Citation Nr: 21039832 Decision Date: 07/01/21 Archive Date: 07/01/21 DOCKET NO. 15-19 617 DATE: July 1, 2021 REMANDED Entitlement to service connection for residuals of nasopharyngeal cancer, to include as due to herbicide agent exposure, is remanded. Entitlement to service connection for a cerebrovascular accident (CVA), to include as due to herbicide agent exposure, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Marine Corps from June 1967 to January 1969, with service in Vietnam. This matter comes before the Board of Veterans' Appeals (Board) from March 2014 and March 2017 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). In October 2018, the Veteran testified at a hearing before the undersigned Veterans Law Judge. The Board remanded the appeal in March 2019 and August 2020 for further development. 1. Entitlement to service connection for residuals of nasopharyngeal cancer, to include as due to herbicide agent exposure, is remanded. 2. Entitlement to service connection for a cerebrovascular accident (CVA), to include as due to herbicide agent exposure, is remanded. The Board regrets further delay but another remand is required. Pursuant to the Board's August 2020 remand directives, an opinion was obtained in November 2020. Initially, the Board notes that in the August 2020 remand instructions, the agency of original jurisdiction (AOJ) was directed to obtain all records of anti-viral antibody testing ordered by Dr. Wolf in October 1994 to rule out Epstein-Barr virus as a source of the Veteran's nasopharyngeal cancer. As of this date, while records have been received from Dr. Wolf, there are none that pertain to any anti-viral antibody testing. As such, Epstein-Barr virus is not conceded by the Board and should not be conceded by the examiner unless and until further evidence definitively reflects the same. Moreover, in the August 2020 remand, the Board asked the examiner to opine on whether it was "medically plausible," based on the Veteran's lay statements and symptomatology, that there was a nexus between the Veteran's cancer and residuals (dry mouth and thyroid dysfunction) and his CVA and conceded herbicide agent exposure. However, in rending the negative opinion, the examiner did not do so, and instead related a conclusory opinion, reasoning agent orange exposure is not listed as a definitive causative agent for nasopharyngeal cancer and stroke. Additionally, the Veteran's submitted medical treatise article was not addressed, and neither was the question of medical plausibility. Thus, this opinions are inadequate, and an addendum opinion is needed to ensure substantial compliance with the Board's August 2020 remand directives. See Stegall, supra. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an examiner other than the March 2020 and November 2020 VA examiners, preferably a physician, to address the etiology of the Veteran's residuals of nasopharyngeal cancer. No additional examination is necessary, unless the examiner determines otherwise. The entire claims file should be made available to the examiner. After reviewing the claims file, the examiner should offer an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's nasopharyngeal cancer and residuals (dry mouth and thyroid dysfunction) are the result of conceded in-service exposure to herbicide agents. In so doing, please do not rely solely on the fact that the condition is not one subject to presumptive service connection based on herbicide agent exposure, as that will result in an inadequate opinion. Instead, please address whether a relationship between the Veteran's cancer residuals and herbicide agent exposure is medically plausible, given your medical expertise and the fact that the Veteran has no family history of such a rare cancer. A complete rationale should be given for all opinions and conclusions expressed. If the examiner cannot provide an opinion without resorting to speculation, it is essential that the examiner explain why an opinion cannot be provided (e.g., the limits of the examiner's knowledge, the limits of medical knowledge in general; or if there is additional evidence that would allow for an opinion on this matter). 2. Then obtain an addendum opinion from an examiner other than the March 2020 and November 2020 VA examiners, preferably a physician, addressing the etiology of the Veteran's CVA. No additional examination is necessary unless the examiner determines otherwise. The entire claims file should be made available to the examiner. After reviewing the claims file, the examiner should offer an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's CVA and associated residuals are the result of conceded in-service exposure to herbicide agents. In addressing this question, please discuss the Veteran's article linking Agent Orange exposure to strokes (see January 2017 Correspondence), and do not rely solely on the fact that the condition is not one subject to presumptive service connection based on herbicide agent exposure. Instead, please address whether a relationship between CVA and herbicide agent exposure is medically plausible, given the article submitted by the Veteran and your medical expertise. A complete rationale should be given for all opinions and conclusions expressed. If the examiner cannot provide an opinion without resorting to speculation, it is essential that the examiner explain why an opinion cannot be provided (e.g., the limits of the examiner's knowledge, the limits of medical knowledge in general; or if there is additional evidence that would allow for an opinion on this matter). S. BUSH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. J. Rogers, 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.