Citation Nr: 22016597 Decision Date: 03/22/22 Archive Date: 03/22/22 DOCKET NO. 16-53 375A DATE: March 22, 2022 REMANDED The issue of entitlement to service connection for large B-cell Burkitt lymphoma (accrued benefits) is remanded. The issue of entitlement to service connection for GI bleed (accrued benefits) is remanded. The issue of entitlement to service connection for febrile neutropenia (accrued benefits) is remanded. The issue of entitlement to service connection for anemia (accrued benefits) is remanded. The issue of entitlement to a total disability rating based on individual unemployability (TDIU) (accrued benefits) is remanded. The issue of entitlement to service connection for the cause of the Veteran's death is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1988 to July 1988, from July 2003 to September 2003, from November 2004 to December 2005, and from November 2006 to February 2013. He died in August 2015. The appellant is the Veteran's surviving spouse. This matter is before the Board of Veterans' Appeals (Board) on appeal from a September 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO), which denied entitlement to service connection for the cause of the Veteran's death; denied entitlement to service connection for B-cell Burkitt lymphoma, GI bleed, anemia, and febrile neutropenia, for accrued benefits purposes; and denied entitlement to a TDIU for accrued benefits purposes. The appellant timely appealed all issues in the September 2015 rating decision. See February 2016 Notice of Disagreement (cause of death, TDIU, febrile neutropenia, lymphoma, and anemia); June 2016 Notice of Disagreement (GI bleed); October 2016 Statement of the Case; November 2016 VA Form 9. In October 2021, the appellant testified at a hearing before the undersigned Veterans Law Judge, a transcript of which is of record. Upon review of the record, the Board finds a remand is necessary to ensure that there is a complete record upon which to decide the appellant's claim so that she is afforded every possible consideration. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159 The appellant contends that the Veteran's B-cell testicular lymphoma, which was listed as his cause of death, had its onset in service. Specifically, she asserts that although the Veteran was not formally diagnosed with lymphoma until 2015, he began displaying symptoms of lymphoma in service, to include nodules, enlarged lymph nodes, enlarged prostate, elevated PSA, erectile dysfunction, nocturia, fatigue, and headaches. See February 2017 Statements in Support of Claim; October 2021 Correspondence; October 2021 Hearing Transcript. She also contends that GI bleed, anemia, and febrile neutropenia were all secondary to B-cell testicular lymphoma. Service treatment records show that the Veteran had an elevated PSA level in August 2011. A January 2012 CT scan shows several nodules and enlarged lymph nodes, as well as a mildly prominent prostate. A July 2012 service treatment record shows that the Veteran was evaluated for erectile dysfunction, nocturia, and urinary tract symptoms. A December 2012 service treatment record shows that the Veteran was evaluated for inguinal swelling and a knot in the pelvic area. An August 2013 private CT scan, which was within one year of the Veteran's discharge, shows multiple nodules in the spleen, increased in size since 2012, which "may represent enlarge lymph node," as well as "moderate to marked enlargement of the prostate." Treatment records from March 2015 show that the Veteran was seen for an enlarged testicle, and an ultrasound showed testicular malignancy, which was ultimately diagnosed as "high-grade lymphoma with a testicular primary." The appellant submitted numerous articles regarding Burkitt-like lymphoma, which indicated that Burkitt's lymphoma affects the prostate in only 0.1% of cases and that it is usually misdiagnosed as BPH (for which the Veteran was service-connected at the time of his death). The articles also indicated that Burkitt's lymphoma affecting the prostate commonly presents as abdominal lymphadenopathy with abdominal pain and other GI symptoms. In a September 2015 medical opinion, a VA examiner opined that the Veteran' s lymphoma was less likely as not related to service because "B cell Burkitt Lymphoma is not considered a health condition recognized for presumptive service connection for Gulf War Veterans." The Board finds that the September 2015 opinion is inadequate. As an initial matter, a medical opinion concluding that a disease is not related to in-service exposures solely because there is no presumption of service connection is inadequate for rating purposes. See Polovick v. Shinseki, 23 Vet. App. 48, 55 (2009) (holding that "to permit the denial of service connection for a disease on the basis that it is not likely there is any nexus to service solely because the