Citation Nr: 1340326 Decision Date: 12/06/13 Archive Date: 12/20/13 DOCKET NO. 10-20 166 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for severe muscle pain. 2. Entitlement to service connection for neurological syndrome. 3. Entitlement to service connection for chronic fatigue syndrome. 4. Entitlement to service connection for sleep disturbances. 5. Entitlement to service connection for abnormal weight loss. 6. Entitlement to service connection for left ankle condition with swelling. 7. Entitlement to service connection for migraine headaches. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD N. Sonia, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1985 to September 1993. This case comes before the Board of Veterans' Appeals (Board) on appeal from an October 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. The Board has not only reviewed the Veteran's physical claims file, but also the Veteran's file on the "Virtual VA" system to insure a total review of the evidence. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. REMAND The Veteran has asserted that he served in the Southwest Asia theater of operations. Service connection may be granted for a Persian Gulf Veteran who exhibits objective indications of chronic disability resulting from undiagnosed illness that became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than September 30, 2011, and which by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317(a)(1). Here, based on the evidence currently of record, the Board is unable to determine if the Veteran served in the Southwest Asia theater of operations. Accordingly, a remand is required to obtain the Veteran's service personnel records. It appears there may be missing VA treatment records. On his 2009 claim, the Veteran identified treatment for all conditions at the VAMC in Long Beach, California, but did not identify the dates of such treatment. He also stated he had received treatment at the VAMC in Dallas, and the RO obtained records from that facility starting in January 2009. In connection with a prior claim, the RO had obtained records from Long Beach for treatment between November 1997 and February 2007. There are currently no records covering the time periods from discharge from service in 1993 to 1997 and from 2007 to 2009. However, the Veteran did note on his claim in 2006 that he had received treatment at the VAMC Dallas in 1994 and at the VAMC Long Beach beginning in 1996. It is possible additional records exist since the only records obtained were those available electronically, and paper records were used at many VA medical facilities until the late 1990s. Moreover, the Veteran was afforded a VA Gulf War examination in March 2012. There is no indication that the examiner reviewed the claims file. In addition, the examiner identified the Veteran's symptoms and indicated his symptoms were more likely than not related to the following: diabetes mellitus; reflex sympathetic dystrophy of the lower limb; osteoarthritis, unspecified whether generalized or localized, involving ankle hyperuricemia; hypovitaminosis; unspecified inflammatory polyarthropathy; herpes genitalis; and gout NOS. However, the examiner did not provide a rationale for this opinion in terms of explaining which claimed symptoms were due to which identified conditions or if the symptoms were due to any undiagnosed illnesses. Therefore, the medical evidence currently of record is insufficient for the Board to render a decision, and this matter must be remanded for additional development of the medical record pursuant to 38 C.F.R. § 3.159(c)(4). See McLendon v. Nicholson, 20 Vet. App. 79 (2006). Next, in a February 2009 VA rheumatology consultation in which the Veteran sought treatment for joint swelling, the Veteran indicated he was pursuing social security disability benefits, and more recent VA records refer to the source of his income as "disability." The Veteran's Social Security Administration (SSA) records are not associated with the claims file and must be obtained on remand as they may be relevant to the claim on appeal. Therefore, the RO must contact SSA to obtain a complete copy of any and all adjudications and the records underlying any adjudication for disability benefits. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c); see also Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010). Accordingly, the case is REMANDED for the following action: 1. Request the Veteran's complete personnel file, to include any and all documents relating to his deployment to Southwest Asia, and associate them with the claims file. All actions to obtain the requested records should be fully documented in the claims file. 2. Contact SSA and obtain a complete copy of any and all adjudications and the records underlying any adjudication for disability benefits. All efforts to obtain SSA records should be fully documented, and a negative response must be provided if records are not available. 3. Request treatment records from the VAMCs in Dallas AND Long Beach dated from 1993 to 1997, AND from 2007 to 2009, and this must include a search of retired or archived records. All negative responses must be documented. 4. Obtain records from the VAMC Dallas for any treatment from June 2012 to the present. 5. Only after obtaining as much of the above evidence is available, then, request that the March 2012 examiner (or a suitable substitute) review the claims file and offer an addendum opinion. The examiner should indicate on the addendum opinion that the claims file was reviewed. The examiner should provide an opinion as to which claimed symptoms are due to which diagnosed or undiagnosed conditions, if any. In short, each symptom must be individually addressed with sufficient rationale rather than grouping all of the symptoms together and relating them to a group of diagnoses. A detailed rationale should be given for all opinions and conclusions expressed. If an opinion cannot be rendered without resorting to speculation, the VA examiner should explain why it would be speculative to respond. 6. After completion of the requested development as outlined above, readjudicate the claims. If the benefit sought is not granted, provide the Veteran and his representative with a supplemental statement of the case and allow an appropriate opportunity to respond thereto. Then return the case to the Board, if in order. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2013). _________________________________________________ MICHELLE L. KANE Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2013).