Citation Nr: 21042642 Decision Date: 07/13/21 Archive Date: 07/13/21 DOCKET NO. 16-60 644 DATE: July 13, 2021 ORDER Service connection for residuals of skin cancer is denied. REMANDED Service connection for a thyroid disorder is remanded. FINDING OF FACT The Veteran's residuals of skin cancer have not been shown to be caused by, aggravated by, or related to any disease, injury, or incident during service. CONCLUSION OF LAW The criteria for service connection for residuals of skin cancer have not been met. 38 U.S.C. §§ 1110, 1112, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.311, 4.1. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from March 1966 to February 1968. The Veteran contends that he is entitled to service connection for residuals of skin cancer and service connection for a thyroid disorder. This case comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions issued in January 2015 and July 2018 by a Department of Veterans Affairs (VA) Regional Office (RO). In September 2019, the Veteran testified at a hearing before a veteran's law judge (VLJ), and a transcript of the hearing is of record. The VLJ who conducted the September 2019 Board hearing is no longer with the Board. The Veteran was informed of this in a June 1, 2021 letter, in which he also was provided the opportunity to have an additional Board hearing. The Veteran declined this offer in a June 23, 2021 letter. In December 2019, the Board remanded the case for additional development. The case now returns to the Board for further adjudication. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. Id.; see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996). Pertinent to a claim for service connection, such a determination requires a finding of a current disability that is related to an injury or disease in service. Watson v. Brown, 4 Vet. App. 309 (1993); see also Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992). Under applicable regulation, the term "disability" means impairment in earning capacity resulting from diseases and injuries and their residual conditions. 38 C.F.R. § 4.1; see also Hunt v. Derwinski, 1 Vet. App. 292, 296 (1991); Allen v. Brown, 7 Vet. App. 439 (1995); Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018) (the term "disability" as used in 38 U.S.C. § 1110 "refers to the functional impairment of earning capacity, not the underlying cause of said disability," and held that "pain alone can serve as a functional impairment and therefore qualify as a disability"). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). In general, service connection for a condition that is claimed to be attributable to ionizing radiation exposure during service may be established in one of three ways. See Davis v. Brown, 10 Vet. App. 209, 211 (1997); Rucker v. Brown, 10 Vet. App. 67, 71 (1997). First, there are diseases that are presumptively service connected in radiation-exposed veterans under 38 U.S.C. § 1112(c) and 38 C.F.R. § 3.309(d). Under this section, if the veteran is deemed to be an "atomic veteran", a veteran that was exposed to radiation due to participating in radiation risk activity listed in the statute, and has one of the presumptive diseases listed under the section, then service connection is warranted subject to provisions of 38 C.F.R. §3.307. Second, service connection can be established under 38 C.F.R. § 3.303(d) with the assistance of the procedural advantages prescribed in 38 C.F.R. § 3.311 if the condition at issue is a radiogenic disease. Third, if the Veteran is not entitlement to relief under sections § 3.309(d) and § 3.311, direct service connection can be established by showing that the disease was incurred during or aggravated by service. See Combee v. Brown, 34 F.3d 1039, 1043 (Fed Cir. 1994). A "radiation-exposed veteran" is defined by 38 C.F.R. § 3.309(d)(3) as a veteran who while serving on active duty or on active duty for training or inactive duty training, participated in a radiation-risk activity. "Radiation-risk activity" is defined to mean onsite participation in a test involving the atmospheric detonation of a nuclear device; the occupation of Hiroshima, Japan or Nagasaki, Japan by United States forces during the period beginning on August 6, 1945, and ending on July 1, 1946; or internment as a prisoner of war (or service on active duty in Japan immediately following such internment) during World War II which resulted in an opportunity for exposure to ionizing radiation comparable to that of the United States occupational forces in Hiroshima or Nagasaki during the period from August 6, 1945 through July 1, 1946. 38 C.F.R. § 3.309(d)(3)(i), (ii). If a claimant does not qualify as a "radiation-exposed veteran" under 38 C.F.R. § 3.309(d)(3) and/or does not suffer from one the presumptive conditions listed in 38 C.F.R. § 3.309(d)(2), the veteran may still benefit from the special development procedures provided in 38 C.F.R. § 3.311 if the veteran suffers from a radiogenic disease and claims exposure to ionizing radiation in service. Under 38 C.F.R. § 3.311, "radiogenic disease" means a disease that may be induced by ionizing radiation. 