Citation Nr: 18151801 Decision Date: 11/20/18 Archive Date: 11/20/18 DOCKET NO. 16-37 510 DATE: November 20, 2018 REMANDED Entitlement to service connection for fatigue is remanded. Entitlement to service connection for residuals of pseudo brain tumor is remanded. Entitlement to service connection for brain lesion is remanded. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty for training (ACDUTRA) in the United States Army Reserves from August 1998 to February 1999 and on active duty in the United States Army from December 2003 to June 2005. With regard to the issue of service connection for pseudo brain tumor, the Veteran did not file a Substantive Appeal in response to the June 2016 Statement of the Case (SOC). Nevertheless, there is no indication that the Agency of Original Jurisdiction (AOJ) closed the case for failure to file a timely substantive appeal because the AOJ certified this issue to the Board in August 2016. See Percy v. Shinseki, 23 Vet. App. 37, 42-45 (2009). REASONS FOR REMAND 1. Entitlement to service connection for fatigue The Veteran filed a claim for Gulf War Syndrome in January 2014. See January 2014 Report of General Information. The Veteran also filed a claim in March 2014 for Chronic Multi Symptom Illness, also known as Gulf War Syndrome. See March 2014 Report of General Information. The Board notes that the Veteran also filed a claim for chronic fatigue syndrome in September 2016. See September 2016 Fully Developed Claim. In October 2015, the Veteran was afforded a VA examination in connection to the application for Gulf War Syndrome. The examiner was requested to explain if the Veteran’s disability pattern was (1) an undiagnosed illness, (2) a diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology, (3) a diagnosable chronic multi-symptom with a partially explained etiology, or (4) a disease with a clear and specific etiology and diagnosis. See October 2015 VA Examination. The examiner found that the Veteran had multiple risk factors for the development of fatigue, including posttraumatic stress disorder (PTSD), insomnia, anemia, Vitamin D deficiency, migraine headaches, life stressors (single mom working full time), and medications (prazosin, topiramate, and frequent temazepam use may all contribute). See October 2015 VA Examination. The examiner opined that the Veteran’s complaint of fatigue was less likely a result of undiagnosed illness or Gulf War exposures and more likely related to previously diagnosed medical conditions. See October 2015 VA Examination. During the pendency of this appeal, the Veteran applied for service connection for fibromyalgia. See April 2016 Supplemental Claim. The Veteran was afforded a VA examination for fibromyalgia in August 2016. See August 2016 VA Examination. During the August 2016 VA examination, the examiner noted that one of the symptoms that the Veteran had, related to her service-connected fibromyalgia, was fatigue. See August 2016 VA Examination, p. 3. In an August 2016 rating decision, the AOJ granted service connection for fibromyalgia with an evaluation of 40 percent effective date of the Veteran’s fibromyalgia application, April 11, 2016. See August 2016 Rating Decision. The Veteran is competent to report the symptoms that she experiences. The Veteran is not competent to diagnose the condition that causes the symptoms that she experiences. Barr v. Nicholson, 21 Vet. App. 303 (2007), 38 C.F.R. § 3.159(a)(2) (2018). In the present case, the Veteran is competent to assert that she suffers from fatigue. However, the Veteran is not competent to assert the etiology of her fatigue. The VA examiners failed to indicate what disabilities contribute to the Veteran’s fatigue and the record has not addressed if the Veteran’s fatigue is a separate and distinct from her service-connected fibromyalgia, PTSD, or other service-connected disabilities. 2. Entitlement to service connection for residuals of pseudo brain tumor 3. Entitlement to service connection for brain lesion Due to the similar dispositions for the claims on appeal, the Board will address them in a common discussion below. The Veteran alleges that her pseudo brain tumor and brain lesion are related to in-service exposure to unknown toxins from burn pits while she was stationed at Camp Spearhead, Kuwait. See January 2014 Report of General Information (Application); May 2018 Appellate Brief. She also alleges that her brain lesions are caused by her service-connected headaches. See August 2016 VA Form 9. Generally, a medical opinion should address the appropriate theories of entitlement. Stefl v. Nicholson, 21 Vet. App. 120, 123-24 (2007). A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). In October 2015, the Veteran was afforded a VA examination for these claims on appeal. The Veteran noted that in 2010 she was noted to have mild/early papilledema and was referred for further testing which led to her diagnosis of pseudo tumor