Citation Nr: 21029895 Decision Date: 05/17/21 Archive Date: 05/17/21 DOCKET NO. 20-12 260 DATE: May 17, 2021 REMANDED Entitlement to service connection for residuals of bladder cancer, to include as due to herbicide exposure, is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1969 to September 1971, with service in Vietnam from June 1969 to June 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In May 2020, the Board remanded the issue on appeal. The Board is obligated by law to ensure that the RO complies with its directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). Substantial compliance with remand directives is not optional or discretionary and the Board errs as a matter of law when it fails to ensure remand compliance. Stegall, 11 Vet. App. at 271. The Board directed the Agency of Original Jurisdiction (AOJ) to request that the Veteran submit authorization to obtain records from his private urologist, Dr. M. The AOJ sent a May 2020 letter to the Veteran requesting the records or authorization for the records. In June 2020, the Veteran responded that he would send in everything soon. In June 2020, the AOJ sent the Veteran a reminder letter regarding the records from Dr. M. That same month, the Veteran submitted additional records from Dr. M. As to this, the Board finds that the AOJ has substantially complied with the 2020 remand directives. However, as addressed below, there has not been substantial compliance as to the Board's request for a medical opinion. Entitlement to service connection for residuals of bladder cancer, to include as due to herbicide exposure, is remanded. In his August 2019 notice of disagreement, the Veteran contends that his bladder cancer is due to herbicide or Agent Orange exposure while he served in Vietnam. In his March 2020 substantive appeal, he reported almost daily exposure to Agent Orange during his service in Vietnam. The Board concludes that remand is warranted for an adequate addendum opinion. Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). An examination report is adequate when it sufficiently informs the Board of a medical expert's judgment on a medical question and the essential rationale for that opinion. Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012). Generally, a medical opinion should address the appropriate theories of entitlement. Stefl v. Nicholson, 21 Vet. App. 120, 123-24 (2007). Service connection based on exposure to herbicides is presumed for certain specified diseases, but not bladder cancer. 38 U.S.C. § 1116(a)(2); 38 C.F.R. § 3.309. Even if a veteran is not entitled to presumptive service connection, service connection may be established with proof of direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994); see also McCartt v. West, 12 Vet. App. 164, 167-68 (1999) (providing that the provisions set forth in Combee are applicable in cases involving claimed herbicides). Post-Board remand, an August 2020 VA urinary tract examination was conducted. The examiner opined that the bladder cancer was less likely as not to have had onset during service, as the STRs were silent for bladder urinary symptoms and the diagnosis was 45 years after service discharge. The examiner also opined that the onset of urinary symptoms in 2010 was due to benign prostatic hypertrophy which was unrelated to bladder cancer. In September 2020, an addendum opinion was obtained from the August 2020 examiner. The examiner opined that the bladder cancer is less likely than not due to or related to service, as it is not on the presumptive service connection list due to herbicide exposure, and is more likely due to a history of smoking, increasing age, and being male. Although the examiner addressed herbicide exposure, it was only to note that bladder cancer was not on the presumptive disabilities list. It is not clear if the examiner considered whether bladder cancer is at least as likely as not due to herbicide exposure despite it not being on the presumptive list. The Board thus finds that the medical expert's judgment on this question is not apparent. Accordingly, remand is required. The matters are REMANDED for the following action: 1. Obtain an addendum opinion regarding the Veteran's bladder cancer. The entire claims file, to include a copy of this REMAND, should be made available to and reviewed by the clinician. The opinion should, among other things, include a discussion of the Veteran's documented history and assertions. The opinion should also identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). The clinician should provide an opinion, with supporting rationale, as to: Whether the Veteran's bladder cancer is at least as likely as not due to herbicide exposure, despite the condition not being present on the presumptive disability list. Explain. 2. Ensure that the medical opinion obtained includes a complete rationale for the conclusions reached. The medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include 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. 3. Readjudicate. C.A. SKOW Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K.M., 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.