Citation Nr: 18146624 Decision Date: 10/31/18 Archive Date: 10/31/18 DOCKET NO. 16-18 193 DATE: October 31, 2018 REMANDED Entitlement to service connection for a disability manifested by dizziness, to include as due to an undiagnosed illness, is remanded. Entitlement to service connection for an organic disability manifested by memory loss, to include as due to an undiagnosed illness, is remanded. Entitlement to service connection for a disability manifested by muscle and joint pain, to include as due to an undiagnosed illness, is remanded. Entitlement to service connection for a disability manifested by indigestion, heartburn and acid reflux to include as due to an undiagnosed illness, is remanded. Entitlement to service connection for headaches, to include as due to an undiagnosed illness, is remanded. Entitlement to service connection for a skin disorder (claimed as acne and skin nodules), to include as due to an undiagnosed illness, is remanded. Entitlement to service connection for sleep apnea is remanded. Entitlement to service connection for a disability manifested by fatigue, to include as due to an undiagnosed illness, is remanded. Entitlement to service connection for an acquired psychiatric disorder, to include depression and anxiety is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1998 to November 2002, including service in Southwest Asia. 1. Entitlement to service connection for a disability manifested by dizziness is remanded In the September 2015 notice of disagreement (NOD), the Veteran contended his disability manifested by dizziness was caused by his anthrax shot series in-service. The Veteran has also supplied evidence to support his contention in September 2015 and April 2016. Accordingly, an addendum opinion is necessary prior to adjudication of the Veteran’s claim. 38 C.F.R. § 3.159(c)(4). 2. Entitlement to service connection for an organic disability manifested by memory loss is remanded The Veteran was afforded a VA examination in May 2017. The examination combined the claim for memory loss with the chronic fatigue, but the examiner only provided a nexus opinion for chronic fatigue. Additionally, the Veteran contends the memory loss is due to his anthrax shot series. As there has not been a medical opinion provided as to the nature and etiology of the Veteran’s memory disability, an addendum opinion is necessary. Id. 3. Entitlement to service connection for a disability manifested by muscle and joint pain is remanded. The Veteran was afforded a VA examination in May 2017. The examination combined the claim for muscle and joint pain with the chronic fatigue, but the examiner only provided a nexus opinion for chronic fatigue. As there has not been a medical opinion provided as to the nature and etiology of the Veteran’s muscle and joint pain, an addendum opinion is necessary. Id. 4. Entitlement to service connection for a disability manifested by indigestion, heartburn and acid reflux illness is remanded. The Veteran was afforded a VA examination in May 2017, and the VA examiner provided a negative nexus opinion. The examiner listed alternative causes for the Veteran’s reflux condition, but failed to indicate which, if any, of the alternative causes applied to the facts of the Veteran’s case. Therefore, the rationale is inadequate, and an addendum opinion is necessary to decide the claim. 5. Entitlement to service connection for headaches is remanded. In the September 2015 NOD, the Veteran contended his headaches were caused by his anthrax shot series in-service. The Veteran was afforded a VA examination in May 2017, and the examiner provided a negative nexus opinion, finding the headaches have a partially explained etiology to include “lack of sleep.” The Veteran’s contention of his headaches being caused by the anthrax shot series has not been addressed by a medical opinion. In addition, in the instant appeal, the issue of service connection for sleep apnea is also before the Board. Therefore, the examiner should also provide an opinion as to whether the Veteran’s headaches are secondary to sleep apnea. 6. Entitlement to service connection for a skin disorder is remanded. The Veteran was afforded a VA examination in May 2017, and the VA examiner provided a negative nexus opinion. The examiner listed alternative causes for the Veteran’s skin condition, but failed to indicate which, if any, of the alternative causes applied to the facts of the Veteran’s case. Therefore, the rationale is inadequate, and an addendum opinion is necessary to decide the claim. Id. The examiner should also address the Veteran’s contention of the anthrax series shot causing the Veteran’s skin condition. See September 2015 NOD. 7. Entitlement to service connection for sleep apnea is remanded. In September 2013, the Veteran contended he experienced sleep apnea symptoms in service, and his sleep apnea was caused by exposure to carbon monoxide and jet fuel. In the April 2016 substantive appeal, the Veteran contended his sleep apnea was caused by the anthrax shot series. The Veteran’s March 2016 examiner provided a negative opinion; however, his lay evidence of experiencing symptoms during service and his contentions of carbon monoxide, jet fuel, and the anthrax shot series causing sleep apnea were not addressed in the rationale. Therefore, an addendum opinion is necessary. 