38 C.F.R. § 3.311(b)(2). Under 38 C.F.R. § 3.311, when a veteran contends that a radiogenic disease, which first became manifest after service though not to a compensable degree within any other applicable presumptive period, is the result of exposure to ionizing radiation in service, an assessment is made as to the size and nature of the radiation dose. 38 C.F.R. § 3.311(a). Except as otherwise provided, the radiogenic disease must become manifest five years or more after exposure. 38 C.F.R. § 3.311(b)(5). If these threshold requirements are met, an assessment as to the size and nature of the radiation dose must be made. 38 C.F.R. §3.311(a)(1). In order to make such an assessment, the RO must request dose information as provided by 38 C.F.R. § 3.311(a)(2). 38 C.F.R. § 3.311(a)(2)(iii) requires that, in claims not based upon participation in atmospheric nuclear testing or Hiroshima and Nagasaki occupation, dose data normally include, but may not be limited to, the Veteran's Record of Occupational Exposure to Ionizing Radiation (DD Form 1141), service treatment records and other records which may contain information pertaining to radiation exposure in service. All such records must be forwarded to the Under Secretary for Health, who will prepare and provide a dose estimate regarding the amount of radiation exposure. 38 C.F.R. § 3.311(a)(2)(iii). If exposure to ionizing radiation is identified, the Veteran's claim must then be referred to the Under Secretary for Benefits for further consideration in accordance with 38 C.F.R. § 3.311(c). That consideration includes determining if such radiation exposure resulted in the veteran's radiogenic disease. Service connection for residuals of skin cancer The Veteran contends that he is entitled to service connection for skin cancer. He asserts that he incurred his skin cancer as a result of in-service exposure to radiation. As an initial matter, the Board finds that evidence of record reflects that the Veteran has diagnoses of melanoma, basal cell carcinoma, and squamous cell carcinoma, as well as residuals thereof, as shown in VA examinations from April 2021. In a July 2008 statement, the Veteran stated that he has had melanomas removed from all parts of his body caused by exposure to ionizing radiation. In a September 2008 statement, the Veteran stated that he was exposed to ionizing radiation in service. His in-service job at Camp Eschborn was to move warheads from one site to another, and his rank was SP5 senior atomic demolitions (ADM) specialist. In a July 2014 statement, the Veteran described an in-service incident where he was delivering atomic weapons in Germany. He boarded a helicopter with atomic weapons. When he arrived at the storage site, other personnel present there informed him that there had been a radiation leak in the bunker where warheads were stored. He stated that all personnel there had gas masks on. No gas masks were provided for him. He was told to leave until they removed the atomic weapon. In an August 2014 Radiation Risk Information Sheet, the Veteran reported that he was with the 317th Engineer Battalion at Camp Eschborn, Germany; and his rank was SP5-E5. He reported that there was an atomic weapon leak at a storage site in Germany, and he remained in the leak area for 40 minutes. He stated that, he boarded a helicopter with a strapped atomic weapon and rode to the storage site. When he arrived at the storage site, masked personnel informed him of an atomic leak on site. He waited for the warhead to be unloaded to the storage site. In a September 2015 statement, the Veteran reported that he was stationed at Camp Eschborn, Germany in 1967 and 1968; and he was a senior ADM specialist while there. He reported that a helicopter landed at his location with a live warhead on board. They needed two guards to ride with them to a storage site. He was not told where they were going. While in the air, the pilot stated, "If we start to go down, I'll try to get over salt water and you push it out." When they arrived at the site and landed, there were loud sirens and people running around with protective gear and gas masks. The Veteran was approached and told there was a leak. The Veteran stayed on the helicopter for 35 to 40 minutes with no protective gear, waiting until they unloaded the warhead. In a November 2016 statement, the Veteran reported that, during service, he was in an ADM platoon attached to the 317th Engineer Battalion. His duties included working and training on nuclear weapons. He reported that a helicopter landed at Camp Eschborn at the AMD site, and two guards were needed to go to a storage site to deliver a live warhead. The Veteran was chosen to go. When he landed, there were alarms going off and people in hazmat suits running around. One person approached him with a suit and gas mask saying they had a leak. He was told to stay on the helicopter until the warhead was unloaded. In a November 2016 VA Form 9, the Veteran stated that he was exposed to a radiation leak while serving with the 317th Engineer Battalion in Germany, and he was transporting a nuclear warhead that developed a leak. In a May 2017 statement, the Veteran reported that the radiation leak occurred in the summer of 1967. He was exposed to radiation while he was waiting in the helicopter with the nuclear warhead with no protective gear. In an October 2017 VA Form 9, the Veteran reported