cerebri. Following the clinical evaluation, the examiner concluded the Veteran’s pseudotumor cerebri was in remission with no current symptoms, insomnia was more likely than not related to PTSD, and multiple past testing did not reveal a diagnosis for findings of fleeting facial paresthesias. During the course of the appeal, the Veteran has asserted symptoms of headaches attributable to her brain tumor. Moreover, review of VA treatment records shows the Veteran is in receipt of non-VA eye care which is relevant to her history for brain tumor and brain lesion. In light of these findings, additional development is needed to properly adjudicate the appeal, to include obtaining an additional VA medical opinion. See 38 U.S.C. § 5103A(a) (2012); 38 C.F.R. § 3.159; Barr, 21 Vet. App. at 312. The matter is REMANDED for the following actions: 1. Contact the Veteran and request that she identify any private treatment facilities or providers relevant to her residuals of brain tumor and brain lesion, to include eye care, and provide her with the appropriate release forms. Then, make appropriate efforts to obtain (a) any outstanding records so authorized for release from any facility identified by the Veteran and (b) all outstanding VA treatment records, to include from the Long Beach VA Medical Center. If these records cannot be located, the AOJ must specifically document the attempts made to locate them and notify the Veteran. 2. Then, return the Veteran’s claims file to the examiner who conducted the October 2015 VA examination so a supplemental opinion may be provided. If that examiner is no longer available, provide the Veteran’s claims file to a similarly qualified clinician. The entire claims file and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. A new examination is only required if deemed necessary by the examiner. First, the examiner must clarify whether the Veteran’s current fatigue is separate and distinct from her service-connected fibromyalgia or service-connected PTSD. If so, the examiner must opine as to the following: (a.) Whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s fatigue began during active service or is related to an incident of service, to include exposure to environmental elements during active service in Kuwait. (b.) Whether it is at least as likely as not that the Veteran’s fatigue is proximately due to or the result of any service-connected disability. (c.) Whether it is at least as likely as not that the Veteran’s fatigue was aggravated beyond its natural progression by any service-connected disability. Note: the Veteran is currently service-connected for the following disabilities: fibromyalgia, PTSD, tension headaches, asthma, lumbar strain, chronic sinusitis, and irritable bowel syndrome. The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. 3. Return the Veteran’s claims file to the examiner who conducted the October 2015 VA examination so a supplemental opinion may be provided. If that examiner is no longer available, provide the Veteran’s claims file to a similarly qualified clinician. The entire claims file and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. A new examination is only required if deemed necessary by the examiner. First, the examiner must clarify whether the Veteran has had any current residuals of her pseudo brain tumor and/or brain lesion at any time since January 2013 (even if since resolved) that are separate and distinct from her service-connected fibromyalgia or service-connected tension headaches. If so, the examiner must opine as to the following: (a.) Whether it is at least as likely as not (50 percent or greater probability) that the current residual(s) began during active service or is related to an incident of service, to include exposure to environmental elements during active service in Kuwait. (b.) Whether it is at least as likely as not that the Veteran’s current residual(s) is proximately due to or the result of any service-connected disability. (c.) Whether it is at least as likely as not that the Veteran’s current residual(a) was aggravated beyond its natural progression by any service-connected disability. Note: the Veteran is currently service-connected for the following disabilities: tension headaches, fibromyalgia, PTSD, asthma, lumbar strain, chronic sinusitis, and irritable bowel syndrome. The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. 4. Then, review the examination reports and medical opinions to ensure that the requested information was provided. If any report or opinion is deficient in any manner, the AOJ must implement corrective procedures. (Continued on the next page)   5. Then, readjudicate the claims. If any decision is adverse to the Veteran, issue a Supplemental Statement of the Case and allow the applicable time for response. Then, return the case to the Board. T. Blake Carter Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD G. DEEMER, ASSOCIATE COUNSEL