Citation Nr: 21030339 Decision Date: 05/18/21 Archive Date: 05/18/21 DOCKET NO. 15-19 324 DATE: May 18, 2021 REMANDED Entitlement to service connection for lung cancer is remanded. Entitlement to service connection for hypoxemia to include secondary service connection to lung cancer is remanded. REASONS FOR REMAND The Veteran served with the United States from November 1966 to November 1970. The Veteran died in April 2014. The Appellant in this case is his surviving spouse. This matter was previously remanded by the Board of Veterans' Appeals (Board) in February 2021. The Board's February 2021 remand directives and the subsequent actions of the agency of original jurisdiction (AOJ) will be discussed below. The Veteran's appeal has been returned to the Board for further appellate consideration. 1. Entitlement to service connection for lung cancer is remanded. Although the Board regrets the additional delay, the Board finds that remand is once again warranted. In particular, remand is required to obtain a medical opinion that complies with the prior Board remand instructions, consider lay statements of record, and provide an adequate rationale. See Stegall v. West, 11 Vet. App. 268, 270-71 (1998) (requiring substantial compliance with remand directives). Before the Veteran passed, he alleged that his lung cancer was due to potentially hazardous substances including (1) radiation associated with radar equipment, (2) exposure to barrels containing Agent Orange while serving on a South Carolina Air Force Base, (3) asbestos contained in the heat shield and other components of a generator that he handled on a daily basis as an aerospace ground equipment repairman. See September 2010 Correspondence. The Veteran's claim was remanded in February 2021 and each contention was addressed by the Board. Regarding the Veteran's contentions the Board made several findings. First, the Board found that the Veteran's lung cancer was not related to or caused by exposure to ionizing radiation in service. The Board relied on the findings of the Secretary of Health's memorandum and Director of Compensations advisory opinion which found that the Veteran's estimated lifetime total radiation did not exceed 100 mSv above natural background and for that reason it was unlikely that lung cancer would be caused by ionizing radiation during military service. See October 2020 VA memorandum; see also October 2020 Advisory Opinion. Second, the Board found that the Veteran's allegations of herbicide exposure were too vague and therefore did not remand for any additional development regarding this contention. Thus, the Board found that the evidence of record did not support the Veteran's contentions that his lung cancer was caused by or was related to radiation exposure or Agent Orange exposure. However, the Board found the Veteran's contention for asbestos exposure required additional development. Notably, the Board remanded the Veteran's claim for a VA examination. Regarding the VA examination, the examiner was directed to opine whether the Veteran's lung cancer was related to his exposure to asbestos while in service. Specifically, the examiner was directed to consider the May 2010 physician's letter which noted a history of asbestos exposure and lung cancer. See February 2021 Board Decision. Following the February 2021 Board remand, VA secured an opinion in March 2021 addressing the Veteran's asbestos contention. The examiner concluded the Veteran's lung cancer was less likely than not incurred in or caused by the claimed in service injury, event, or illness. The examiner noted that the Veteran was diagnosed with bronchoalveolar carcinoma of the lungs and that there are different causes for different types of lung cancers. The examiner conceded that the Veteran was exposed to asbestos while in military service. However, the examiner reasoned that in his review of medical literature, there was no medical connection between asbestos and bronchoalveolar carcinoma. Therefore, he found it was less likely than not related. See March 2021 Medical Opinion. The Board concludes that the March 2021 addendum opinion is inadequate. Specifically, the March 2021 opinion did not comply with the February 2021 remand directive. The examiner did not provide a complete rationale which discussed the May 2010 letter from the Veteran's former oncologist. See Stegall, supra; 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). Instead, the examiner conceded asbestos exposure and provided a generic rationale and relied on his literature review, which found no medical connection between asbestos and bronchoalveolar carcinoma. Thus, because the examiner provided an insufficient rationale contrary to prior remand directives and did not specifically address the Veteran's May 2010 letter from his former oncologist, remand is required. See Stegall, supra. In light of above, the Board concludes that the VA opinion is inadequate for the purpose of readjudicating the Appellant's appeal, and thus, another remand is required. 2. Entitlement to service connection for hypoxemia to include secondary service connection to lung cancer is remanded. Although the Board regrets the additional delay, the Board finds that remand is once again warranted. The Board previously remanded this matter in February 2021 for additional development finding that the Veteran's claim for hypoxemia was inextricably intertwined with his claim for lung cancer because he contended that these disabilities were caused of aggravated by his lung cancer condition. See February 2021 Board Decision. As the claim for service connection for lung cancer is once again remanded for additional development, the claim for service connection for hypoxemia is again found to be intertwined with the claims for service connection for lung cancer remanded herein, and thus, must also be remanded to the AOJ. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that two issues are "inextricably intertwined" when they are so closely tied together that a final Board decision cannot be rendered unless both issues have been considered). The matters are REMANDED for the following action: 1. Obtain a medical opinion for the nature and etiology of the Veteran's lung cancer. Based on the review of the record (and examination if needed) the examiner should answer the following: Is it at least as likely as not (a 50 percent probability or higher) that the Veteran's lung cancer is related to active service, to include exposure to asbestos which the Veteran believed was contained in the generator he had daily contact with as an aerospace ground equipment repairman? The examiner must address the May 2010 letter from the Veteran's former oncologist which suggested his lung cancer was related to either smoking or exposure to asbestos. See March 2011 Medical Treatment Record p. 8. 2. If the RO finds service connection for lung cancer is warranted, schedule an examination (or telehealth interview, review of the record, etc. if an in-person examination is not feasible) for Veteran's hypoxemia. The claims file should be made available to the clinician for review. Based on the review of the record (and examination if needed) the examiner should answer the following: Is it at least as likely as not (a 50 percent probability or higher) that the Veteran's hypoxemia was either (1) caused by or (2) aggravated by his lung cancer? Why or why not? Separate opinions as it pertains to causation and aggravation for each disability is required. A complete medical rationale for all opinions expressed must be provided, to include discussing the specific facts of this Veteran's case. If an opinion cannot be provided without resorting to speculation, the examiner should provide complete explanations of why this is so. In so doing, the examiner is requested to explain whether any inability to provide a more definitive opinion is the result of a need for additional information, or the limits of current medical knowledge have been exhausted in providing an answer to that particular question. Saudiee Brown Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Emily A. Kotroco 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.