that he was on a helicopter guarding a warhead. Alarms started going off, and he was told there was a leak. People at the delivery site wore protective gear, but he did not have protective gear. He asserted that radiation exposure resulted in skin cancer. He reported that he has had multiple skin cancer removals. At the September 2019 Board hearing, the Veteran reported that, in 1967, he was chosen to accompany an atomic weapon on an aircraft. The pilot had stated that, if they do not make it, they would have to push the weapon into the water. They made it to their destination. However, several people dressed in hazard equipment came to retrieve this weapon only to learn that there was some form of leakage. The Veteran was not provided with protective gear. The Veteran contended that he was on the aircraft with the leakage from this atomic weapon, which was a radiation source. He believes that his skin cancer was a result of exposure to this radiation. The Veteran reported that, during active service, he was a senior ADM specialist, and he supervised three or four service members. Their job was to make repairs and, in a war situation, to deploy the lethal weapons. He noted that he never had to detonate a weapon, and he was not present during testing of the weapons. He also noted that he was not given a Geiger counter or other tool to read levels of radiation. The Veteran's military personnel records reflect that the Veteran served as a combat engineer, an ADM specialist, and senior ADM specialist; and he had training in atomic demolition. He served with the 317th Engineer Battalion in Germany. However, the Veteran's service treatment records (STRs) are silent for any complaint, diagnosis, or treatment of skin-related problems during the Veteran's active service. In a July 2008 letter, Ms. BV stated that, after reviewing the Veteran's records, she felt it would be in the Veteran's best interests if he were to open a claim for C&P with the RO for skin cancer based on exposure to ionizing radiation. However, Ms. BV did not give any medical opinion or rationale on whether the Veteran's skin cancer was more likely than not due to radiation exposure, nor did she give any opinion or reasoning concerning the Veteran's likelihood of success in such a claim. In a September 2015 letter, Dr. JS reported that the Veteran has skin cancer and hypothyroidism, and he served in atomic demolition, thus resulting in him as likely as not having radiation poisoning and exposure. However, Dr. JS's statement gave no rationale or evidential support for his statement. Thus, the Board finds that Dr. JS's statement cannot be afforded probative weight. At an April 2021 VA examination for skin conditions, the VA examiner diagnosed the Veteran with melanoma, basal cell carcinoma, and squamous cell carcinoma. The Veteran reported that the first lesion appeared in 1997. Treatment has included lesion removal and freezing lesions off. Current symptoms include multiple scars, ear disfigurement, and discomfort related to scars. The Veteran stated that he experiences embarrassment when going out in public, such as when he goes to church. He stated that he was ashamed of his appearance, and he is not able to go out in the sun. He wears long sleeves and a large hat when he goes outside. His spouse mows the lawn and does the yard work. The Veteran had used topical ammonium lactate on a constant or near constant basis over the past 12 months. The last time the Veteran had a lesion excision was around December 2020, and it was for a lesion of the right neck. He has also had cryotherapy lesion removal with the most recent treatment in April 2021 for skin carcinoma to the right neck. The residuals of skin cancer effects 20 to 40 percent of the total body area and 5 to 20 percent of the exposed body area. The VA examiner noted that the Veteran has significant scarring to the bilateral upper extremities, anterior trunk, posterior trunk, face, head, and neck with disfigurement of the right ear. The April 2021 VA examiner found that the claimed condition was at least as likely as not (50 percent or greater probability) incurred in or caused by the claimed in-service injury, event, or illness. The VA examiner noted that the Veteran served in the military during the Vietnam Era from 1966 1968 as a senior ADM specialist. He set up nuclear weapons and had to transport live nuclear war heads via helicopter to various locations during his time stationed in Germany. The VA examiner also noted that the Veteran reported that he was ill equipped and did not have access to personal protective equipment such as radiation detection meters, or radiation suits. The VA examiner explained that there is statistically significant evidence based medical research that shows skin cancer related to occupational radiation exposure has been reported in aircrews, uranium miners, nuclear weapons test participants and nuclear industry workers. Human radiation exposure in environmental, occupational and therapeutic settings elevates risk of BCCs as opposed to any other skin cancer. The examiner cited various studies and stated that there is statistically significant evident based research that identifies radiation exposure in military populations as a causative agent for