Citation Nr: 18153466 Decision Date: 11/27/18 Archive Date: 11/27/18 DOCKET NO. 14-31 876 DATE: November 27, 2018 REMANDED Entitlement to service connection for osteoarthritis, other than of the lumbar spine, to include as secondary to service-connected Crohn’s disease, is remanded. Entitlement to service connection for a sleep disability, to include as secondary to service-connected Crohn’s disease, is remanded. Entitlement to service connection for irritable bowel syndrome (IBS), to include as secondary to service-connected Crohn’s disease, is remanded. Entitlement to service connection for fibromyalgia, to include as secondary to service-connected Crohn’s disease, is remanded. Entitlement to an increased rating for Crohn's disease is remanded. Entitlement to a total disability rating based on individual unemployability due to service connected disabilities (TDIU), is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1991 to June 1993. 1. Entitlement to service connection for osteoarthritis is remanded. The Veteran contends that he has osteoarthritis which is related to service-connected disabilities. At a June 2018 hearing, the Veteran testified that he had pain in the joints, including the shoulders, elbows, knees, fingers, hands, and ankles. The Veteran testified that he believed these symptoms were related to service-connected Crohn’s disease or osteoporosis. In an August 2018 private medical letter, the Veteran’s doctor opined that treatment with long-term steroids caused osteoporosis, which in turn caused osteoarthritis. The Board finds that a joints examination is needed to determine if any diagnosed joint disability, other than osteoarthritis of the spine, is related to service-connected disabilities, specifically osteoporosis. When VA obtains an examination or opinion, the examination or opinion must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). 2. Entitlement to service connection for a sleep disability is remanded. The Veteran contends that he has a sleep disability which is related to Crohn’s disease. In an October 2012 VA examination, the Veteran reported difficulty sleeping and that he had been diagnosed with insomnia. The examiner noted that the Veteran had never had a sleep study performed. At a June 2018 hearing, the Veteran testified that he first experienced symptoms of sleep disturbance in 1992, when he first developed problems with Crohn’s disease. The Veteran testified that he continued to experience symptoms of sleep disturbance to the present. At the hearing, the Veteran’s representative stated that the claim should be recharacterized from sleep apnea to include any sleep disability. In an August 2018 private medical letter, the Veteran’s doctor opined that the Veteran’s sleep disturbances were due to diarrhea and abdominal pain associated with Crohn’s disease. The Board finds that a new VA examination is needed to obtain an opinion regarding any sleep disability and any relationship to service or service-connected Crohn’s disease. When VA obtains an examination or opinion, the examination or opinion must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). 3. Entitlement to service connection for fibromyalgia is remanded. The Veteran contends that diagnosed fibromyalgia is related to service-connected Crohn’s disease, specifically long-term use of steroids for treatment of Crohn’s disease. The Veteran was provided with a VA examination in April 2015 for fibromyalgia. The examiner opined that diagnosed fibromyalgia was not related to service-connected Crohn’s disease as Crohn’s disease was a separate and distinct condition of unclear etiology. The examiner did not specifically address any possible effect of long-term steroid use or other medication use on the development or aggravation of fibromyalgia. The examiner also noted that adrenal insufficiency can cause symptoms similar to fibromyalgia. Subsequent to the April 2015 examination, the Veteran was service-connected for adrenal insufficiency associated with Crohn’s disease. The Veteran’s VA medical records indicate a diagnosis of fibromyalgia. The Board finds that a remand is necessary to obtain an opinion to clarify whether the diagnosed fibromyalgia is related to steroid medication taken for Crohn’s disease, or is related to now service-connected adrenal insufficiency. When VA obtains an examination or opinion, the examination or opinion must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). 4. Entitlement to service connection for irritable bowel syndrome (IBS) is remanded. The Veteran contends that he has IBS related to service-connected Crohn’s disease. In an October 2012 VA examination, the examiner noted that the Veteran did not have a diagnosis of IBS, and that the cause of the Veteran’s gastrointestinal complaints was Crohn’s disease. January 2018 VA medical records noted a prior medical history of IBS and Crohn’s disease. June 2018 private medical records show a diagnosis of IBS. In an August 2018 private medical letter, the Veteran’s doctor opined that he believed IBS was related to Crohn’s disease. The Board finds that a VA examination is needed to reconcile the conflicting evidence of record, specifically the current diagnosis of IBS and opinion relating it to Crohn’s disease. When VA obtains an examination or opinion, the examination or opinion must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). 5. Entitlement to an increased rating for Crohn's disease is remanded. The Board finds that a more contemporaneous VA examination is required to properly assess the current severity of the disability. The Veteran was last provided with a VA examination for Crohn’s disease in March 2015. While, generally, the mere passage of time is not a sufficient basis for another examination, further allegations of a worsening condition have been set forth by the Veteran since the prior examination. Palczewski v. Nicholson, 21 Vet. App. 174 (2007). Specifically, at a June 2018 hearing, the Veteran testified that symptoms of Crohn’s disease had worsened since the prior VA examination. Therefore, remand is necessary to obtain a current examination for the disability. 