connection for a heart disability, to include supraventricular arrythmia and cardiomyopathy, is remanded. Entitlement to service connection for diabetes mellitus, type II, is remanded. Entitlement to service connection for chronic obstructive pulmonary disease (COPD) is remanded. Entitlement to service connection for a bilateral eye disability, to include primary open angle glaucoma, is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU), to include extraschedular consideration, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from April 1945 to October 1945. The Veteran died in February 2018. The Appellant is his surviving spouse. In September 2017, the Veteran testified at a videoconference Board hearing before the undersigned Veterans Law Judge. A transcript of the proceeding is associated with the claims file. This case was previously remanded in March 2019 for further development. 1. Entitlement to service connection for a prostate disability Pursuant to the March 2019 Board remand, a medical opinion was obtained in April 2020. The examiner opined that the Veteran's prostate disability, to include hypertrophy of the prostate, was not at least as likely as not aggravated beyond its natural progression by his service-connected bronchial asthma with mixed restrictive and obstructive lung disease, as there was no objective evidence to support a diagnosis of prostate cancer. As to benign prostatic hyperplasia (BPH), the VA examiner indicated that peer-reviewed medical literature did not support bronchial asthma as a cause or aggravating factor of the disability. An addendum medical opinion was obtained in July 2020. The VA examiner opined that it was less likely than not that the Veteran's prostate disability was incurred in or caused by service. In support of the opinion, the VA examiner cited to and noted that the peer-reviewed medical literature did not support that exposure to dichlorotetrafluoroethane (DDT) as the causative or aggravating agent to a prostate condition. Unfortunately, the Board finds that this opinion does not substantially comply with the Board's March 2019 remand directives. Stegall v. West, 11 Vet. App. 268 (1998); see also Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (affirming that a medical opinion is adequate if it provides sufficient detail so that the Board can perform a fully informed evaluation of the claim). In this regard, although the July 2020 VA examiner opined that the Veteran's prostate disability was not related to service, to include exposure to DDT, she failed to provide sufficient rationale for the finding. Specifically, the medical literature cited by the examiner notes health impacts, to include impacts to reproductive health; however, the VA examiner does not adequately explain how the medical literature supports a negative nexus between the prostate disability and DDT. As to secondary service connection, although the April 2020 VA examiner determined the Veteran's prostate disability was not aggravated beyond its natural progression by his service-connected bronchial asthma with mixed restrictive and obstructive lung disease, she failed opine if the prostate disability was caused by the service-connected bronchial asthma with mixed restrictive and obstructive lung disease. Lastly, the VA examiner cites a June 2019 medical opinion that has not been associated with the Veteran's claims file. Consequently, the Board finds that a remand is necessary to obtain a new opinion relating to the claim of entitlement to service connection for a prostate disability, to include hypertrophy of the prostate, and to associate the outstanding June 2019 VA medical opinion with the claims file. 2. Entitlement to service connection for a heart disability Pursuant to the March 2019 Board remand, a medical opinion was obtained in April 2020. The examiner opined that the Veteran's heart disability, to include supraventricular arrhythmia and cardiomyopathy, was not at least as likely as not aggravated beyond its natural progression by his service-connected bronchial asthma with mixed restrictive and obstructive lung disease. In support of the opinion, the VA examiner stated that the Veteran's asthma diagnosis predated the atrial fibrillation diagnosis; thus, medical evidence did not support such determination. She further noted that the peer-reviewed medical literature did not support bronchial asthma as the cause or aggravating factor for atrial fibrillation and opined that the Veteran's atrial fibrillation was likely due to long history of hypertensive cardiomyopathy. An addendum medical opinion was obtained in July 2020. The VA examiner opined that it was less likely than not that the Veteran's heart disability was incurred in or caused by service. In support of the opinion, the VA examiner cited to and noted that the peer-reviewed medical literature did not support DDT as the causative or aggravating agent to heart condition. Unfortunately, the Board finds that the opinions do not substantially comply with the Board's March 2019 remand directives. Stegall, supra; see also Barr, supra. In this regard, although the July 2020 VA examiner opined that the Veteran's heart disability was not related to service, to include exposure to DDT, she failed to provide sufficient rationale for the finding. Specifically, the medical literature cited by the examiner notes health impacts, to include impacts to include impacts to reproductive health and neurotoxicity; however, the VA examiner does not adequately explain how the medical literature supports a negative nexus between the heart disability and DDT. Moreover, the VA examiner failed to provide sufficient rationale for the finding that the Veteran's atrial fibrillation was likely due to long history of hypertensive cardiomyopathy. As to secondary service connection, although the April 2020 VA examiner determined