all cancers including skin cancers. Therefore, the VA examiner found that the claimant's residuals of skin cancer are at least as likely as not directly related to the radiation exposure that he had during his active service. The Board has additionally reviewed the balance of the Veteran's other medical treatment records, and the findings are substantially similar to those noted in the VA examinations and other medical evidence described above. In a September 2014 letter, the Army Dosimetry Center reported that they had researched the files for records of exposure to ionizing radiation for the Veteran, and they were unable to locate any records for him. In the December 2019 Board decision, the Board acknowledged the Veteran's assertions that his military occupational specialty (MOS) duties placed him in a radiation exposed environment. The Board noted that, while the Veteran worked as an atomic demolitions' specialist, he admits that he did not have to detonate any bombs. The Board found that, based on the evidence of record, the Veteran has not participated in any radiation risk activity listed in the statute. The Board also acknowledged that the evidence indicates that the Veteran has been diagnosed with skin cancer, which is a disease listed under 38 C.F.R. § 3.311(b)(2). The Board noted that the RO requested records concerning the Veteran's exposure to radiation from the U.S. Army Dosimetry Center in August 2014; and the U.S. Army Dosimetry Center responded in September 2014 that they were unable to locate any record of exposure to ionizing radiation for the Veteran. The RO also requested DD Form 1141, but the document was not a matter of record. However, the Board found that the RO did not continue the development required by 38 C.F.R. § 3.311(a)(2)(iii), which instructs that any records pertaining to radiation exposure should be forwarded to the Under Secretary for Health, who will be responsible for preparation of a dose estimate, to the extent feasible, based on available methodologies. In other words, even though the U.S. Army concluded that no information could be provided for the Veteran, the RO did not have discretion to stop developing the claim. The Board stated that service records show that the Veteran was stationed in Germany and worked as an atomic demolitions' specialist. The Veteran provided details regarding his MOS duties and an event in which he alleges he was exposed to radiation. Additionally, the evidence includes a medical opinion from a doctor stating the Veteran's skin cancer and hypothyroidism is related to radiation poisoning and exposure. The Board stated that the RO made a determination concerning exposure to radiation based solely on the service department's lack of dosimetry data, without forwarding the case to the Under Secretary for Health first. Thus, the Board remanded the case in order for the agency of original jurisdiction (AOJ) to forward the claims file to the Under Secretary of Health for the preparation of the dose estimate. Then the case was to be referred to the Under Secretary for Benefits for further consideration of the Veteran's claim. Additionally, the Board stated that, if it is determined that the presumptive provisions of 38 C.F.R. §3.311 are not applicable in this case, the Veteran should be afforded a VA examination to determine the nature and etiology of his claimed skin cancer. In a September 2020 memorandum, the Director of Compensation Service forwarded the case to the Under Secretary for Health to obtain a dose estimate. In an October 2020 memorandum, the VA Under Secretary for Health, through the Director, Post-9/11 Ere Environment Health Program, and the VA Under Secretary for Benefits assigned the Veteran a dose of 1.0 rem (total effective dose equivalent), which is calculated as 0.5 rem per year x 2 calendar years of claimed radiation exposure (1967 and 1968). They explained that radiation dose is the prime factor to consider when determining causation of radiation induced disease, and being in the vicinity of a radiation source does not necessarily mean a significant exposure occurred. They noted that the Health Physics Society, in their position statement PS010-4, Radiation Risk in Perspective, stated that, below levels of about 100 mSv [10 rem] above background from all sources combined, the observed radiation effects in people are not statistically different from zero. They concluded that while skin cancer is a radiogenic disease covered under 38 CFR 3.311, the Veteran's estimated lifetime total radiation dose (1.0 rem) did not exceed 100 mSv (10 rem) above natural background. Therefore, they determined that it is unlikely that skin cancer of any type was caused by exposure to ionizing radiation during military service. In an October 2020 advisory opinion, the Director of Compensation Service acknowledged that, as noted in the Under Secretary for Health memorandum, the Veteran was assigned a total radiation dose of 1.0 rem (total effective dose equivalent) for the two calendar years of claimed radiation exposure (1967 and 1968) based on the nature and location of the Veteran's service as described in the claim file. The Director noted that the Health Physics Society, in their position statement PS010-4, Radiation Risk in