8. Entitlement to service connection for a disability manifested by fatigue, to include as a qualifying chronic disability under 38 C.F.R. § 3.317 is denied. Because of the facts found in this case, the Board is treating this claim as separate from the claim for service connection for muscle and joint pain, to which it was originally linked on appeal. The Veteran was afforded an addendum opinion in November 2017 by the same medical professional who provided the May 2017 examination. The examiner changed her diagnosis, finding no chronic fatigue syndrome. The examiner determined the fatigue was caused by the Veteran’s obstructive sleep apnea, low testosterone, low cortisol, current medications, his general anxiety, and chronic joint paints. As the claim for service connection for sleep apnea is being remanded, this claim must be remanded as well, as being inextricably intertwined. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). 9. Entitlement to service connection for an acquired psychiatric disorder, to include depression and anxiety is remanded. An April 2014 buddy statement from B.S.P provided lay evidence of the Veteran exhibiting symptoms of a psychiatric disorder. A May 2014 statement from the Veteran’s mother noted the Veteran showing symptoms during active service. In the June 2014 NOD the Veteran reported experiencing symptoms during active service. In the April 2016 substantive appeal, the Veteran contended that the anthrax shot series caused depression. The Veteran was afforded a VA examination in May 2017. The examiner provided a negative nexus opinion; however, the Veteran’s lay evidence of experiencing symptoms during service and his contention of the anthrax shot series causing depression were not addressed in the rationale. Therefore, an addendum opinion is necessary. The matters are REMANDED for the following action: 1. Make efforts to obtain all outstanding medical records in accordance with 38 C.F.R. § 3.159(c). 2. After all outstanding records have been associated with the claims file, forward the Veteran’s file to a qualified VA medical professional (or multiple examiners, if deemed necessary) in order to obtain addendum opinions as to the current nature and etiology of the nine disabilities claimed on appeal (as listed in paragraph (a.) below). A full medical history should be documented in the examination report. The claims file should be made available to the examiner(s). All studies and tests deemed necessary by the examiner(s) should be performed. The Veteran’s lay contentions must be addressed in full. The examiner is asked to address the following: (a.) Provide a current diagnosis for the Veteran’s conditions which may be manifested by: 1.) a disability manifested by dizziness; 2.) an organic disability manifested by memory loss; 3.) a disability manifested by muscle and joint pain; 4.) a disability manifested by indigestion, heartburn and acid reflux; 5.) headaches; 6.) a skin disorder; 7.) sleep apnea; 8.) a dizziness manifested by fatigue; and 9.) an acquired psychiatric disorder at any time during the period on appeal. (b.) If the Veteran does not now have, but previously had, any diagnosed condition, when did that condition resolve? (c.) For each diagnosed disorder, is it at least as likely as not (a 50 percent or greater probability) that the disorder had its onset during or is otherwise related to any event or injury during active duty, to include anthrax series shots? (d.) If a nexus to service cannot be established for any abnormality, please provide an opinion as to whether the disability pattern is consistent with: (1) an undiagnosed illness, (2) a diagnosable but medically unexplained chronic multisymptom illness of unknown etiology, (3) a diagnosable chronic multisymptom illness with a partially explained etiology, or (4) a disease with a clear and specific etiology and diagnosis. (e.) If, after reviewing the claims file, it is determined that the Veteran’s disability pattern is consistent with either (3) a diagnosable chronic multi-symptom illness with a partially explained etiology, or (4) a disease with a clear and specific etiology and diagnosis, then please provide a medical opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that the disability pattern or diagnosed disease is related to environmental exposures experienced by the Veteran during active duty, to include his service in Southwest Asia. (f.) Provide an opinion as to whether the Veteran’s headache condition is at least as likely as not (50 percent or greater probability) caused or aggravated (increased in severity beyond the natural progress of the disorder) by his sleep apnea. In answering all questions, please articulate the reasoning underpinning the conclusions. That is, (1) identify what facts and information--whether found in the record or outside the record--support the opinion, and (2) explain how that evidence justifies the opinion. Simply providing potential causes of the conditions is not adequate without connecting them to the evidence in the Veteran’s record. A. C. MACKENZIE Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD B. N. Quarles, Associate Counsel