6. Entitlement to TDIU is remanded. The Board finds that the claims for service connection, increased rating for Crohn’s disease, and entitlement to TDIU are inextricably intertwined, and the claim for TDIU must also be remanded. Harris v. Derwinski, 1 Vet. App. 180 (1991). The matters are REMANDED for the following action: 1. Identify any VA or private medical records of treatment that are not already of record and associate them with the claims file. 2. Schedule the Veteran for a VA joints examination with a medical doctor examiner who has not previously examined him. The examiner must review the claims file and should note that review in the report. The rationale for all opinions should be provided. The examiner should explicitly provide the following opinions: (a.) Identify any joint disabilities, including fibromyalgia, and specifically opine whether a diagnosis of fibromyalgia is warranted. For each joint disability found, to include fibromyalgia and osteoarthritis, is it at least as likely as not (50 percent or greater probability) that the joint disability was incurred during service, or is due to any event, disease, or injury during service. (b.) For each joint disability found, to include fibromyalgia and osteoarthritis, is it at least as likely as not (50 percent or greater probability) that the joint disability is due to or the result of a service-connected disability, to include Crohn’s disease or osteoporosis or any medication taken for a service-connected disability? (c.) For each joint disability found, to include fibromyalgia and osteoarthritis, is it at least as likely as not (50 percent or greater probability) that the joint disability has been aggravated (permanently increased in severity beyond the natural progression of the disability) by a service-connected disability, to include Crohn’s disease or osteoporosis or any medication taken for a service-connected disability? (d.) Is it at least as likely as not (50 percent or greater probability) that a fibromyalgia disability is due to or the result of a service-connected disability, to include medication for treatment of Crohn’s disease, osteoporosis, or adrenal insufficiency? (e.) Is it at least as likely as not (50 percent or greater probability) that a fibromyalgia disability has been aggravated (permanently increased in severity beyond the natural progression of the disability) by a service-connected disability, to include medication for treatment of Crohn’s disease, osteoporosis, or adrenal insufficiency? 3. Schedule the Veteran for a VA examination to determine the nature and etiology of any sleep disability. The examiner must review the claims file and should note that review in the report. All tests and studies deemed necessary by the examiner must be performed. A complete rationale must be given for all opinions and conclusions. Based on a review of the claims file and the clinical findings of the examination, the examiner is requested to provide the following opinions: (a.) Is it at least as likely as not (50 percent or greater probability) that the Veteran has a sleep disability that was caused by or is related to service. The examiner should specifically address the lay testimony of the Veteran regarding symptoms of sleep disturbance experienced in 1992. (b.) Is it at least as likely as not (50 percent or greater probability) that the Veteran has a sleep disability that is due to or the result of a service-connected Crohn’s disease disability or any other service-connected disability or medication taken for a service-connected disability? (c.) Is it at least as likely as not (50 percent or greater probability) that the Veteran has a sleep disability that has been aggravated (permanently increased in severity beyond the natural progression of the disability) by a service-connected Crohn’s disease disability or any other service-connected disability or medication taken for a service-connected disability? 4. Schedule the Veteran for a VA examination to determine the nature and etiology of any IBS disability. The examiner must review the claims file and should note that review in the report. All tests and studies deemed necessary by the examiner must be performed. A complete rationale should be provided for all opinions and conclusions. Based on a review of the claims file and the clinical findings of the examination, the examiner is requested to provide the following opinions: (a.) Is it at least as likely as not (50 percent or greater probability) that the Veteran has an IBS disability that was caused by or is related to service? (b.) Is it at least as likely as not (50 percent or greater probability) that the Veteran has an IBS disability that is due to or the result of a service-connected Crohn’s disease or adrenal insufficiency disability or any other service-connected disability or medication taken for a service-connected disability? The examiner should specifically address the August 2018 private medical letter relating current IBS to Crohn’s disease. (c.) Is it at least as likely as not (50 percent or greater probability) that the Veteran has an IBS disability that has been aggravated (permanently increased in severity beyond the natural progression of the disability) by a service-connected Crohn’s disease disability or adrenal insufficiency or any other service-connected disability or medication taken for a service-connected disability? The examiner should specifically address the August 2018 private medical letter relating current IBS to Crohn’s disease. 5. Schedule the Veteran for a VA examination to ascertain the current nature and severity of service-connected Crohn’s disease. All indicated studies should be performed if deemed necessary by the examiner for the evaluation of the Veteran under the pertinent rating criteria. (a.) The examiner should identify all symptoms and impairment associated with the Veteran’s Crohn’s disease, noting their frequency and severity. The examiner should take into consideration symptoms and impairments during flare-ups. (b.) The examiner should include a statement as to the effect of the service-connected disabilities on the Veteran’s occupational functioning and daily activities. The examiner should review the claims file and should note that review in the report. The examiner should provide a complete rationale for any opinions provided. The examiner should describe the symptoms and effects of all of the service-connected disabilities on employment. The examiner should opine as to whether, without regard to the Veteran’s age or the impact of any nonservice-connected disabilities, it is at least as likely as not (50 percent probability or greater) that the service-connected disabilities, either separately or in combination, make the Veteran unable to secure or follow a substantially gainful occupation consistent with his education and occupational experience. If the Veteran is felt capable of work, the examiner should state what type of work and what accommodations would be necessary due to the service-connected disabilities. The examiner should set forth a complete rationale for all opinions expressed and conclusions reached. Harvey P. Roberts Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD H. Ahmad, Associate Counsel