Perspective, stated that, below levels of about 100 mSv [10 rem] above background from all sources combined, the observed radiation effects in people are not statistically different from zero. The Director stated that sometimes an opinion will be received which basically states, "X is due to radiation". However, the opinion will often not consider the actual level of radiation exposure, and such opinions would clearly be flawed. To have probative value, a medical opinion must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Medical opinions that are speculative, general, or inconclusive in nature do not provide a sufficient basis upon which to support a claim. McLendon v. Nicholson, 20 Vet. App. 79, 85 (2006). Furthermore, such an opinion would not be consistent with sound scientific evidence. The Court has held that to allow the opinions of individual doctors to trump the collective view of experts would be an impermissible expansion of available remedies beyond those explicitly provided by Congress. Nevertheless, "it is the total analysis provided by the medical professional that must be weighed and considered by the Board." Such an opinion does not consider actual exposure level and is therefore not probative. The Director noted that the Veteran was diagnosed with squamous cell carcinoma (SCC) approximately 47 years after initial exposure to ionizing radiation, and he was diagnosed with basal cell carcinoma (BCC) approximately 48 years after exposure. The Veteran was between 19 to 21 years old at the time of exposure. Records show he is a Caucasian male and a former smoker (having quit smoking in 2007), and he chews tobacco. The Veteran also has a positive family history for his mother with colon cancer and his brother with lung cancer. He was a welder for 30 years before retiring. No post-service radiation exposure is noted or reported. Based on the scientific evidence referenced in the memorandum from the VA Under Secretary for Health and a review of the evidence in its entirety, the Director of Compensation Service determined that there is no reasonable possibility that the Veteran's skin cancer can be attributed to ionizing radiation exposure during military service. The Board finds that, as noted by the December 2019 Board remand, the Veteran has not participated in any radiation risk activity listed in 38 C.F.R. § 3.309(d). The Board also acknowledges that skin cancer is a radiogenic disease listed in 38 C.F.R. § 3.311. The Board acknowledges that the April 2021 VA examiner found that the Veteran's claimed skin cancer was at least as likely as not caused by the claimed in-service radiation exposure. However, the VA examiner based her opinion primarily on the Veteran's own reports of in-service radiation exposure and not on the Veteran's actual dose estimate regarding the amount of radiation exposure. The April 2021 VA examiner's opinion did not address the Director of Compensations Services' October 2020 advisory opinion or the Veteran's actual dose estimate of radiation exposure, which failure maligns the opinion and limits its probative value. The Board affords greater probative weight to the findings in the October 2020 advisory opinion by the Director of Compensation Service, as those findings considered all of the pertinent evidence of record, to include the Veteran's dose estimate of radiation exposure, as well as the Veteran's statements, service records, and relevant medical history, and provided a complete rationale. Moreover, the Director of Compensation Service offered clear conclusions with objective supporting data as well as reasoned medical explanations connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). Based on the foregoing, the Board finds that the preponderance of the evidence is against finding that the Veteran's skin cancer is caused by, aggravated by, or related to any disease, injury, or incident in service, to include in-service radiation exposure. Thus, service connection for skin cancer is not warranted. The Board has considered the Veteran's statements that his skin cancer is caused by or related to his active service, to include in-service radiation exposure. However, the Veteran, as a lay person, does not have the requisite training and experience necessary to address such a complex medical matter as the etiology or cause of his skin cancer. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). In this regard, the etiology of such disorders involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship and, thus, may not be competently addressed by lay statements. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (explaining that while the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Thus, the Board finds that the Veteran's assertions as to the etiology of his skin cancer are not competent evidence and, consequently, are afforded no probative weight. Based on the above, the Board finds that the preponderance of the evidence is against a grant of service connection for skin cancer. In reaching the foregoing conclusions, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal; and his claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. REASONS FOR REMAND The law provides that VA shall make reasonable efforts to assist a claimant in obtaining evidence to substantiate a claim. