Citation Nr: 22017657 Decision Date: 03/25/22 Archive Date: 03/25/22 DOCKET NO. 15-33 381A DATE: March 25, 2022 THE ISSUES 1. Entitlement to service connection for squamous cell carcinoma. 2. Entitlement to service connection for basal cell carcinoma with scarring. REMANDED Entitlement to service connection for squamous cell carcinoma is remanded. Entitlement to service connection for basal cell carcinoma with scarring is remanded. REASONS FOR REMAND The Veteran served on active duty from November 1966 to August 1969, to include service in the Republic of Vietnam. The Veteran was awarded the Purple Heart Medal for his honorable service. He died in November 2019. These matters come before the Board of Veterans' Appeals (Board) on appeal from an August 2015 rating decision issued by a Regional Office (RO) of the United States Department of Veterans Affairs (VA). In November 2020, the Veteran's surviving spouse was substituted as the Appellant. As to the matters on appeal, the late Veteran and the Appellant presented sworn testimony before the undersigned Veterans Law Judge at an October 2018 Board hearing. A transcript of the proceeding has been associated with the claims file. These matters were previously denied by the Board in July 2019. However, as submitted evidence had not been considered in the decision, it was vacated in April 2020. The Board thereafter remanded the claims for further evidentiary development in April 2021 and November 2021. Although regretting the additional delay, the Board finds that remand is again needed to ensure compliance with the prior remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). 1. Entitlement to service connection for squamous cell carcinoma is remanded. 2. Entitlement to service connection for basal cell carcinoma with scarring is remanded. The Appellant has contended that the Veteran's squamous cell carcinoma and basil cell carcinoma were the result of his active service, to include his presumed exposure to herbicide agents and/or exposure to ultraviolet light while in Vietnam and/or as secondary to his use of immunosuppressive therapy to treat his service-connected Crohn's disease. The November 2021 remand directed the RO to obtain a medical opinion that specifically considered April 2019, August 2019, and June 2019 private medical opinions and a medical article discussing the use of azathioprine and the increased risk of developing nonmelanoma skin carcinomas The Board instructed the examiner to address whether it was at least as likely as not that the Veteran's squamous cell and basal cell carcinomas were proximately due to or the result of the long-term immunosuppressive therapy used to treat his service-connected Crohn's disease. The examiner was also instructed to address whether it was at least as likely as not that his squamous cell and basal cell carcinomas underwent any incremental increase in disability, regardless of its permanence, due to or the result of the long-term immunosuppressive therapy used to treat the Veteran's service-connected Crohn's disease. Finally, the examiner was asked to opine whether it was at least as likely as not that the Veteran's squamous cell and basal cell carcinomas were proximately due to or the result of exposure to ultraviolet light while on active service. A VA examiner undertook the required review in February 2022. Unfortunately, the Board finds the reports inadequate. While the reports addressed the submitted article it did not meaningfully address the private opinions highlighted in the remand order. See Stegall v. West, 11 Vet. App. at 271 (holding that a remand by the Board confers upon the Veteran, as a matter of law, the right to compliance with its remand instructions, and imposes upon VA a concomitant duty to ensure compliance with the terms of the remand). The matters are REMANDED for the following action: 1. Obtain a VA medical opinion from an appropriate VA examiner regarding the etiology of the Veteran's squamous cell and basal cell carcinomas. Following a complete review of the electronic claims file, including a copy of this REMAND, the VA examiner is requested to address the following inquiries: a. Is it at least as likely as not that the Veteran's squamous cell and basal cell carcinomas were proximately due to or the result of the long-term immunosuppressive therapy used to treat his service-connected Crohn's disease? b. Is it at least as likely as not that the Veteran's squamous cell and basal cell carcinomas underwent any incremental increase in disability, regardless of its permanence, due to the long-term immunosuppressive therapy used to treat his service-connected Crohn's disease? See Ward v. Wilkie, 31 Vet. App. 233 (2019). (i) The term "incremental increase in disability" means additional impairment of earning capacity. Objective measurement, or numerical quantification, is not required to ascertain an increase in disability. Moreover, any "incremental increase in disability" need not be permanent. c. Is it at least as likely as not that the Veteran's squamous cell and basal cell carcinomas were proximately due to or the result of exposure to ultraviolet light while on active service? d. The VA examiner is specifically requested to consider and address the April 2019, August 2019, and June 2019 private medical opinions, as well as the medical article discussing azathioprine and the increased risk of developing nonmelanoma skin carcinomas in addressing the first two issues. The examiner is also requested to consider and address the November 2016 opinion and any other relevant documents in addressing the third issue. e. The VA examiner must provide a complete rationale for any opinion expressed that is based on the examiner's clinical experience and medical expertise; established medical principles; and citation to the evidence of record, as appropriate. (Continued on next page.) 2. After the above development, and any additionally indicated development, has been completed, readjudicate the claim. Michael A. Pappas Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. E. Geary, 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.