Citation Nr: 22005441 Decision Date: 02/01/22 Archive Date: 02/01/22 DOCKET NO. 16-50 776 DATE: February 1, 2022 REMANDED Entitlement to service connection for hepatocellular carcinoma is remanded. REASONS FOR REMAND The Veteran served on active duty from April 1966 to February 1970. This appeal was previously before the Board in October 2021, at which time it was remanded to the agency of original jurisdiction (AOJ) so that a medical opinion could be obtained that addressed the Veteran's theory of entitlement that his currently-diagnosed hepatocellular carcinoma was related to his exposure to hazardous toxins, such as trichloroethylene (TCE), through his use of cleaning solvents and degreasers as an airplane mechanic. A medical opinion was obtained in November 2021; however, as will be explained, the opinion is insufficient to adjudicate the Veteran's claim for service connection. After noting the Veteran's VA treatment for hepatocellular carcinoma, as well as information from the VA and the Centers for Disease Control and Prevention (CDC) discussing the hazardous nature of TCE and the possible association between TCE and liver cancer, the examiner concluded that the Veteran's hepatocellular carcinoma was less likely than not related to his in-service exposure to TCE. The examiner reasoned that, while there was an association between TCE exposure and certain cancers, particularly kidney cancer, "the current literature search does not show a preponderance of evidence that TCE definitively causes hepatocellular carcinoma." It appears that the examiner applied the incorrect standard for the purposes of this appeal in finding that "the current literature search does not show a preponderance of evidence that TCE definitively causes hepatocellular carcinoma." Indeed, the standard applicable in this case is an "at least as likely as not" standard. As such, the AOJ should obtain a medical opinion from a competent medical professional(s) to determine whether the Veteran's hepatocellular carcinoma is at least as likely as not (approximately 50 percent probability) related to his military service, to include any possible in-service exposure to TCE. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The matters are REMANDED for the following action: 1. Ask the Veteran's representative to submit printed or electronic copies of all medical treatise evidence and/or Internet research articles he wishes VA to consider in support of the Veteran's claim, as identified in the October 2021 appellate Brief. 2. After all available records have been associated with the claims file, obtain an addendum opinion from a competent medical professional to determine whether the Veteran's hepatocellular carcinoma is at least as likely as not related to his military service, to include any possible in-service exposure to TCE. The claims folder must be made available to the medical professional. The need for an additional examination is left to the discretion of the medical professional selected to write the opinion. Following a review of the record, the medical professional should respond to the following: Is it at least as likely as not (approximately 50 percent probability) that the Veteran's hepatocellular carcinoma is related to his active duty service, to specifically include exposure to hazardous materials, such as TCE, through his use of cleaning solvents and degreasers as an airplane mechanic? In offering any opinion, the medical professional must consider the full record, to include the medical evidence quoted in the October 2021 appellate brief. Also, the medical professional shoulder consider the information from the VA and the CDC cited by the November 2021 opinion provider that discussed the hazardous nature of TCE, as well as the possible association between TCE and liver cancer. Please note that the appropriate standard in this case is the "at least as likely as not" standard, meaning approximately 50 percent probability. A such, a preponderance of the evidence need not show the presence of a relationship between the liver cancer and the Veteran's chemical exposures, nor is proof of definitive causation needed. A clearly-stated rationale for any opinion offered should be provided. (Continued on Next Page) 3. Thereafter, readjudicate the appeal. V. Chiappetta Veterans Law Judge Board of Veterans' Appeals Attorney for the Board James R. Springer, 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.