the Veteran's heart disability was not aggravated beyond its natural progression by his service-connected bronchial asthma with mixed restrictive and obstructive lung disease, she failed opine if the heart disability was caused by the service-connected bronchial asthma with mixed restrictive and obstructive lung disease. Lastly, the VA examiner cites a June 2019 medical opinion that has not been associated with the Veteran's claims file. Consequently, the Board finds that a remand is necessary to obtain a new opinion relating to the claim of entitlement to service connection for a heart disability, to include supraventricular arrhythmia and cardiomyopathy, and to associate the outstanding June 2019 VA medical opinion with the claims file. 3. Entitlement to service connection for diabetes mellitus, type II Pursuant to the March 2019 Board remand, a medical opinion was obtained in July 2020. The VA examiner opined that it was less likely than not that the Veteran's diabetes mellitus was incurred in or caused by service. In support of the opinion, the VA examiner cited to and noted that the peer-reviewed medical literature did not support DDT as a causative or aggravating agent to diabetes mellitus. An addendum medical opinion was obtained in August 2020. The examiner opined that the Veteran's diabetes mellitus, type II, was not at least as likely as not aggravated beyond its natural progression by his service-connected bronchial asthma with mixed restrictive and obstructive lung disease, as there was no evidence in the medical record that the Veteran's diabetes mellitus was aggravated beyond its natural progression by bronchial asthma with mixed restrictive and obstructive lung disease. The VA examiner noted that the medical records indicated the Veteran's diabetes mellitus was controlled on metformin, as he had an A1C of 6.7. Unfortunately, the Board finds that these opinions do not substantially comply with the Board's March 2019 remand directives. Stegall, supra; see also Barr, supra. In this regard, although the July 2020 VA examiner opined that the Veteran's diabetes mellitus was not related to service, to include exposure to DDT, she failed to provide sufficient rationale for the finding. Specifically, the medical literature cited by the examiner notes health impacts, to include impacts to include impacts to reproductive health and neurotoxicity; however, the VA examiner does not adequately explain how the medical literature supports a negative nexus between diabetes mellitus and DDT. As to secondary service connection, although the August 2020 VA examiner determined the Veteran's prostate disability was not aggravated beyond its natural progression by his service-connected bronchial asthma with mixed restrictive and obstructive lung disease, she failed to provide sufficient rationale for the finding. Moreover, she failed to opine if the diabetes mellitus was caused by the service-connected bronchial asthma with mixed restrictive and obstructive lung disease. Consequently, the Board finds that a remand is necessary to obtain a new opinion relating to the claim of entitlement to service connection for diabetes mellitus. 4. Entitlement to service connection for COPD Pursuant to the March 2019 Board remand, a medical opinion was obtained in July 2020. The VA examiner opined that it was less likely than not that the Veteran's COPD was incurred in or caused by service. In support of the opinion, the VA examiner cited to and noted that the peer-reviewed medical literature did not support DDT as a causative or aggravating agent to COPD. Unfortunately, the Board finds that these opinions do not substantially comply with the Board's March 2019 remand directives. Stegall, supra; see also Barr, supra. In this regard, although the July 2020 VA examiner opined that the Veteran's COPD was not related to service, to include exposure to DDT, she failed to provide sufficient rationale for the finding. Specifically, the medical literature cited by the examiner notes health impacts, to include impacts to include impacts to reproductive health and neurotoxicity; however, the VA examiner does not adequately explain how the medical literature supports a negative nexus between COPD and DDT. As to secondary service connection, the VA examiner failed to provide an opinion as to whether the Veteran's COPD was caused or aggravated beyond its natural progression by his service-connected bronchial asthma with mixed restrictive and obstructive lung disease. Consequently, the Board finds that a remand is necessary to obtain a new opinion relating to the claim of entitlement to service connection for COPD. 5. Entitlement to service connection for a bilateral eye disability Pursuant to the March 2019 Board remand, a medical opinion was obtained in July 2019. The examiner opined that the Veteran's eye disability, to include glaucoma, was less likely than not incurred in or caused by service. She further opined that it was less likely than not that the Veteran's glaucoma was caused or aggravated by his exposure to DDT or his service-connected bronchial asthma with mixed restrictive and obstructive lung disease. In support of the opinion, the VA examiner stated that the exact etiology of the Veteran's glaucoma was unknown; however, she noted that the Veteran's disability was consistent with primary open angle glaucoma, which was not caused by other conditions or pathology. Thus, the VA examiner determined that the Veteran's glaucoma was likely a hereditary condition. Unfortunately, the Board finds that this opinion does not substantially comply with the Board's March 2019 remand directives. Stegall, supra; see also Barr, supra. In this regard, the VA examiner failed to provide rationale for the conclusions that the Veteran's eye disability could not be related to service, to include exposure to DDT, or his service-connected bronchial asthma with mixed restrictive and obstructive lung disease. Consequently, the Board finds that a remand is necessary to obtain a new opinion relating to the claim of entitlement to service connection for an eye disability, to include glaucoma. 