Citation Nr: 21031515 Decision Date: 05/24/21 Archive Date: 05/24/21 DOCKET NO. 16-48 693 DATE: May 24, 2021 REMANDED Entitlement to service connection for a disability manifested by neck and scalp cysts is remanded. Entitlement to service connection for hepatitis C with cirrhosis of the liver is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from December 1976 to March 1981. These matters come before the Board of Veterans' Appeals (Board) on appeal from a rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded the claim of entitlement to service connection for a disability manifested by neck and scalp cysts for additional development in November 2018 and April 2020. Unfortunately, there has not been substantial compliance with the Board's previous remand directive and another remand is required. Stegall v. West, 11 Vet. App. 268, 271 (1998). Although an examination was provided in August 2020, and an addendum opinion obtained in September 2020, for the reasons provided below, they are inadequate. Where VA provides an examination or obtains an opinion, it must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). 1. Entitlement to service connection for a disability manifested by neck and scalp cysts. The Veteran contends the disability manifested by neck and scalp cysts began in service after he was exposed to ionizing radiation on Enewetak Atoll from February 1979 to July 1979. The April 2020 Board remand directed the VA examiner to "consider and discuss the Veteran's competent lay reports of observable symptomatology, the October 1979 service treatment record that shows the Veteran complained of facial irritation that started when he was on Enewetak Atoll, and the November 2005 VA treatment record that notes the Veteran had experienced cysts on his face and scalp for many years." See BVA Decision (April 2020). An August 2020 VA skin examination reflects a diagnosis of pilar cyst (date of diagnosis as July 2006); no current symptoms; and the Veteran reported having had since March 2019 4 pilar cyst removed. VA obtained medical opinions in July 2020 and September 2020 from the same clinician, which reflect that the condition was less likely than not cause by or the result of in-service injury or disease. However, neither opinion discussed the evidence referenced in the Board's April 2020 remand. Although the clincian discussed the Veteran's report that he had a cyst removed during service, the opinion provides no indication that the examiner considered all of the relevant evidence as directed by the Board. Indeed, the July 2020 opinion reflect only that: The Veterans medical condition does not support current diagnosis condition related to veterans claimed disability. The claimed condition is not related because they were removed after military service. The cysts has [sic] been diagnosed as pilar cysts, they are heridity [sic] cyst with autosomal dominant transmission and has no relation to trauma or environmental exposure. The September 2020 addendum opinion reflects that "facial radiation is a kind of trauma exposure which we expect to see the complication immediately like ulceration, problem with wound healing." See C&P Exam (September 2020). However, the clinician provided no reasoning, or any discussion at all, on why the Veteran's in-service complaints of facial irritation in October 1979 and facial rash in April 1980 did not indicate an immediate complication from trauma exposure. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) ("most of the probative value of a medical opinion comes from its reasoning"). Therefore, to ensure that VA has met its duty to assist, remand is required. A remand by the Board imposes upon the Secretary of VA a concomitant duty to ensure compliance with the terms of the remand. Where remand orders of the Board are not complied with, the Board errs in failing to ensure compliance. Stegall, 11 Vet. App. at 271. 2. Entitlement to service connection for hepatitis C with cirrhosis of the liver. Regarding the Veteran's claim for entitlement to service connection for hepatitis C with cirrhosis of the liver, the Veteran submitted a timely notice of disagreement (NOD May 2017) with a March 2017 rating decision, but a statement of the case has not yet been issued. A remand is required for the agency of original jurisdiction to issue a statement of the case. 38 C.F.R. §§ 20.200, 20.904(c); Manlincon v. West, 12 Vet. App. 238, 240-41 (1999). The matters are REMANDED for the following action: 1. Send the Veteran and his representative a statement of the case that addresses the issue of service connection for hepatitis C with cirrhosis of the liver. 2. Obtain the Veteran's updated VA treatment records and associate them with the evidence of record. 3. Thereafter, obtain an addendum opinion from a qualified medical professional to address the origin of the Veteran's disability manifested by cysts on the neck and scalp. The claims file should be made available and reviewed by the examiner. Following consideration of the evidence of record (both lay and medical), the examiner is asked to address the following: Is it at least as likely as not (a 50 percent or greater probability) that the Veteran's disability manifested by cysts on the neck and scalp had its onset during, or is otherwise related to, active service, to include as due to exposure to radiation? In providing an answer to the above question, the examiner should consider and discuss, among other things, the Veteran's competent lay reports of observable symptomatology, the October 1979 service treatment record that shows the Veteran complained of facial irritation that started when he was on Enewetak Atoll, and the November 2005 VA treatment record that notes the Veteran had experienced cysts on his face and scalp "for many years." (Continued on the next page) 4. Ensure that the VA medical opinion supports 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, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). C.A. SKOW Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Thaddaeus J. Cox, Associate 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.