statistical analysis does not support presumptive service connection, would, in effect, permit the denial of direct service connection simply because there is no presumptive service connection"). Moreover, the examiner did not discuss whether the Veteran's in-service and post-service symptoms were manifestations of lymphoma, which is essentially the crux of the appellant's argument. Absent an adequate medical opinion on this issue, the record is insufficient for the Board to render a decision on the appellant claim and a remand is necessary. Regarding the claim of entitlement to service connection for anemia, a remand is required for issuance of a statement of the case. In this regard, the appellant expressly disagreed with the denial of entitlement to service connection for anemia in her February 2016 notice of disagreement. However, the October 2016 statement of the case did not address this issue. Accordingly, the issue of entitlement to service connection for anemia is remanded for issuance of a statement of the case pursuant to Manlincon v. West, 12 Vet. App. 238 (1999). Finally, the remaining service connection claims and the claim of entitlement to a TDIU are inextricably intertwined with the issue of entitlement to service connection for lymphoma, and they are deferred pending the development requested herein. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). The matters are REMANDED for the following action: 1. Provide the appellant and her representative with a statement of the case regarding the issue of entitlement to service connection for anemia. Advise them of the time period in which to perfect the appeal. If the appellant perfects an appeal of this issue in a timely fashion, then return the case to the Board for its review, as appropriate. 2. Obtain and associate with the claims file any outstanding VA treatment records documenting treatment for the issues on appeal. The appellant should also be afforded the opportunity to identify and submit any outstanding private treatment records. 3. After any additional records are associated with the claims file, obtain an addendum opinion regarding the etiology of the Veteran's B cell Burkitt lymphoma. The entire claims file and a copy of this Remand must be made available to the reviewing examiner and the examiner shall indicate in the report that the claims file was reviewed. After reviewing the claims file, the examiner should offer an opinion as to whether it is at least as likely as not (i.e., 50 percent probability or greater) that the Veteran's lymphoma was incurred in, caused by, or is otherwise related to, the Veteran's active military service, to include his Gulf War exposures as well as his in-service complaints and treatment for enlarged lymph nodes, enlarged prostate, elevated PSA, and GI symptoms. The examiner should also provide an opinion as to whether it is at least as likely as not (i.e., 50 percent probability or greater) that the Veteran's lymphoma was present within one year of service discharge. In providing these opinions, the examiner must fully review and comment on the appellant's statements and summarizations of the Veteran's service treatment records and post-service treatment records, which she contends show symptoms of lymphoma in service and/or within the first post-service year. The examiner must also review and comment on the treatise evidence submitted by the appellant discussing the symptoms and misdiagnoses related to Burkitt lymphoma affecting the prostate/testicles. Additionally, the examiner may not rely solely on the fact that the Veteran's conditions are not on the presumptive list of diseases associated with Gulf War exposures. Rather, the opinion should explain why any statistical or medical studies are found to be persuasive or unpersuasive and should address whether there are other risk factors that might be the cause of the Veteran's condition or whether it manifested in an unusual manner. The examiner's report must reflect consideration of the Veteran's entire documented medical history and assertions and all lay evidence. If the examiner is unable to provide an opinion without resort to speculation, he or she should explain why this is so and what, if any, additional evidence would be necessary before an opinion could be rendered. The examiner must provide a thorough rationale for each opinion given. 4. After the above development, and any additionally indicated development, has been completed, readjudicate the issues on appeal, including the inextricably intertwined issues. If the benefit sought is not granted to the appellant's satisfaction, send the appellant and her representative a Supplemental Statement of the Case and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. B. MULLINS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Kipper, 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.