6. Entitlement to a TDIU Finally, the Veteran's claim of entitlement to a TDIU is inextricably intertwined with the issues addressed above and will be remanded. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that issues are inextricably intertwined and must be considered together when a decision concerning one could have a significant impact on the other). The matters are REMANDED for the following action: 1. Obtain and associate with the claims file the June 2019 prostate and heart conditions VA medical opinions. All efforts to obtain such records should be documented in the claims file. 2. Undertake a records-based medical examination by qualified examiners to address the issues of entitlement to service connection for prostate, heart, and eye disabilities, diabetes mellitus, and COPD. The entire claims file, including a copy of this remand, must be made available to, and be reviewed by, the VA examiner. Following a thorough review of all the medical and lay evidence of record, the examiner should provide an opinion as to the following: (a.) With regard to the prostate disability claim, the examiner should provide an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran's prostate disability, to include hypertrophy of the prostate, (i) had its onset in service or is otherwise etiologically related to active service, to include as due to in-service exposure to dichlorotetrafluoroethane (DDT), (ii) was caused by his service-connected bronchial asthma with mixed restrictive and obstructive lung disease; or (iii) was aggravated beyond its natural progression by his service-connected bronchial asthma with mixed restrictive and obstructive lung disease. (b.) With regard to the heart disability claim, the examiner should provide an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran's heart disability, to include supraventricular arrythmia and cardiomyopathy, (i) had its onset in service or is otherwise etiologically related to active service, to include as due to in-service exposure to DDT, (ii) was caused by his service-connected bronchial asthma with mixed restrictive and obstructive lung disease; or (iii) was aggravated beyond its natural progression by his service-connected bronchial asthma with mixed restrictive and obstructive lung disease. (c.) With regard to the diabetes mellitus claim, the examiner should provide an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran's diabetes mellitus (i) had its onset in service or is otherwise etiologically related to active service, to include as due to in-service exposure to DDT, (ii) was caused by his service-connected bronchial asthma with mixed restrictive and obstructive lung disease; or (iii) was aggravated beyond its natural progression by his service-connected bronchial asthma with mixed restrictive and obstructive lung disease. (d.) With regard to the COPD claim, the examiner should provide an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran's COPD (i) had its onset in service or is otherwise etiologically related to active service, to include as due to in-service exposure to DDT, (ii) was caused by his service-connected bronchial asthma with mixed restrictive and obstructive lung disease; or (iii) was aggravated beyond its natural progression by his service-connected bronchial asthma with mixed restrictive and obstructive lung disease. (e.) With regard to the eye disability claim, the examiner should provide an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran's bilateral eye disability, to include primary open angle glaucoma, (i) had its onset in service or is otherwise etiologically related to active service, to include as due to in-service exposure to DDT, (ii) was caused by his service-connected bronchial asthma with mixed restrictive and obstructive lung disease; or (iii) was aggravated beyond its natural progression by his service-connected bronchial asthma with mixed restrictive and obstructive lung disease. In providing these opinions, the examiner must discuss and acknowledge the Veteran's competent and credible lay assertions of exposure to DDT during service. For purposes of the requested opinions, the examiner is reminded that the Veteran's service treatment records are deemed to be damaged/partially unavailable and that the absence of in-service documentation of the claimed exposure to DDT is an insufficient basis, by itself, for a negative opinion. See Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). The examiner is reminded that it is not sufficient to cite passages from medical literature without explaining how the medical literature is relevant in the instant case, i.e., the VA examiner must identify the medical literature relied upon and explain how the medical literature supports the underlying opinion by applying the content of the medical literature to the facts, including medical and lay evidence, in instant case. Rationale for all requested opinions shall be provided. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). 3. To help avoid future remand, ensure that all requested actions have been accomplished (to the extent possible) in compliance with this remand. If any action is not undertaken, or is taken in a deficient manner, appropriate corrective action should be undertaken. See Stegall, 11 Vet. App. at 271. 4. After completing the above actions and any other necessary development, the inextricably intertwined issue of the Veteran's entitlement to a TDIU also must be adjudicated. A. S. CARACCIOLO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Tracy O. Joseph, 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.