Citation Nr: 21031469 Decision Date: 05/22/21 Archive Date: 05/22/21 DOCKET NO. 14-28 260A DATE: May 22, 2021 REMANDED Entitlement to service connection for squamous cell carcinoma of the left tonsil, to include as secondary to herbicide agent exposure, is remanded. Entitlement to service connection for a back disorder, to include as secondary to herbicide agent exposure, is remanded. REASONS FOR REMAND The Veteran had active duty service from July 1968 to December 1970. The Veteran passed away in October 2012, and the Appellant is his surviving spouse. This matter is before the Board of Veterans' Appeals (Board) on appeal of an August 2011 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The Appellant has been substituted as the claimant for the purposes of all claims that were pending at the date of the Veteran's death. 38 U.S.C. § 5121A. She testified at a hearing before the undersigned in October 2017. In March 2018, the Board remanded the above listed claims for additional development. At that time the Board also remanded a claim seeking an increased rating for a posttraumatic stress disorder (PTSD) so that a statement of the case (SOC) could be provided. The SOC was issued in March 2019. The Appellant has not perfected an appeal as to this claim and it is no longer in appellate status. VA has a duty to ensure any medical examination or opinion it provides is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (overruled on other grounds, Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013)). A medical opinion is adequate where it is based upon consideration of the full medical history and describes a disability in sufficient detail so that the Board's evaluation will be fully informed. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). 1. Entitlement to service connection for squamous cell carcinoma of the left tonsil, to include as secondary to herbicide agent exposure is remanded. The Veteran served in Vietnam and his exposure to herbicide agents is conceded. Squamous cell carcinoma of the tonsils is not one of the conditions presumptively linked to this exposure. See 38 C.F.R. § 3.309(e). The Appellant submitted copies of prior Board decisions where service connection was established on a direct basis for similar cancers due to in-service exposure to herbicide agents. Based on this evidence, the Board remanded the claim to obtain a medical opinion which evaluated whether the Veteran's squamous cell carcinoma of the tonsil was directly related his military service, including exposure to herbicide agents. In July 2019, a VA examiner opined squamous cell carcinoma of the tonsil was less likely than not due to the conceded herbicide exposure. He observed the "[p]rimary risk factors for head [and] neck cancer include tobacco use, alcohol consumption, viral infection, radiation, diet, genetics and occupational chemical exposure." The Veteran had a history of smoking and using alcohol. However, the examiner also observed the National Academy of Sciences Veterans and Agent Orange Update of 2018 (NAS 2018 update) "indicates there is limited evidence to determine or suggest a causative association between squamous cell tonsillar cancer disorders and . . . herbicide exposure." Other medical literature found the chemical TCDD (tetrachlorodibenzo-p-dioxin) was a carcinogen or a potential carcinogen. He concluded that the "majority of scientific evidence . . . does not support an equipoise argument supporting tonsillar cancer being etiologically related to . . . herbicide exposure." The examiner also stated the Veteran's military personnel records did not indicate the amount, route, or duration of his in-service exposure to herbicide agents. This implies the nature of the Veteran's exposure may be determinative of whether a causal link is established. Yet, the examiner dismissed the Veteran's conceded herbicide exposure without explaining what level of exposure would support a causal link to tonsillar cancer and whether it was likely the Veteran's exposure met or exceeded this level. The rationale is inadequate to support the opinion. An additional medical opinion must be obtained. Id. 2. Entitlement to service connection for a back disorder is remanded. The Veteran filed a claim seeking service connection for a back disability. The service treatment records show, in January 1969, he reported generalized dorsal and lumbar vertebral area pain which had persisted over a three-month period. These records also document the Veteran experienced back pain following an in-service motor vehicle accident in July 1970. During his December 1970 separation physical, the Veteran reported recurrent back pain since the motor vehicle accident. Full range of motion in the back was noted. A VA spine examination was provided in December 2010. The examiner diagnosed thoracolumbar spondylosis with lumbar disc bulge L5-S1, but he opined the condition was less likely than not causally related to an in-service back condition. In March 2018, the Board found this opinion was inadequate and remanded the claim so that a new etiology opinion could be obtained. In July 2019, a new VA etiology opinion was issued. The VA examiner opined the back disability was less likely than not related to the Veteran's military service. He explained that spinal spondylosis is the result of disk degeneration that occurs with aging. The condition is associated with changes in the discs which result in increased mechanical stress at the cartilaginous end plates. The examiner stated the service treatment records documented a "soft tissue back injury and treatments." This type of injury resulted from trauma to the muscles, tendons, ligaments, or fascia, but not from trauma to the vertebrae or discs. Since the vertebrae and discs were not impacted, the in-service injuries were unlikely to be the cause of the Veteran's degenerative disc disease and degenerative joint disease. These conditions were more likely related to ongoing repetitive injuries rather than to a traumatic event. Here, the examiner did not explain how he determined that the in-service injures did not impact the Veteran's vertebrae and discs. In addition, the examiner reported the NAS 2018 Update found "sufficient evidence to suggest an associative causality between herbicide exposure and the development of degenerative spondylosis." He did not provide any opinion as to whether the Veteran's conceded herbicide exposure was causally related to his lumbar spondylosis. The rationale supporting the opinion is incomplete and the opinion is inadequate to evaluate the claim. Id. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from the July 2019 VA examiner who previously reviewed the Veteran's claim. If this examiner is unavailable, obtain an addendum opinion from an appropriate clinician. The examiner must review the entire claims file. The examiner is asked to opine whether the Veteran's squamous cell carcinoma of the tonsil was at least as likely as not related to his military service, including conceded exposure to herbicide agents. If the examiner determines that some level of exposure to herbicide agents is associated with squamous cell carcinoma of the tonsil, a full explanation for this finding must be provided. If the examiner determines it is less likely than not that the Veteran's level of exposure met the level needed to support a finding of causation, a full explanation for this finding must be provided. 2. Obtain an addendum opinion from the July 2019 VA examiner who previously reviewed the Veteran's claim for a back disability. If this examiner is unavailable, obtain an addendum opinion from an appropriate clinician. The examiner must review the entire claims file. The examiner is asked to opine whether the Veteran's back disability is at least as likely as not related his active military service, including reports of in-service back pain and an in-service motor vehicle accident. If the examiner determines that the nature of the in-service back injury and symptomatology do not reflect in-service trauma to the vertebrae or discs, a complete explanation for this finding must be provided. The examiner must also discuss the NAS 2018 Update and any evidence therein of a link between herbicide exposure and spinal spondylosis. The examiner must then opine whether the Veteran's back disability is at least as likely as not causally related to his in-service exposure to herbicide agents. A complete rationale must be provided for all opinions. M. HYLAND Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Jeanne Celtnieks 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.