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). Such assistance includes providing the claimant with a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on a claim. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). If a medical examination report does not contain sufficient information to allow an informed Board decision, then the rating board must return the report as inadequate. See 38 C.F.R. § 4.2; Bowling v. Principi, 15 Vet.App. 1, 12 (2001); Ardison v. Brown,6 Vet.App. 405, 407 (1994). Once VA undertakes to provide a medical examination, VA must provide an adequate examination or, at a minimum, notify the claimant why one will not or cannot be provided. 38 C.F.R. § 4.2; Barr v. Nicholson, 21 Vet.App. 303, 311-12 (2007). An examination "is adequate where it is based upon consideration of the veteran's prior medical history and examinations and also describes the disability, if any, in sufficient detail so that the Board's 'evaluation of the claimed disability will be a fully informed one.'" Stefl v. Nicholson, 21 Vet.App. 120, 123 (2007) (quoting Ardison v. Brown, 6 Vet.App. 405, 407-08 (1994)); Green v. Derwinski, 1 Vet.App. 121, 124 (1991). Service connection for a thyroid disorder The Veteran contends that he is entitled to service connection for a thyroid disorder. He asserts that he incurred his thyroid disorder as a result of in-service exposure to radiation. As discussed in the previous section, the Veteran has reported, and his military personnel record reflects, that he served as a senior atomic demolition (ADM) specialist during active service. In 1967 and 1968, he was stationed with the 317th Engineer Battalion at Camp Eschborn, Germany. As an ADM specialist, his duties included working and training on nuclear weapons. At the September 2019 Board hearing, the Veteran stated that his job was to make needed repairs to nuclear weapons and, in a war situation, to deploy the weapons. He noted that he never had to detonate a weapon, and he was not present during testing of the weapons. He also noted that he was not given a Geiger counter or other tool to read levels of radiation. As also discussed in the previous section, the Veteran has described an incident where he believes he was exposed to the radiation that he asserts caused his thyroid disorder. In a September 2015 statement, the Veteran reported that, in the summer of 1967, a helicopter landed at his location with a live warhead on board. They needed two guards to ride with them to a storage site. He was not told where they were going. While in the air, the pilot stated, "If we start to go down, I'll try to get over salt water and you push it out." When they arrived at the site and landed, there were loud sirens and people running around with protective gear and gas masks. The Veteran was approached and told there was a leak. The Veteran stayed on the helicopter for 35 to 40 minutes with no protective gear, waiting until they unloaded the warhead. In the December 2019 Board decision, the Board acknowledged that the Veteran asserts that his military occupational specialty (MOS) duties as an ADM specialist placed him in a radiation exposed environment. The Board noted that, while the Veteran worked as an atomic demolitions' specialist, he admits that he did not have to detonate any bombs. The Board found that, based on the evidence of record, the Veteran has not participated in any radiation risk activity listed in the statute. The Board also found that hypothyroidism is not one of the radiogenic diseases enumerated in 38 C.F.R. § 3.311. However, the Veteran could still establish service connection for hypothyroidism on a direct basis. See Combee v. Brown, 34 F.3d 1039, 1043 (Fed Cir. 1994). The Board remanded the issue to afford the Veteran a VA examination to determine the nature and etiology of his claimed thyroid disorder. The Board notes, as the December 2019 Board decision implied, because hypothyroidism is not a radiogenic disease, the Veteran is not entitled to, nor does the record contain, an advisory opinion from the Director of Compensation Service concerning the etiology or cause of his thyroid disorder. However, the evidence contained in the October 2020 memorandum from the Under Secretary of Health and the October 2020 advisory opinion from the Director of Compensation Service, including the Veteran's assigned dose estimate of radiation exposure, is still relevant to the issue of service connection for a thyroid disorder. In an October 2020 memorandum, the VA Under Secretary for Health, through the Director, Post-9/11 Era Environment Health Program, and the VA Under Secretary for Benefits assigned the Veteran a dose of 1.0 rem (total effective dose equivalent), which is calculated as 0.5 rem per year x 2 calendar years of claimed radiation exposure (1967 and 1968). They explained that radiation dose is the prime factor to consider when determining causation of radiation induced disease, and being in the vicinity of a radiation source does not necessarily mean a significant exposure occurred. They noted that the Health Physics Society, in their position statement PS010-4, Radiation Risk in Perspective, stated that, below levels of about 100 mSv [10 rem] above background from