Citation Nr: 18142164 Decision Date: 10/12/18 Archive Date: 10/12/18 DOCKET NO. 16-33 660 DATE: October 12, 2018 REMANDED Entitlement to service connection for a low back disorder is remanded. Entitlement to service connection for Lyme disease is remanded. Entitlement to service connection for migraines/headaches is remanded. Entitlement to service connection for insomnia is remanded. REASONS FOR REMAND The Veteran had served on active duty for training from April 2011 to August 2011, with additional periods of Army Reserve duty. This appeal comes to the Board of Veterans’ Appeals (Board) from an October 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Hartford, Connecticut. The Board notes that the Veteran’s original appeal included the issues of entitlement to service connection for a right hip disorder and a left hip disorder. However, in a June 2016 rating decision, the RO granted service connection for bursitis of the right hip and bursitis of the left hip. The Veteran has not disagreed with the rating or the effective date assigned; therefore, these matters are not in appellate status. See Grantham v. Brown, 114 F. 3d 1156, 1158 (Fed. Cir. 1997) (holding that a separate notice of disagreement must be filed to initiate appellate review of “downstream” elements such as the disability rating or effective date assigned). 1. Entitlement to service connection for a low back disorder is remanded. 2. Entitlement to service connection for Lyme disease is remanded. 3. Entitlement to service connection for migraines/headaches is remanded. 4. Entitlement to service connection for insomnia is remanded. A remand is warranted to afford the Veteran a VA examination for her low back disorder, Lyme disease, headaches/migraines, and insomnia. The Veteran has never been afforded a VA examination for these conditions. A May 2012 Reserve service treatment record shows that the Veteran was diagnosed with back strain. In September 2015, the Veteran had a private sleep study performed and was diagnosed with snoring and unspecified organic insomnia. See October 2015 Medical Treatment Record – Non-Government Facility. The Veteran asserts that her headaches/migraines, Lyme disease, insomnia, and low back disorder are directly related to her active duty military service. Specifically, she contends that all of her conditions stem from being bitten by a tick while in basic training and contracting Lyme disease. Several attempts had been made to try to figure out what was causing her disorders while on active duty, but it was finally diagnosed and properly treated in 2013, almost 18 months after the initial complaint. She asserts that the Lyme disease went untreated for that time, and it resulted in the subsequent issues of headaches, insomnia, and the low back disorder that is secondary to the service-connected hip bursitis. See August 2018 Appellate Brief. As the Veteran has not been afforded VA examinations for these claimed conditions, the Board finds that the evidence of record is sufficient to trigger VA’s duty to assist in providing the Veteran with VA examinations to determine whether her Lyme disease, low back disorder, insomnia, and migraines/headaches are etiologically related to her military service. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The matters are REMANDED for the following action: 1. Obtain any outstanding VA treatment or private treatment records and associate with the claims file. Request the Veteran to fill out and return an authorized release form (VA Form 21-4142), for any facility where the Veteran received private treatment for her conditions, to include Orthopedics in Middletown. 2. Following completion of the above, schedule the Veteran for VA examinations to determine the nature and etiology of her Lyme disease, low back disorder, insomnia, and migraines/headaches. The record and a copy of this remand must be made available and reviewed by the examiner in conjunction with the examination. All necessary tests should be completed. A complete history should be obtained from the Veteran. (a.) The VA examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that her Lyme disease, low back disorder, insomnia, and migraines/headaches are of service onset or otherwise related to her active military service. (b.) Regarding the low back disorder, the VA examiner should provide an opinion as to whether it is at least as likely as not (i.e., 50 percent or greater probability) that her low back disorder is caused by her service-connected left hip and right hip bursitis. (c.) Regarding the low back disorder, is it at least as likely as not (i.e., 50 percent or greater probability) that her low back disorder is aggravated (i.e., any worsening beyond normal progression of the disability) by her service-connected left hip bursitis and right hip bursitis. (d.) Regarding the low back disorder, if aggravation is found, the examiner should also state, to the extent possible, the baseline level of disability prior to aggravation. This may be ascertained by the medical evidence of record and also by the Veteran’s statements as to the nature, severity, and frequency of her observable symptoms over time. (e.) When responding, the examiner should consider the lay statements of record regarding the nature and onset of the symptoms. The examiner is advised that the Veteran is competent to report symptoms and treatment. Also, the mere absence of evidence of contemporaneous treatment in the service treatment records cannot, standing alone, serve as the sole basis for an unfavorable opinion. (f.) All answers to the questions listed above must be supported by a clear rationale. The examiner is asked to explain in detail the underlying reasoning for his or her opinions, to include citing to relevant evidence, supporting factual data, prior medical opinions, and medical literature, as appropriate. If any requested opinion cannot be provided without resorting to mere speculation, the examiner must explain why a more definitive response is not possible or feasible. In other words, merely saying he or she cannot respond will not suffice. BARBARA B. COPELAND Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. Crawford, Associate Counsel