all sources combined, the observed radiation effects in people are not statistically different from zero. The October 2020 advisory opinion from the Director of Compensation Service acknowledged the findings in the October 2020 memorandum from the Under Secretary for Health. At an April 2021 VA examination for thyroid conditions, the VA examiner diagnosed the Veteran with hypothyroidism. The Veteran reported that the condition began at least 10 years ago. His symptoms have included constipation and fatigue. He stated that he has constant fatigue and no energy to do anything. He currently takes medication for the condition. The April 2021 VA examiner found that the Veteran's hypothyroidism is at least as likely as not directly related to his active service. The VA examiner noted that the Veteran served in the military from March 1966 to February 1968 as a senior ADM specialist where he set up nuclear weapons and had to transport live nuclear war heads via helicopter to various locations during his time stationed in Germany. The Veteran reported that he was ill equipped and did not have access to personal protective equipment such as radiation detection meters, or radiation suits. The VA examiner stated that there is statistically significant evidence based medical research that shows hypothyroid can be caused from radiation exposure. The thyroid gland is well known to be vulnerable to radiation. Not only thyroid cancers but also non-malignant thyroid diseases, including benign thyroid nodules, autoimmune thyroid diseases (such as Graves' disease and Hashimoto's thyroiditis) and also non-autoimmune (or destructive) hypothyroidism have been reported to be induced by a wide dose range of radiation (Nagayama, 2018). The Board finds that the April 2021 VA examiner did not adequately consider or address the Veteran's actual dose estimate of radiation exposure from the October 2020 memorandum from the Under Secretary of Health, nor did she consider or address the evidence in the October 2020 advisory opinion from the Director of Compensation Service. Additionally, the Board finds that the April 2021 VA examiner's rationale that hypothyroid "can be caused" from radiation exposure is inadequately speculative for purposes of allowing the Board to make a fully informed decision on service connection for a thyroid disorder. Therefore, the Board finds that remand is necessary to obtain an addendum opinion concerning the etiology of the Veteran's thyroid disorder. The VA examiner must provide an opinion as to whether the Veteran's thyroid disorder was caused by, aggravated by, or otherwise related to his active service, to include radiation exposure. In offering such opinion, the VA examiner must consider and address the Veteran's statements concerning in-service radiation exposure. The VA examiner must also consider and address the evidence contained in the October 2020 memorandum from the Under Secretary of Health (through the Director, Post-9/11 Era Environment Health Program), as well as any relevant evidence in the October 2020 advisory opinion from the Director of Compensation Service. This evidence includes but is not limited to the dose estimate of radiation exposure assigned to the Veteran. Accordingly, the matter is REMANDED for the following action: Obtain an addendum medical opinion to determine the etiology of the Veteran's thyroid disorder. The opinion should be provided by a VA examiner who has not previously examined the Veteran. The claims file must be made available to and reviewed by the examiner in conjunction with the examination. After review of the evidence, the examiner should provide an opinion as to whether it is at least as likely as not (i.e., 50 percent or greater probability) that the Veteran's thyroid disorder was caused by, aggravated by, or otherwise related to his active service, including but not limited to any in-service exposure to radiation. In offering such opinion, the VA examiner must consider and address the lay statements of record, including but not limited to any statements by the Veteran concerning in-service radiation exposure. The VA examiner must also consider and address the evidence contained in the October 2020 memorandum from the Under Secretary of Health (through the Director, Post-9/11 Era Environment Health Program), as well as any relevant evidence in the October 2020 advisory opinion from the Director of Compensation Service. This evidence includes but is not limited to the dose estimate of radiation exposure assigned to the Veteran. The Board notes that, in order to substantially comply with this directive, it will not be sufficient to simply include the above-named evidence in the list of evidence considered. The examiner must specifically address this evidence in his or her opinion and give a complete rationale for why he or she agrees or disagrees with the findings in this evidence. The examiner should consider any other pertinent evidence of record, as appropriate. (Continued on the next page) All findings by the examiner should be reported in detail, and all opinions must be accompanied by a clear and complete rationale. Z. SAHRAIE Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Dawn A. Leung, 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.